Health policy and hospital mergers : how the impossible became possible
This study seeks to explain major shifts in health policy. It takes as case studies two governmentally-led hospital mergers in the 1990s - one in London and one in Reykjavik - when national governments, as part of broader administrative reforms, decided to merge teaching hospitals in their capitals. The decision to merge, and the implementation of the decision, followed a long history in both cities, in which the mergers had been repeatedly held up as highly desirable but had always been blocked or abandoned. The merger decisions in the 1990s represent “the impossible becoming possible”. And they stand out as defining moments because of the way they shape the successive course of events in the health care systems. By answering the empirical question why it was possible to merge these hospitals in the 1990s but not in the 1980s, the research aims to contribute to a body of literature that seeks to improve theoretical understanding about how health care systems are shaped by national governments. It carries out two sets of analysis: historical analysis of the main explanatory factors within the health care arenas in both cities; and political analysis of the degree of political authority and will for action of the governments of Britain and Iceland in the 1980s and 1990s. The research concludes that in both cases the merger decisions in the 1990s are best understood as resulting from a confluence of three main factors: 1) weakening cohesion inside the health care arenas; 2) national governments with a long-term hold on power providing an opportunity to consolidate political authority and will through which the wider context of the reform agenda was adopted, 3) the prolonged continuity of executive forces in the governments providing specific political actors with scope for action. In bringing these factors together, ideas which had once united and divided groups of actors in the health care arenas and caused fragmentations in the old order, became glue to the new structure. Theoretical interpretations of the findings suggest that public policies “happen”, as opposed to being made. The merger decisions can be seen more as indicative of past development within the health care systems than as directive themselves. Political interventions, however, changed the balance between groups of actors in the system resulting in strengthening of influence of particular groups of actors, who now possess ever greater control over where, how, when, how much and at what price medical services are provided.