The impact of economic rationalism and new public management on health and welfare services : accounting for the gap between social health care policy and practice in two Scottish maternity care units

• Main Author: Lincoln, M. G.
• Published: University of Edinburgh 2004
• Subjects: 361
• Online Access: http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.653919

The administration of welfare in Britain and beyond, in the last thirty years, has seen a series of changes culminating into the new public management (NPM) approach in the delivery of public services. Current literature suggests that traditional collectivist values underlying state welfarism are at risk under the precepts NPM and economic rationalism (Hood 1991; Clarke and Newman 1997; Hunter 2002). Selecting decentralised budget management as one key aspect of NPM, this thesis tests out its impact on two key policy recommendations, ‘service user choice’ and ‘continuity of care’ as set out by the Cumberledge Report (1993). The design of the enquiry consists of a merger of two opposite methodological approaches: questions put to participants are informed by a NPM framework; at the same time, the openness of the interview schedule also allowed, in part, the inclusion of a grounded theoretical approach, characteristic of Glaser and Strauss (1967). The study took place in Scotland where two highly contrastive maternity units, in terms of size, internal culture and geographical location, were investigated. Tape-recorded in-depth interviews, of around 45-90 minutes each, were carried out with a sample of 43 consultant obstetricians, junior doctors, paediatricians, midwives, and key financial management personnel. The comparison of the two sites highlights how organisational size, structure and the midwifery system in place can impinge on the viability and implementation of social health policies such as those recommended in <i>Changing Childbirth</i>. Whilst economic rationalism has hampered the full expression of service user choice and continuity of care owing largely to inadequate staffing or practitioner skills, the dictates of new public management have had a more turbulent impact on the larger than on the smaller unit. One contribution of this thesis is the finding that service user choice is not only constrained by economic rationalism but by internal institutional agendas as well - a consideration, which, to a certain extent, is likely to be applicable to all health and welfare services. Another key contribution is the identification of the distinct forces that combine to obstruct the implementation of social health policies. Apart from complex economic, organizational and institutional influences, one significant obstructing influence is the obstetricalisation of childbirth. The gap between social health policy and practice is widening further as mergers take precedence over the retention of smaller, relatively low-tech maternity care units. This structural change that is aimed at fulfilling the perceived needs of ‘medical safety’ is increasingly likely to render <i>Changing Childbirth</i> recommendations into impracticable propositions. The thesis concludes that a comprehensive approach towards health and welfare, where service user choice and continuity of care are recognised, and which considers the social context in which economic action takes place is expected to lead to improved health and welfare and outcomes overall.