"Health, Risk & Society"

Hutter, Bridget M.

doi: 10.1080/13698570701782338pmid: N/A

Abstract Risk regulation analyses the organization and institutional settings for risk regulation and regulatory practice. This special issue focuses on risk regulation research with respect to two main areas of health care: infrastructure and service provisions and the risk regulation of critical areas relating to patient safety. This editorial draws out some of the main themes in risk regulation studies as they relate to these papers. Risk and governance issues consider which risks attract state regulatory responses and how risk debates connect with regulatory policy making. The emergence and reform of risk regulation and governance regimes is examined and varying perspectives offered on the status of experts, expertise and professionals in risk regulation. Many risk regulation initiatives are the result of public sector modernization programmes where the transferability of approaches and tools are taken for granted. How organizations respond to risk regimes and the extent to which organizations create their own risk regulation regimes thus become a clear focus in this volume. In medical situations, risk regulation may lead to resistance rather than openness and learning. The unintended consequences of risk regulation is an important theme: new financial frames of reference come into collision with other professional perspectives and performance data may be misinterpreted and misused. One strong message is that risk regulation in the UK is in a state of flux and that learning from crises and routine organizational data and experience are crucial in the resolution of the present difficult web of risk regulation initiatives.

Kurunmäki, Liisa; Miller, Peter

doi: 10.1080/13698570701782395pmid: N/A

Abstract Payment by Results (PbR) is one of the most fundamental changes in NHS policy since the introduction of the ‘internal market’ in 1991. It is also one of the most visible and influential attempts across the same period to modernize the NHS through accounting and, more specifically, costing. As a funding system, PbR promises to pay providers fairly and transparently by using a ‘standard national tariff.’ However, like all accounting based reforms, PbR encounters the range of professions and expertises active in the domain. Like all costing systems that give visibility where previously it was lacking, PbR creates new calculable spaces and new risks. The aim of the paper is threefold. First, we seek to chart the nature of the arena within which PbR operates. We identify the multiple actors that are influential in the regulatory field of health service provision, and focus on three types of actor in particular, namely the National Institute for Health and Clinical Excellence (NICE), Monitor and professional medical associations. We argue that these three actors need to be viewed as representative of different types of expertise (schematically speaking, health economics, accounting and medicine) and that, to understand fully the nature of the regulatory game in the healthcare arena, PbR needs to be analysed not as a stand alone intervention but as enmeshed within the inter-professional complex that emerges out of the interaction of these three types of expertise. Second, we argue that we need to focus on the ways in which PbR, along with other regulatory interventions in the healthcare field, such as those of NICE and Monitor, seek to create new and sometimes competing calculable spaces based on different entity assumptions. Third, we argue that to understand empirically the dynamics of healthcare reform in the UK we need to examine the extent to which PbR creates new calculating selves, or a hybridizing of the calculating and medical self. The regulatory complex within which PbR operates may, we argue, produce contradictory incentives and thereby contribute to systemic provision risks.

Aldred, Rachel E.

doi: 10.1080/13698570701782411pmid: N/A

Abstract This paper analyses NHS Local Improvement Finance Trust (LIFT), a relatively new policy that shifts UK primary care premises into corporate ownership. LIFT is a more radical version of the Private Finance Initiative (PFI), and may indicate the future direction of neoliberal welfare services. Like PFI, LIFT foregrounds issues of risk and regulation, enabling their reconceptualization. This echoes certain themes present in the sociology of risk, including the idea that the welfare state has created and amplified, rather than managed, risk. Under LIFT, risks are constructed as (a) primarily economic and (b) primarily from the point of view of the large commercial organizations involved. Evidence presented here depicts banks as risk averse, challenging assumptions that private firms display risk-taking behaviour. The prioritization of economic risks is shown to amplify social risks, and to produce threats to social regulation. These threats are amplified by unequal power relationships within these new ‘local health economies.’ It is argued that LIFT is undermining the NHS's social embeddedness in local areas, partly by threatening the position of general practitioners and other small business or community organizations. Ultimately, the model is likely to generate new social and economic risks currently obscured by official discourse around LIFT.

