Provider diversity in the English NHS: a study of recent developments in four local health economies

Objectives: The overall objective of the research was to assess the impact of provider diversity on quality and innovation in the English NHS. The aims were to map the extent of diverse provider activity, identify the differences in performance between Third Sector Organisations (TSOs), for-profit private enterprises, and incumbent organisations within the NHS, and the factors that affect the entry and growth of new private and TSOs. Methods: Case studies of four Local Health Economies (LHEs). Data included: semi-structured interviews with 48 managerial and clinical staff from NHS organizations and providers from the private and Third Sector; some documentary evidence; a focus group with service users; and routine data from the Care Quality Commission and Companies House. Data collection was mainly between November 2008 and November 2009. Results: Involvement of diverse providers in the NHS is limited. Commissioners’ local strategies influence degrees of diversity. Barriers to the entry for TSOs include lack of economies of scale in the bidding process. Private providers have greater concern to improve patient pathways and patient experience, whereas TSOs deliver quality improvements by using a more holistic approach and a greater degree of community involvement. Entry of new providers drives NHS Trusts to respond by making improvements. Information sharing diminishes as competition intensifies. Conclusions: There is scope to increase the participation of diverse providers in the NHS, but care must be taken not to damage public accountability, overall productivity, equity and NHS providers (especially acute hospitals, which are likely to remain in the NHS) in the process.

Perspectives on community representation within the Extractive Industries Transparency Initiative: experiences from south-east Madagascar

This article critically examines the nature and quality of governance in community representation and civil society engagement in the context of trans-national large-scale mining, drawing on experiences in the Anosy Region of south-east Madagascar. An exploration of functional relationships between government, mining business and civil society stakeholders reveals an equivocal legitimacy of certain civil society representatives, created by state manipulation, which contributes to community disempowerment. The appointment of local government officials, rather than election, creates a hierarchy of upward dependencies and a culture where the majority of officials express similar views and political alliances. As a consequence, community resistance is suppressed. Voluntary mechanisms such as Corporate Social Responsibility (CSR) and the Extractive Industries Transparency Initiative (EITI) advocate community stakeholder engagement in decision making processes as a measure to achieve public accountability. In many developing countries, where there is a lack of transparency and high levels of corruption, the value of this engagement, however, is debatable. Findings from this study indicate that the power relationships which exist between stakeholders in the highly lucrative mining industry override efforts to achieve "good governance" through voluntary community engagement. The continuing challenge lies in identifying where the responsibility sits in order to address this power struggle to achieve fair representation.

Circles of support and accountability: criminal justice volunteers as the 'Deliberative public'

This paper provides a review of the role played by volunteers within one particular offender management and reintegration scheme in the United Kingdom. Circles of Support and Accountability (COSA) draw on the expertise of volunteer members of the public to create supportive monitoring frameworks around sex offenders following their release from prison. The paper presents evidence as to the motivations of these volunteers, and argues that they play a crucial role in the success of the scheme, as they provide an instrumentally-useful form of reintegrative social contact to a socially-excluded offender population, and perform a symbolically important role as representatives of the wider community in taking ownership of offender management practices on behalf of the wider society. This is particularly significant in grounding those processes in the communicative practices of the social sphere, providing powerful reasons for intervention that reinforce the work that COSA do.

Healthcare providers in the English National Health Service: public, private or hybrids?

In recent years it has been noted that boundaries between public and private providers of many types of welfare have become blurred. This paper uses three dimensions of publicness to analyse this blurring of boundaries in relation to providers of healthcare in England. The authors find that, although most care is still funded and provided by the state, there are significant additional factors in respect of ownership and social control which indicate that many English healthcare providers are better understood as hybrids. Furthermore, the authors raise concerns about the possible deleterious effects of diminishing aspects of publicness on English healthcare. The most important of these is a decrease in accountability

Privatisation, empowerment and accountability: What are the policy implications for establishing effective farmer organisations?

Weak institutional development and information flows have constrained the extent to which the small-holder farming sector in developing countries can significantly drive growth and poverty reduction. Thisis despite widely implemented economic liberalisation policies focussing on market efficiency. Farmerorganisations are viewed as a potential means of addressing public and private institutional failure but thishas frequently been limited by inequalities in access to power and information. This article investigatestwo issues that have received little research attention to date: what role downward accountability plays inenabling farmer organisations to improve services and markets, and what influences the extent to whichdownward accountability is achieved. Kenya Tea Development Agency (KTDA), one of the largest farmerorganisations in the world (>400,000 farmers) is examined alongside wider literature. Mixed methodswere used including key informant interviews, and eight months of participant observation followedby a questionnaire survey. The article concludes that without effective downward accountability farmerorganisations can become characterised by institutions and mechanisms that favour elites, restrictedweak coordination and regulation, and manipulated information flows. This in turn reduces individuals’incentives to invest. If farmer organisations are to realise their potential as a means of enabling the small-holder sector to significantly contribute to economic growth and poverty reduction, policy and researchneeds to address key factors which influence accountability including: how to ensure initial processes information of farmer organisations establish appropriate structures and rules; strong state regulation toenhance corporate accountability; transparent information provision regarding actions of farmer organi-sation leaders; and the role independent non-government organisations can play. Consequently attentionneeds to focus on developing means of legitimising rights, building poor people’s capacity to challengeexclusion, and moving from rights to obligations regarding information provision.

Strengthening citizen agency and accountability through ICT

We investigated the role of Information and Communication Technologies (ICT, namely mobile phones) in support of citizen agency and its potential in calling authorities to account. We focused on Eastern Africa and we used a mixed methodology, which allowed us to explore the current uses of ICT to strengthen accountability and to forecast the growth of mobile phones' adaption in that region. Evidence from both analyses suggests that there are two main areas where citizen agency and ICT can reinforce each other in bottom–up and horizontal processes: participation and engagement of citizens, and the diffusion of information.

Accountability and ideology: when left looks right and right looks left

Abstract Managers face hard choices between process and outcome systems of accountability in evaluating employees, but little is known about how managers resolve them. Building on the premise that political ideologies serve as uncertainty-reducing heuristics, two studies of working managers show that: (1) conservatives prefer outcome accountability and liberals prefer process accountability in an unspecified policy domain; (2) this split becomes more pronounced in a controversial domain (public schools) in which the foreground value is educational efficiency but reverses direction in a controversial domain (affirmative action) in which the foreground value is demographic equality; (3) managers who discover employees have subverted their preferred system favor tinkering over switching to an alternative system; (4) but bipartisan consensus arises when managers have clear evidence about employee trustworthiness and the tightness of the causal links between employee effort and success. These findings shed light on ideological and contextual factors that shape preferences for accountability systems.