On penalties and the Patient's Charter: Centralism v de-centralised governance in the NHS

Abstract

A paradox of the 1991 British NHS reforms is that increased central control over policy and strategy goes hand in hand with greater operational de-centralisation. Some commentators argue that market structures are leading to a dispersal of power, with local purchasers and providers assuming greater responsibility for the governance of their own relationships. Drawing inter alia on the Foucauldian concept of 'governmentality', they contend that 'action at a distance' or 'steering at a distance' is supplanting traditional bureaucratic regulation. Health authorities use contracts as a mechanism to constrain providers to deliver targets set by Government. We draw on a recent qualitative study of the NHS in Wales to examine the use of penalty clauses to enforce Patient's Charter guarantees for waiting times. This mechanism, which appears to govern the purchaser/provider relationship from within, turns out to be significantly constrained by continuing central direction. Moreover, informal resistance strategies, similar to those used in the past to counter bureaucratic regulation, operate to limit the impact of decentralised contractual governance.