Jones, LA; (2017) Sedimented governance in the English NHS. In: Bevir, M and Waring, J, (eds.) Decentring Health Policy: Learning from British Experiences in Healthcare Governance. (pp. 17-33). Routledge: London, United Kindom.

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Abstract

Narratives of governance emphasise a shift in modes of organisation and action from public sector bureaucracies towards markets and networks. The extent and nature of this shift is the subject of debate, with some arguing that it has been overstated, that public-sector bureaucracies remain widespread, and others asking ‘do governments do less, or have they merely changed the way they do things?’ (Bevir, 2013). Adopting a historical lens, Bevir accounts for the shift towards markets and networks as originating in the twin trends of modernist social science – neoliberalism and rational economics on the one hand, and modernist sociology on the other. Neoliberalism and rational economics have produced policies based on a critique of bureaucracies and a perceived superiority of the market and the management practices of the private sector. Modernist sociology has produced a critique of markets, in terms of coordination and steering, and a belief that efficiency and effectiveness derive from stable relationships characterised by trust. From the viewpoint of modernist sociology both bureaucracies and markets have failed to address ‘wicked problems’, those complex and contested social problems that require networks of individuals and organisations across sectors. Significantly for this chapter, both sets of reforms – markets and networks – continue the bureaucratic faith in modernist expertise which continues to play a key role in governance. In this chapter I develop an account of contemporary healthcare governance that combines insights from the governance and governmentality literatures (Bevir, 2011). I approach this task by, first, exploring the interaction of markets, networks and hierarchies. Drawing on a decentred theory of governance (Bevir, 2013) I locate this interaction in a context of situated agency and local traditions. Second, I consider how, in this contemporary context of ‘sedimented’ governance, governing is accomplished through inscription practices that align local action with government ambitions. My analysis draws on a study of local efforts to implement a national policy for ‘integrated care’. This policy required local agencies to work collaboratively in networks to deliver services. Networks were, initially, granted autonomy from central control and promised the ‘freedom to innovate’. What became evident, over the course of the research, was the resurgence of hierarchy, despite much of the pre-existing bureaucratic architecture of the NHS being dismantled by recent NHS reforms. The result was a hybrid form of governance whereby hierarchical control was exerted through networks. While in some localities hierarchical forms of control were contested and resisted, in others the perceived need to respond to this regime came to dominate the activities of local actors. In addition to hierarchical forms of control, governmental ambitions were also realised through a less visible assemblage of expert knowledges, procedures, calculations and documents. Looking specifically at two elements of this assemblage – data collection and analysis undertaken by NHS England (the ‘Pioneer stocktake’) and a policy evaluation commissioned from an academic team – I show how these analytical methodologies worked as indirect control technologies, constituting a particular version of integrated care and shaping local action.

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