• Patient Choice in The NHS - Governance reforms

• Open Source Software - A 'new' type of governance?

• The BBC - Building 'Public Value'?

Patient Choice in The NHS

The NHS has undergone periodic bouts of reform.  Recent reforms (like some of those in the past) can be understood as attempts to move from hierarchical modes of governance to market based ones.  Here are some relevant quotes from a paper I wrote in Public Administration:

"‘ Choice ’ for patients is the cornerstone of the recent government White Paper (2004). It is clear that patient choice will create markets and market forms of governance, something which raises conflicts with the founding principles of the NHS. Choice is also used to signal the responsibility patients have to improve their own health, and to imply a liberating redistribution of power. These and other senses of choice suggest that examining the term is useful in understanding NHS governance, and examining whether it is simply a (market) governance mechanism, or signals new forms of engagement in the co-production of healthcare."

"The moral, political and organizational complexities inherent in making sense of healthcare governance and accountability are glossed over, as choice is used to signal seemingly straightforward causal processes:
       

       Patient choice will be a key driver of the system and resources will
       flow to those hospitals and healthcare providers that are able to
       provide patients with the high-quality and responsive services they
       expect. (DH 2004a, p. 12)

This implies that systemic improvement is conditioned by a simple relationship between choice (implicitly competition), quality and resources. One problem with choice is that it presupposes inequality (or choice would be redundant), which is antithetical to the founding values of the NHS. Informed choice also requires access to information, and, potentially, mobility (if it means travelling elsewhere for treatment). Both of these are forms of immaterial, or non-economic ‘ cultural capital ’ (Bourdieu 1986). Using Bourdieu ’ s (1986) framework, they are ‘ embodied ’ , directly incorporated within individuals and infl uencing what is in their power to do. Embodied capital cannot be transmitted instantaneously and inequalities in this type of capital are not immediately obvious. The costs of transferring this type of capital are also high. This can mean that inequalities are harder to address, and that patterns of inequity are reproduced (Bourdieu and Passeron 1977)."

So, introducing this governance reform 'patient choice' may result in inequality, or be contrary to the NHS founding principles.

REFERENCES

Bourdieu , P . 1986 . The Forms of Capital , in J . Richardson ( ed .), Handbook of Theory and Research for the Sociology of Education . London : Greenwood Press , pp . 241 – 58 .

Bourdieu , P . and J . Passeron . 1977 . Reproduction in Education, Society, and Culture . Beverly Hills, CA : Sage .

DH (Department of Health) . 2004c . ‘ Choosing Health: Making Healthier Choices Easier ’ . London : HMSO .

Morrell, K. (2006) 'Policy as Narrative:  New Labour's reform of the National Health Service', Public Administration, 84, 2, 367-385.

Open Source Software

A really nice, recent paper describe the phenomenon of open source (free, shared over the Internet) software - suggesting it can be seen as a new form of governance.  It's not a market, network or hierarchy the authors argue.  Here are some relevant quotes, the paper's reference is:
   
    Demil, B. and Lecocq X. (2006) 'Neither Market nor Hierarchy nor
    Network: The Emergence of Bazaar Governance', Organization Studies,
    27(10): 1447–1466.

p1447
"A growing body of literature describes the open source phenomenon in the software industry. Drawing on transaction cost economics, we propose that open source projects illustrate a new generic governance structure — which we label bazaar governance — based on a specific legal contract: the open licence. We characterize this structure in terms of its strengths and weaknesses and compare it to market, firm and network forms. Low levels of control and weak incentives intensity are distinctive features of bazaar, lending a high uncertainty to governed transactions. However, bazaar governance promotes the openness of open source communities, which can generate strong positive network externalities and subsequent efficiency in cumulative transactions."

