What Might the English NHS Learn About Quality from Tuscany? Moving from Financial and Bureaucratic Incentives Towards ‘Social’ Drivers

Governance systems which are based on assumptions of purposive-rational action have received significant criticism. For example recent quality and performance frameworks of the English NHS have tended towards incentives and sanctions, and have been critiqued in terms of both the logic on which they are run as well as a 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 discussion 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' dominated system. Secondly, it discusses 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 development. Implications – for the English NHS and governance more widely – are then considered. 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 is accordingly outlined