Demortain, David

doi: 10.1080/13698570701782437pmid: N/A

Abstract This paper deals with the relation between regulatory crises and regulatory change. It considers the question of whether factors that explain how accidents or disasters escalate into a regulatory crisis also explain subsequent reforms. Looking at the evolution of post-marketing drug safety and at the crisis caused by the discovery of the fatal effects and market withdrawal of the drug cerivastatin in 2001, it investigates the conditions in which shared solutions to a regulatory crisis emerge. It argues that regulatory change is a process by which existing or emerging technologies come to be framed as a solution to the crisis. Framing means aligning the actors of the regulatory space around common schemes of interpretations of what is needed to improve the regulatory framework. The case study points at the power of scientific and medical experts to foster such cognitive alignment.

Macrae, Carl

doi: 10.1080/13698570701782452pmid: N/A

Abstract Patient safety has emerged as one of the key risks facing advanced healthcare systems. Enormous efforts are being made in healthcare to manage and regulate these risks. One widespread approach involves collecting, analysing and learning from minor safety incidents and near-miss events, following the success of such systems in safety-critical industries such as aviation and chemical processing. This paper examines the nature and role of worker participation in safety incident-reporting systems. It argues that actively engaging with local personnel throughout the analysis and learning process (both drawing on their knowledge and influencing their practice) is a key reason for the success and regulatory efficacy of these reporting systems. The paper examines both the design of current patient safety reporting systems in healthcare, and the situated practices that support similar reporting systems in the airline industry. This analysis suggests that the concept of worker participation has not, at present, been heavily emphasized in patient safety reporting systems. The paper concludes by conceptualizing participation in a form that can be applied in healthcare, and examining how participation can support three key aims of risk regulation in healthcare: producing knowledge, creating accountability and supporting leadership.

Lloyd-Bostock, Sally M.; Hutter, Bridget M.

doi: 10.1080/13698570701782460pmid: N/A

Abstract Risk-based regulation is growing in popularity and in the UK has official backing as part of the government's modernization programme. State and non-state regulators alike are under pressure to adopt risk-based approaches. With radical reform of the General Medical Council (GMC) in progress, the rhetoric of risk-based regulation is used by both the Department of Health and the GMC, and is evident in the 2007 White Paper Trust, Assurance and Safety—The Regulation of Health Professionals in the 21st Century. This paper focuses on the dilemmas inherent in risk-based approaches to regulation by the GMC. Two sources of difficulty are examined. First, the evidential demands can be heavy and costly. Databases and information sources related to patient safety and the performance of doctors are proliferating, but have important limitations. Second, decisions about which risk factors to include and how to weight them are riddled with difficulties, both technical and normative. One attraction of risk-based approaches is that they seem to offer objectivity, but it is questionable how far this is possible in practice. Risk information is neither generated nor used against a neutral background. In the medical regulation arena, questions of public trust and confidence are crucial: risk-based regulation does not help deal with these. Furthermore, a focus on individual doctors and a certain amount of blame and sanctioning would seem to be integral to regulatory functions of such bodies as the GMC. The paper poses fundamental questions about how blame-free these systems really can be.

Bevan, Gwyn

doi: 10.1080/13698570701782494pmid: N/A

Abstract This paper outlines the way in which professional self regulation of quality of healthcare was integral to the creation of the National Health Service (NHS) in 1948, and to the way the NHS was organized for the next 50 years. It describes the crisis in quality that emerged in the late 1990s. It describes the government's initial responses to that crisis, which were to require NHS organizations to implement systems of clinical governance, and create the Commission for Health Improvement (CHI) to inspect its implementation through visits to each NHS organization. The paper discusses Reports from Inquiries into three scandals, and considers the further changes made to governance and regulation of quality with the abolition of CHI and the National Care Standards Commission, which inspected the private sector, to be succeeded by the Healthcare Commission with a new approach to regulation. It examines three promises of that new approach: the use of national standards; being ‘light touch’ and proportionate using ‘intelligent’ (or ‘smart’) information, as opposed to being organized on a comprehensive programme of visits; and developing a common approach to the NHS and private sectors.