Hostname: page-component-8448b6f56d-tj2md Total loading time: 0 Render date: 2024-04-20T21:28:11.632Z Has data issue: false hasContentIssue false

Complementary logics of target-setting: hierarchist and experimentalist governance in the Scottish National Health Service

Published online by Cambridge University Press:  20 June 2016

Laura Schang*
Department of Management, London School of Economics and Political Science, England, UK
Alec Morton
Department of Management Science, Strathclyde Business School, University of Strathclyde, Scotland, UK
*Correspondence to: Laura Schang, PhD, Department of Health Services Management, Munich School of Management, Ludwig-Maximilians-Universität München, Schackstraße 4, 80539 München, Germany. Email:


Where policy ends are contested and means for change are ambiguous, imposing central targets on local organisations – what we call hierarchist governance – is problematic. The concept of experimentalist governance suggests that target-setting should rather be a learning process between central regulators and local organisations. However, the relationship between experimentalist and hierarchist governance remains unclear. Existing literature suggests that the learning-oriented experimentalist logic is hard to reconcile with a hierarchist logic focussed on accountability for results. We examine whether complementary use of hierarchist and experimentalist ideas is possible. Drawing on experiences from Scotland, we find that experimentalist and hierarchist logics can co-exist in the same performance management system. Each logic served distinct roles with respect to target-setting, implementation and accountability. The emphasis on experimentalism was stronger where ends and means were contested (the case of shifting the balance of care for older people) than where both ends and means seemed obvious initially (the case of health care-associated infections, where target-setting followed a more hierarchist logic). However, governance drifted towards experimentalism when rising rates of community-acquired infections decreased clarity about effective interventions. The nature of policy issues and changes therein over time appear to be important conditions for synergies between governance logics.

© Cambridge University Press 2016 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)