pp1477-8
"Through the 1960s, the sharing of basic software source code among programmers was commonplace and informal (Lerner and Tirole 2002). The concept of cooperative source-code development across a network, however, was born with the Advanced Research Projects Agency Network (ARPAnet), established in 1969 by the US Department of Defense. By the beginning of the 1980s, efforts to formalize this informal development methodology had begun to appear. In 1985, Richard Stallman designed the GNU General Public License (GPL) in response to MIT’s decision to license some of the source code of its software to commercial firms. In 1991, Linus Torvalds released the core source code for the Linux operating system in an internet newsgroup, looking for improvements. But it was not until internet access became widespread that free software really bloomed. Because ‘free’ software ‘might understandably have an ominous ring to the ears of business people’ (Von Hippel and Von Krogh 2003: 210), the term ‘open source’ was coined to emphasize the practical benefits of open licensing and to extend most of the free software principles to for-profit organizations (Raymond 1999). Open source gained public recognition in 1998, when Netscape decided to make [over page] its Web browser an open source product (Mozilla) and IBM adopted the Apache Web server, another prominent open source product. Interactions between open source projects and private companies soon became commonplace, demonstrating that open source is not only an ideological movement but also a sustainable business model."

A simplified version of the diagram they use to outline this is shown below:

Market

Hierarchy

Network

Bazaar

Incentives High

Incentives Low

Incentives Mid

Incentives Low

Control Low

Control High

Control Mid

Control Low

e.g. buying and selling shares

e.g. working in a bureaucracy

e.g. collaboration between firms

e.g. open source software

The BBC - Building 'Public Value'?

In 2004, the BBC put forward a bid to keep its unique status among broadcasters.  This bid was anchored in the language of 'public value', a phrase coined by the Harvard academic Mark Moore to describe the common task facing managers in public organisations.  While private sector managers can talk about maximising shareholder value (so Moore argues), it is harder for public sector managers to talk about their sole or prime purpose in this way.  This is because public organisations serve many different purposes and constituencies (they have a different 'authorising environment'), and they do not make a profit like private sector companies do.  This is an interesting case for exploring what things can and cannot be measured and costed, for seeing whether there is or should be a difference between public and private organisations, and for understanding the provision of a public good, i.e. broadcasting.  The more we accept that there are differences between these things, the more convincing the case the BBC makes for special treatment is.  Here are some quotes showing how the BBC makes its case.  The full document, 'Building public value
Renewing the BBC for a digital world', is freely available on the web.

p6

"Broadcasting is a civic art. It is intrinsically public in ambition and effect. We may experience it individually, but it is never a purely private transaction. To turn on a TV or radio is to enter a communal space and to be constantly aware of and influenced by that fact. This shared experience may itself represent a significant public value – the communal glue which some call social capital. But that is only one of many potential wider benefits. A programme may make me more likely to vote, or to look at my neighbour in a new, more positive light. It may encourage both of us to spruce up our houses and improve our neighbourhood. A programme I turn to for pure relaxation may unexpectedly teach me something of real value. In a national emergency, the right broadcast information might save my life."

p8

"The BBC creates public value in five main ways:
• Democratic value: the BBC supports civic life and national debate by providing trusted and impartial news and information that helps citizens make sense of the world and encourages them to engage with it.
• Cultural and creative value: the BBC enriches the UK’s cultural life by bringing talent and audiences together to break new ground, to celebrate our cultural heritage, to broaden the national conversation.
• Educational value: by offering audiences of every age a world of formal and informal educational opportunity in every medium, the BBC helps build a society strong in knowledge and skills.
• Social and community value: by enabling the UK’s many communities to see what they hold in common and how they differ, the BBC seeks to build social cohesion and tolerance through greater understanding.
• Global value: the BBC supports the UK’s global role by being the world’s most trusted provider of international news and information, and by showcasing the best of British culture to a global audience.
These are the BBC’s public purposes."

In arguing for its special status, the BBC made the case for what it thought the particular authorising environment that governed its work should be.  It promoted certain governance reforms in the wake of a scandal relating to the way in which one of its reporters had characterised the government's treatment of intelligence information.  These governance reforms were less far reaching than many of its competitor organisations had wanted.