A comparative analysis of quality incentives in healthcare systems in england and tuscany: ‘fiduciary reputation’ rather than ‘standards and sanctions’

Governance systems which are based on assumptions of purposive-rational action have received significant criticism. For example the quality and performance frameworks of the English NHS function on the basis of incentives and sanctions, and have been critiqued in terms of both the logic on which they are run as well as the lack of evidence for their success. Yet the limitation of much of these critical appraisals is the failure to propose concrete, empirically-grounded alternatives. Thus as a means of adding to the literature, this paper seeks to perform three functions. Firstly it reviews the theoretical and empirical literature around governance in the English NHS as a basis of understanding the limitations of this ‘standards and sanctions’ system. Secondly, it will set out a theoretically grounded alternative to purposive-rational approaches based on a more normative oriented understanding of human action and the ‘civilising processes’ of moral obligation. Thirdly it will present findings from research into the governance system applied in Tuscany, Italy as evidence of the effectiveness of using the reputation of professionals and departments as a basis of facilitating quality in the absence of sanctions. Implications – for the English NHS and governance more widely – are then discussed.