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Purpose – The aim of this paper is to examine the diffusion of a new surgical procedure with lower per-case cost and how its diffusion path is affected by the simultaneous introduction of a new drug class that may be an effective treatment to prevent surgery. In particular, we examine whether a process of technology substitution exists that influences the diffusion process of the surgical technology. Given their different cost implications, the interaction of these two different technologies, surgery and drug intervention, is relevant from the perspective of health expenditure. This is of particular interest in health care as technology adoption and diffusion has been cited as a major driver of expenditure growth. Such expenditure growth has been increasingly targeted through the use of market-orientated policy tools aimed at increasing efficiency. Our research is thus addressing the question of how economic incentives influence the diffusion process and we discuss the impact of a set of incentives on hospital behavior.

Design/methodology – Hospital admission data for the financial years 1998/1999 to 2007/2008 in England are used to empirically test the contribution of prescription uptake and market-oriented reforms. Dynamic panel data models are used to capture any changes in technology preference during the period of study.

Findings – Our results suggest that the hospital sector exhibits a strong new technology preference, tempered by the interaction of competition for patients and the ability of the primary care sector to substitute treatments.

Value/originality – Given the current fast technological change, we examine the technological race occurring in the health care sector. We account simultaneously for the diffusion of different technologies not only within the same typology but also with technologies of a different class.

What is our unit of analysis and by implication what are the boundaries of our cases? This is a question we grapple with at the start of every new project. We observe that case studies are often referred to in an unreflective manner and are often conflated with geographical location. Neat units of analysis and clearly bounded cases usually do not reflect the messiness encountered during qualitative fieldwork. Others have puzzled over these questions. We briefly discuss work to problematise the use of households as units of analysis in the context of apartheid South Africa and then consider work of other anthropologists engaged in multi-site ethnography. We have found the notion of ‘following’ chains, paths and threads across sites to be particularly insightful.

We present two examples from our work studying commissioning in the English National Health Service (NHS) to illustrate our struggles with case studies. The first is a study of Practice-based Commissioning groups and the second is a study of the early workings of Clinical Commissioning Groups. In both instances we show how ideas of what constituted our unit of analysis and the boundaries of our cases became less clear as our research progressed. We also discuss pressures we experienced to add more case studies to our projects. These examples illustrate the primacy for us of understanding interactions between place, local history and rapidly developing policy initiatives. Understanding cases in this way can be challenging in a context where research funders hold different views of what constitutes a case.

Purpose: In this chapter, we examine the National Health Service (NHS) and Adult Social Care (ASC) in England, focussing on policies that have been introduced since 2000 and considering the challenges that providers face in their quest to provide a high standard and affordable health service in the near future.

Methodology/Approach: We discuss recent policy developments and published analysis covering innovations within major aspects of health care (primary, secondary and tertiary) and ASC, before considering future challenges faced by providers in England, highlighted by a 2017 UK Parliament Select Committee.

Findings: The NHS and ASC system have experienced tightening budgets and serious financial pressure, with historically low real-terms growth in health funding from central government and local authorities. Policymakers have tried to overcome these challenges with several policy innovations, but many still remain. With large-scale investment and reform, there is potential for the health and social care system to evolve into a modern service capable of dealing with the needs of an ageing population. However, if these challenges are not met, then it is set to continue struggling with a lack of appropriate facilities, an overstretched staff and a system not entirely appropriate for its patients.

The article considers the challenges involved in measuring the performance of local public service networks through an empirical analysis of Comprehensive Area Assessments (CAAs), a short-lived but pioneering attempt to gauge the effectiveness of local governments, health trusts, police and fire services in England.

Primary data about the implementation and impact of CAAs were gathered using a mixed method approach, including surveys of local public services, inspectorates and residents together with focus groups and semi-structured interviews in 12 case study areas.

CAAs encouraged agencies to strive to achieve better partnership working but did not provide sufficiently robust comparative data to enable managers to benchmark their performance against other areas or identify good practice elsewhere. Policy makers hoped that citizens would use CAAs to hold services to account but the process failed to attract media or public interest.

The logic of a more ‘joined-up’ approach to performance assessment of local partnerships is compelling. But in practice it is difficult to achieve because institutional arrangements at a national level mean that different sectors work within very different budget systems, professional networks and performance frameworks. Assessing the outcomes achieved by local partnerships also presents new challenges for inspection agencies and requires them to use new kinds of evidence.

This is the only attempt to date to evaluate CAAs and adds to an understanding of the challenges of assessing the performance of local public service partnerships. It highlights new questions for researchers and policy makers about the types of evidence needed to measure partnership performance and the extent to which the public may use the results.

Purpose – European studies of alternative food networks have covered primarily rural or periurban initiatives that connect producers and consumers directly. For the most part, those studies overlook nonprofit urban community initiatives. This chapter begins to address the gap by presenting preliminary findings from a study that examines the development of community food initiatives that sell green produce in London.

Design/methodology/approach – The first part of the chapter draws on content analysis of literature produced by 15 initiatives and presents a brief overview. The second part presents case study analysis of the organizational, physical, and social context of two of the initiatives.

Findings – The findings indicate that many urban green produce initiatives have an explicit emphasis on the demand side of the producer–consumer connection. Those that emphasize sustainably produced food and fair trade may have difficulty drawing low-income customers, even if located in areas with high levels of deprivation. Initiatives oriented toward basic food access rather than sustainability are expanding their scope to include more “local” food.

Originality/value – Although this study does not represent urban green produce initiatives throughout England or beyond, it provides some examples of how such initiatives can develop and the extent to which they claim social justice and environmental considerations in their efforts. This study is a step toward empirical examination of nonprofit urban green produce initiatives, and contributes to a broader, more inclusive conceptualization of alternative food networks.

In the United Kingdom under the New Labour government from 1997 to 2010, there was a shift of power away from local towards central government, leading to a situation in which the role of public service organisations could appear to be mainly implementing priorities set by central government and complying with national standards, enforced through the setting of targets and the use of performance management frameworks. The key performance management systems, and the standards within them, became increasingly focused on outcomes, defined as the results that services produce that have an impact on the lives of service users and citizens – the benefits of the service rather than the volume or quality of the outputs (Willis & Bovaird, 2011).