Steering, Knowledge and the Challenge of Governance Evaluation: The Case of National Health Service Governance and Reform in England

• DOI: 10.1177/0095399719883564
• Date: 01 August 2020
• Published date: 01 August 2020
• Subject Matter: Articles

https://doi.org/10.1177/0095399719883564

Administration & Society

2020, Vol. 52(7) 1069 –1100

© The Author(s) 2019

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DOI: 10.1177/0095399719883564

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Article

Steering, Knowledge

and the Challenge of

Governance Evaluation:

The Case of National

Health Service

Governance and Reform

in England

Dan Greenwood1 and Thomas Mills2

Abstract

Drawing from “robust political economy” (RPE) literature, we address

evaluative questions concerning governance effectiveness in the face

of complex, cross-cutting problems. Central to RPE is the challenge of

coordination, with its fundamental epistemological dimension requiring

close attention to stakeholder knowledge about policy impacts. This focus

contrasts with process-orientated analysis predominant in political science

and public administration and enables holistic governance evaluation that

draws from various, often demarcated, research fields. This is demonstrated

through a focus on the evolution of health governance in England, particularly

how diabetes services in England were affected by the 2012 Health and

Social Care Act.

Keywords

governance, coordination, complexity, evaluation, health

1University of Westminster, London, UK

2Bradford Institute for Health Research, UK

Corresponding Author:

Dan Greenwood, University of Westminster, 32-38 Wells Street, London W1B 2HW, UK.

Email: d.greenwood2@westminster.ac.uk

883564AASXXX10.1177/0095399719883564Administration & SocietyGreenwood and Mills

research-article2019

1070 Administration & Society 52(7)

Introduction

The challenge of how to “steer” society toward policy goals (Peters & Pierre,

1998) in the face of complex, or “wicked” problems’ is a central concern in

political science and public administration literatures on governance. There

are different understandings of “steering” and the institutional arrangements

required to achieve this. Osborne and Gaebler (1992), influential in the early

advocacy of new public management (NPM), advocated “steering rather than

rowing.” The term “steering” is sometimes used more broadly to acknowl-

edge that not all solutions can be defined centrally and that “meta gover-

nance” of networks is required to allow actors scope for decentralized

coordinative activity (Torfing, Peters, Pierre, & Sørensen, 2012). Studies

exploring NPM approaches of performance measurement and outsourcing to

the private sector in a range of sectors have highlighted the tensions and prob-

lems these often entail in the context of complexity (Bevan & Hood, 2006;

Head & Alford, 2015). This has influenced the case for collaborative network

arrangements to foster trust, learning, and innovation in policy delivery

(Ansell & Gash, 2008). This article addresses the need highlighted by these

debates for conceptual frameworks to enable closer, more holistic consider-

ation of the effectiveness of different governance arrangements and policy

strategies.

The “robust political economy” (RPE) approach to analyzing institutions

emerged recently from the heterodox, Austrian tradition in economics

(Boettke & Leeson, 2004; Pennington, 2011). Here, we use key RPE con-

cepts to propose and employ a methodology to meet the need for governance

evaluation in the context of complexity. Central to RPE is a conception of

“coordination” that, like the notion of steering in governance scholarship, is

concerned with allowing actors flexibility in how they translate goals into

practice. As Section 2 explains, RPE emphasizes the epistemological dimen-

sion of anticipating impacts, learning and innovation as of integral impor-

tance to achieving coordination. The approach highlights the need for detailed

attention to the various, often contested, stakeholder understandings of the

substantive impacts of governance arrangements and policy strategy. Here,

we demonstrate how this approach to institutional analysis, with its rich, out-

come-orientated conceptualization of coordination, can complement what

Hood and Margetts (2007) and Greenwood (2016), describe as the process-

orientated focus of political science and public administration. RPE has ori-

gins in the work of pro-market, classical liberal Austrian economists who

were firmly entrenched on one side of a rather dualistic debate with socialists

about the strengths and weaknesses of markets and planning as mechanisms

for allocating resources. Yet, we argue, the approach is highly applicable to

Greenwood and Mills 1071

contemporary governance arrangements involving a hybrid of market and

nonmarket processes across multiple scales. Some recent RPE contributions

(e.g., Pennington, 2011), although primarily conceptual, discuss such con-

temporary governance applications, particularly in relation to environmental

resources. However, there remains a lack of extended, empirically orientated

RPE analyses of such hybrid arrangements.

Here, we explain and illustrate the contemporary pertinence of RPE

through a focus on health governance, in particular the English National

Health Service (NHS) which involves a hybrid of hierarchical structures, net-

works, and quasi-market arrangements. Section 3 introduces key aspects of

coordination challenges in the English NHS concerning scale, mechanisms,

and sectors. Section 4 reviews the insights into these aspects of coordination

challenges offered by various health research approaches. We argue they

leave open the need for further, holistic evaluation of the governance arrange-

ments shaping policies and interventions and the interrelationships they

involve between public, private, and third sector across different scales. The

positivist character of the limited research evaluating health governance

means broader approaches are required that are sensitive to a greater range of

values and contested understandings of outcomes. Section 5 draws on RPE to

set out a methodology for holistic governance evaluation through a focus on

coordination. In Section 6, we illustrate the potential of this approach, with its

strong, detailed epistemological focus, through a case study of diabetes care

in the English NHS. This case study illustrates how the RPE conception of

coordination enables us to draw together and enrich findings from the cur-

rently demarcated subfields of health evaluation research, promoting more

holistic evaluation. Section 7 discusses potential future applications of the

approach to governance evaluation across a range of scales and policy sec-

tors. Section 8 concludes.

RPE and the Challenge of Coordination in

Governance

Political science and public administration scholarship have engaged in

various ways with the widely recognized challenge of “steering” within

contemporary governance. Critics of NPM have highlighted the problems

involved in centrally defining performance measures and targets, given

the complexities of public services and the multiple, often incommensu-

rable values requiring consideration (Bevan & Hood, 2006). The intro-

duction of purchaser–provider splits and outsourcing has also been

criticized for increasing administration costs and frustrating collaboration