Schisms in the Church: National Health Service Systems and Institutional Divergence in England and Wales

Since devolution, the four countries of the United Kingdom have pursued strikingly different National Health Service (NHS) reforms. While England created a supply-side market more radical than the previous internal market system, Wales moved to a softer version of the purchaser/provider split emphas...

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Bibliographic Details
Published in:	Journal of health and social behavior 2008-12, Vol.49 (4), p.400-416
Main Authors:	Hughes, David, Vincent-Jones, Peter
Format:	Article
Language:	eng
Subjects:	Biological and medical sciences Cognition Comparative Analysis Comparative Health and Health Care Comparative studies Competition Delivery of Health Care - organization & administration Economic regulation Economic Structure England Environmental conditions Environmental economics General aspects Governance Government Health care industry Health care organizations Health Care Reform Health Policy Health Services Health systems. Social services Humans Medical sciences Mental health National health services Normativity Organization of mental health. Health systems Organizational Change Parliaments Pilot Projects Political risk Politics Primary health care Psychology. Psychoanalysis. Psychiatry Psychopathology. Psychiatry Public health care Public health. Hygiene Public health. Hygiene-occupational medicine Regulation Regulatory agencies Regulatory reform Schisms Social psychiatry. Ethnopsychiatry Socialized Medicine State government State Medicine State Policy Wales
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Summary:	Since devolution, the four countries of the United Kingdom have pursued strikingly different National Health Service (NHS) reforms. While England created a supply-side market more radical than the previous internal market system, Wales moved to a softer version of the purchaser/provider split emphasizing localism. This article deploys institutional theory to analyze the forces shaping change, and describes the hybrid forms of economic organization emerging, including the economic regulation model implemented in England. The schism that has resulted in separate NHS subsystems warrants a different analysis from the more familiar phenomenon of infield divergence. We argue that schism was triggered by political-regulatory influences rather than economic or other social institutional forces, and predict that other decentralized public health care systems may follow a similar path. While political-regulatory, normative, and cognitive institutional influences push in the same direction in Wales, the misalignment of political-regulatory and normative elements in England looks set to result in a period of organizational turbulence.
ISSN:	0022-1465 2150-6000