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Über dieses Buch

This monograph applies Kingdon’s Multiple Streams Framework to two policymaking episodes of implementing pay for performance in general practice, conducted in England and New Zealand. The Framework’s explanatory power for policymaking in Westminster majoritarian jurisdictions is tested and, based on rigorous comparative analysis, recommendations are made for its refinement.
The monograph also offers striking lessons for policymakers about how to negotiate successfully with general practitioners.

Inhaltsverzeichnis

Frontmatter

Chapter 1. A Tale of Two Countries

Policymakers need to know why policy changes or varies between sectors or countries, to improve their ability to design effective policies. This compelling comparative analysis of two case studies of pay-for-performance policymaking within general practice in similar countries, England and New Zealand, uncovers the drivers of each policymaking process and the reasons for differing outcomes. An innovative analytical framework is introduced, testing the comparative utility of single-approach theories that cite the influence of institutions, interest groups, the rational choices made by individuals, ideas or socio-economic factors, and a multi-theoretic approach, John Kingdon’s Multiple Streams Framework.

Verna Smith

Chapter 2. Analysing Public Policy: Does Kingdon’s Multiple Streams Framework Help?

Kingdon’s Multiple Streams Framework is a popular multi-theoretic approach which explains non-incremental policy change by synthesising elements from structural and agency-based theories. However, the Framework has attracted much critical commentary, particularly for its neglect of institutional dynamics and the importance of history in policymaking processes. Its five central elements of policies, politics, problems, policy windows and policy entrepreneurs are presented, subsequent enhancements described and examples given of its growing use internationally to explain public policymaking. This research takes on the challenge to test two core hypotheses of the Framework: the conditions required for non-incremental change and the need for policy entrepreneurs to couple three streams at the agenda-setting phase. The findings of the research challenge these hypotheses and make the case for refinement of the Framework.

Verna Smith

Chapter 3. A Comparison of the English and New Zealand General Practice Sub-Systems

Comparative analysis has been described as the closest social science can get to generating and testing hypotheses. Here, the history and features of the general practice sub-systems of the English and New Zealand national health services are compared and contrasting features identified in order to understand their differing processes of policymaking. Despite many similarities at their time of origin and in recent episodes of health policy reform, the two general practice systems have diverged widely in important elements. The gradual development of a single-payer state-sponsored partnership between general practitioners and the state in England is contrasted with the growth of a multi-payer system in New Zealand in which general practitioners had a fractious relationship and no formal partnership with the state.

Verna Smith

Chapter 4. England: Context and the Quality and Outcomes Framework

England’s Quality and Outcomes Framework is one of the most ambitious, large-scale pay-for-performance schemes ever designed for general practitioners. Negotiated between the British Medical Association and the state between 2001 and 2004, the detailed story of its design is told in rich detail, often in the voices of the policymakers. Drawing on insights from 12 qualitative interviews with participating or proximate policymakers in England, the context and background to the policymaking is set out and the transformative intentions of policymakers revealed. The reader is allowed to see who was involved, what was done, how it was done and how it was implemented. Significant barriers which threatened the process, and enablers which supported it, are described and discussed.

Verna Smith

Chapter 5. Utility of Kingdon’s Framework: Policymaking in England

Kingdon’s Multiple Streams Framework hypothesises that policy change happens when policymakers’ preferences are ambiguous, there is fluid participation and unclear technology, and entrepreneurs are able to exploit this uncertainty in brief windows. These hypotheses are challenged in this case study of policymaking in England between 2001 and 2004. Both the Multiple Streams Framework and five single-approach theories of policy change (institutions, groups, rational choice, ideas and socio-economic circumstances) are tested against the case study evidence of design of a pay-for-performance scheme. Kingdon’s Framework is the most useful approach but fails to encourage recognition of the powerful institutional and interest group factors at work. Amendments to the Framework to reflect ownership and governance arrangements and the role of state-appointed institutional entrepreneurs are recommended.

Verna Smith

Chapter 6. New Zealand: Context and the Performance Programme

In a dramatic contrast to the pay-for-performance scheme designed in England between 2001 and 2004, a much smaller scheme, the Performance Programme, was also being designed in New Zealand between the Ministry of Health and advisory groups of primary care stakeholders. Drawing on insights from 14 qualitative interviews with proximate policymakers, the context of and background to the policymaking are set out. The intentions of policymakers and the detailed story of the process to bring these to fruition are told in rich detail, often in the voices of the policymakers. The reader is allowed to see who was involved, what was done, how it was done and how it was implemented. Significant barriers that threatened the process and enablers that supported it are described and discussed.

Verna Smith

Chapter 7. Utility of Kingdon’s Framework: Policymaking in New Zealand

Kingdon’s theory that loosely coupled policymaking environments are ripe for exploitation by an exogenous policy entrepreneur is challenged by this New Zealand case study of pay-for-performance policymaking. His hypothesis, that non-incremental change occurs where ambiguity of preferences, fluid participation and unclear technology exist, is partly supported. In a comparative study in which both Kingdon’s Multiple Streams Framework and five single-driver theories of policy change are systematically applied to the case study evidence, the Multiple Streams Framework is found to be the most useful. However, it fails to encourage recognition of the powerful institutional and interest group factors or the influence of history at work. Amendments to the Framework reflecting historical antecedents, ownership and governance arrangements, and the role of state-appointed institutional entrepreneurs are recommended.

Verna Smith

Chapter 8. The Two Case Studies Compared

Bargaining power is shown to be the driver of non-incremental policy change and variation in a thought-provoking comparative analysis of two health policymaking case studies. England’s policymakers were able to integrate a pay-for-performance scheme design into contractual negotiations with the British Medical Association, leading to increased funder influence over general practitioners and opportunities to improve population health outcomes. Contemporaneously, New Zealand’s policymakers lacked these powers, delivering a much smaller scheme. Kingdon’s Multiple Streams Framework fails to offer adequate explanations for the policymaking in these two majoritarian, parliamentary political systems. Recommendations are made for modifications to the Framework to recognise the importance of institutional context in the Politics Stream, variation in entrepreneurial activity and policy outcomes (not just outputs).

Verna Smith

Chapter 9. Conclusion

A compelling case is made to adapt and improve the ability of Kingdon’s Multiple Streams Framework to predict planned, purposeful and orderly non-incremental policymaking in majoritarian parliamentary jurisdictions. New Institutionalist, institutional rational choice and network literatures are used, in addition to Kingdon’s Framework, to explain what happened in two case studies of pay-for-performance policymaking in general practice in England and New Zealand between 2001 and 2007. Rare rich descriptions of public policymaking in the general practice sub-systems of these two countries are delivered, offering many insights of both practical and theoretical assistance to those interested in the dynamics of policymaking.

Verna Smith

Backmatter

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