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The National Health Service is key to Britain’s welfare state, and has been subject to repeated reform initiatives. Such reforms rarely “fix” the problems for which they are introduced, but evaluations have neglected the significance of local action. Reform implementation involves local translation of politically contextualized ideas into workable practice. I focus on implementation processes and the role of professions. Ethnographic data reveal local actors engaging with policy objectives to protect existing structures within the boundaries of official reform rhetoric. Actors employ multiple strategies to maintain existing systems. Rather than “failing,” policy is made through localized collaboration.

Much has been made of economizing. Yet, social scientists have paid little attention to the moment of economic failure, the moments that precede it, and the calculative infrastructures and related processes through which both failing and failure are made operable. This chapter examines the shift from the economizing of the market economy, which took place across much of the nineteenth century, to the economizing and marketizing of the social sphere, which is still ongoing. The authors consider a specific case of the economizing of failure, namely the repeated attempts over more than a decade to create a failure regime for National Health Service (NHS) hospitals. These attempts commenced with the Health and Social Care Act 2003, which drew explicitly on the Insolvency Act 1986. This promised a “failure regime” for NHS Foundation Trusts modeled on the corporate sector. Shortly after the financial crash, and in the middle of one of the biggest scandals to face NHS hospitals, these proposals were abandoned in favor of a regime based initially on the notion of “de-authorization.” The notion of de-authorization was then itself abandoned, in favor of the notion of “unsustainable provider,” most recently also called the Trust Special Administrators regime. The authors suggest that these repeated attempts to devise a failure regime for NHS hospitals have lessons that go beyond the domain of health care, and that they highlight important issues concerning the role that “exit” models and associated calculative infrastructures may play in the economizing and regulating of public services and the social sphere more broadly.

This paper is about how a command system allocated resources under profound uncertainty. The command system was the Soviet economy, the period was Stalin's dictatorship, and the resources were designated for military research & development. The context was formed by the limits of the existing aviation propulsion technology, the need to replace it with another, and uncertainty as to how to do so. We observe the formation of a quasi-market in which rival agents proposed projects and competed for funding to carry them out. We find rivalry and rent seeking, imperfectly regulated by principals. As rent seeking spread and uncertainty was reduced, the quasi-market was closed down and replaced by strict hierarchical allocation and monitoring. In theory, a dictator cannot commit to refrain from taxing the returns from today's effort tomorrow; therefore, we expect agents in a command system to seek only short-term returns from quasi-market activity. Agents’ willingness to invest in the Soviet quasi-market for inventions is ascribed to a reputation mechanism that enforced long-run returns.

A common observation is that both single- and multi-payer health care systems will achieve lower overall costs if they use primary care gatekeeping. Questioning this common wisdom, we focus on the health care access system, that is, the way in which patients gain access to health care. Gatekeeping, the use of primary care providers to control access to more specialized physician and hospital services, has come under intense scrutiny in the United States and in Europe. The few international comparative studies that have focused on the issues of quality of care, cost containment, and patient satisfaction find weak or no support for common assumptions about gatekeeping. Hence, we examine the institutional environments in seven countries in order to: (a) define and categorize health care access systems; (b) identify the components of a health care access system; (c) explore the notion of a strategic fit between health care financing systems and access system configurations; and (d) propose that the health care access system is a key determinant of process-level cost efficiency. Drawing upon institutional and governance theories, we posit that the structure and organization of an access system is determined by how it addresses six essential questions: Who is covered? Which services are included? What are the points of access? How much time elapses before access? What are the ways of selecting among points of access? and Are services and their quality the same for everyone? This analytical framework reveals that national health care access systems vary the most in their points of access, access times, and selection mechanisms. These findings and our explanations imply that access systems are one of the only tools for demand management, that any lasting change to an access system typically is implemented over an extended time period, and that managers of health care organizations often have limited freedom to define governance structures and shape health care service production systems.