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The Challenge to Change -- Contents -- Acknowledgments -- List of Abbreviations -- Introduction -- 1. Health Care Systems in the United States and the United Kingdom: A Lifetime of Change -- 2. Turbulence in the Two Systems -- 3. Measuring and Rewarding Performance: Imposing Change from above in the United Kingdom -- 4. Regulating the Front Line from Above: The Joint Commission and Hospital Regulation in the United States -- 5. Pushing Back from the Front Line: Staff Responses to Privatization in the National Health Service

There is constant pressure on hospitals to improve health care delivery and increase cost effectiveness. New initiatives are the order of the day in the dramatically different health care systems of the United States and Great Britain. Often, as we know all too well, these efforts are not successful. In The Challenge to Change, Rebecca Kolins Givan analyzes the successes and failures of efforts to improve hospitals and explains what factors make it likely that the implementation of reforms will be rewarded by positive transformation in a particular institution's day-to-day operation. Givan's in-depth qualitative case studies of both top-down initiatives and changes first suggested by staff on the front lines of care point clearly to the importance of all hospital workers in effecting change and even influencing national policy.Givan illuminates the critical role of workers, managers, and unions in enabling or constraining changes in policies and procedures and ensuring their implementation. Givan spotlights an Anglo-American model of hospital care and work organization, even while these countries retain their differences in access and payment. Entrenched professional roles, hierarchical workplace organization, and the sometimes-detached view of policymakers all shape the prospects for change in hospitals. Givan provides important examples of how the dedication and imagination of the people who work in hospitals can make all the difference when it comes to providing quality health care even in a challenging economic environment.

It is a curious feature of the debate about the UK Labour government's modernization agenda that the consequences for trade unions have been almost wholly neglected. Focusing on a case study of UNISON, the public service trade union that is dominant in local government and health, this paper argues that UNISON has emulated key aspects of the modernization agenda, adopting a dual strategy to union renewal. It has attempted to rebuild workplace organization, but has placed strong emphasis on managerial‐led renewal, adopting many components of the target culture. These measures have created tensions within the organization that mirror some of the broader contradictions of the modernization agenda. The paper concludes by considering the implications of these findings for public service union renewal.

AbstractWhen the British National Health Service was founded in 1948, professional employees and support staff, with the exception of family doctors, worked directly for the state. Since the 1980s, private employment in the National Health Service (NHS) has steadily grown. Beginning with the outsourcing of support services, the number of privately-employed workers in the National Health Service has gradually increased. This paper argues that marketization in the health sector has increased dramatically under the New Labour government. As policymakers have moved from ideological to pragmatic justifications for marketization, union opposition has similarly become more pragmatic and less ideological. With unions unable to stop these reforms, they have turned to the practical concerns of their members in partially-privatized workplaces under complex employment arrangements. This article shows that while ideologically opposing marketization, unions and employees have been forced into a more pragmatic position. Research at two privately-funded public hospitals shows that unions in the workplace have used their resources to protect their members, as thwarting the involvement of the private sector is nearly impossible.