Audit Scotland (2013), NHS Financial Performance 2012/13, Edinburgh: Audit Scotland.Google Scholar
Audit Scotland (2014), Reshaping Care for Older People, Edinburgh: Audit Scotland.Google Scholar
Barbour, J., Morton, A. and Schang, L. (2014), ‘The Scottish NHS: meeting the financial challenge ahead’, Fraser of Allander Economic Commentary, 38: 126146.Google Scholar
Barzelay, M. (1992), Breaking Through Bureaucracy: A New Vision for Managing in Government, Berkeley, CA: University of California Press.Google Scholar
Bevan, G. (2010), ‘Performance measurement of ‘Knights’ and ‘Knaves’: differences in Approaches and Impacts in British Countries after Devolution’, Journal of Comparative Policy Analysis, 12: 3356.Google Scholar
Bevan, G. and Hood, C. (2006), ‘What’s measured is what matters: targets and gaming in the English public health care system’, Public Administration, 84: 517538.CrossRefGoogle Scholar
Bevan, G., Karanikolos, M., Exley, J., Nolte, E., Connolly, S. and Mays, N. (2014), The Four Health Systems of the United Kingdom: How do They Compare?, London: The Health Foundation and The Nuffield Trust.Google Scholar
Blackman, T., Elliott, E., Greene, A., Harrington, B., Hunter, D., Marks, L., McKee, L., Smith, K. and Williams, G. (2009), ‘Tackling health inequalities in post-devolution Britain: do targets matter?’, Public Administration, 87: 762778.Google Scholar
Carter, N. (1989), ‘Performance indicators – backseat driving or hands off control’, Policy and Politics, 17: 131138.CrossRefGoogle Scholar
Commission on the Future Delivery of Public Services (2011), ‘Report on the future delivery of public services by the commission chaired by Dr Campbell Christie’, Cheadle Heath, APS Group Scotland.Google Scholar
Davies, H. (2005), Measuring and Reporting the Quality of Health Care: Issues and Evidence From the International Research Literature, Edinburgh: NHS Quality Improvement Scotland.Google Scholar
Eberlein, B. (2010), ‘Experimentalist Governance in the European Energy Sector’, in C. F. Sabel and J. Zeitlin (eds), Experimentalist Governance in the European Union, Oxford: OUP, 6178.Google Scholar
Ernst, K., Wismar, M., Busse, R. and McKee, M. (2008), ‘Improving the Effectiveness of Health Targets’, in M. Wismar, M. McKee, K. Ernst, D. Srivastava and R. Busse (eds), Health Targets in Europe: Learning from Experience, Copenhagen: World Health Organisation, on behalf of the European Observatory on Health Systems and Policies, 4149.Google Scholar
Farrar, S., Harris, F., Scott, T. and McKee, L. (2004), ‘The Performance Assessment Framework: experiences and perceptions of NHS Scotland’, a report to the Analytical Service Division, Directorate of Performance Management and Finance, Scottish Executive Health Department. Aberdeen: Health Economics Research Unit and Department of Management Studies, University of Aberdeen.Google Scholar
Fierlbeck, K. (2014), ‘The changing contours of experimental governance in European health care’, Social Science & Medicine, 108: 8996.CrossRefGoogle ScholarPubMed
Fischer, M. and Ferlie, E. (2013), ‘Resisting hybridisation between modes of clinical risk management: contradiction, contest, and the production of intractable conflict’, Accounting, Organisations and Society, 38: 3049.CrossRefGoogle Scholar
Fossum, J. E. (2012), ‘Reflections on experimentalist governance’, Regulation & Governance, 6: 394400.CrossRefGoogle Scholar
Freeman, T. (2002), ‘Using performance indicators to improve health care quality in the public sector: a review of the literature’, Health Services Management Research, 15: 126137.CrossRefGoogle ScholarPubMed
Goddard, M., Mannion, R. and Smith, P. (2000), ‘Enhancing performance in health care: a theoretical perspective on agency and the role of information’, Health Economics, 9: 95107.Google Scholar
Greer, S. (2004), Territorial Politics and Health Policy, Manchester: Manchester University Press.Google Scholar
Guest, G., Bunce, A. and Johnson, L. (2006), ‘How many interviews are enough? An experiment with data saturation and variability’, Field Methods, 18: 5982.CrossRefGoogle Scholar
HAI Taskforce (2008), ‘Healthcare Associated Infection Taskforce Delivery Plan April 2008 to March 2011’ [5 April 2014].Google Scholar
Haley, R. W., Culver, D. H., White, J. W., Morgan, W. M., Emori, T. G., Munn, V. P. and Hooton, T. M. (1985), ‘The efficacy of infection surveillance and control programs in preventing nosocomial infections in United-States hospitals’, American Journal of Epidemiology, 121: 182205.CrossRefGoogle Scholar
Hocepied, C. and de Streel, A. (2005), ‘The ambiguities of the European electronic communications regulation’, in E. J. Dommering and N. A. N. M. van Eijk (eds), The Round Table Expert Group on Telecommunications Law, Amsterdam: Amsterdam University Press, 139190.Google Scholar
Hood, C. (2007), ‘Public service management by numbers: why does it vary? Where has it come from? What are the gaps and the puzzles?’, Public Money & Management, 27: 95102.CrossRefGoogle Scholar
Hood, C. and Jackson, M. (1994), ‘Keys for locks in administrative argument’, Administration & Society, 25: 467488.CrossRefGoogle Scholar
Hsieh, H. F. and Shannon, S. E. (2005), ‘Three approaches to qualitative content analysis’, Qualitative Health Research, 15: 12771288.Google Scholar
Jacobs, R., Martin, S., Goddard, M., Gravelle, H. and Smith, P. (2006), ‘Exploring the determinants of NHS performance ratings: lessons for performance assessment systems’, Journal of Health Services Research & Policy, 11: 211217.CrossRefGoogle ScholarPubMed
Joint Improvement Team(JIT) (2014), Annual Report 2013/14, Edinburgh: Joint Improvement Team.Google Scholar
Johnston, L., Lardner, C. and Jepson, R. (2008), Overview of Evidence Relating to Shifting the Balance of Care: A Contribution to the Knowledge Base, Edinburgh: Scottish Government Social Research.Google Scholar
Lawton, K., Mckevitt, D. and Millar, M. (2000), ‘Coping with ambiguity: reconciling external legitimacy and organisational implementation in performance measurement’, Public Money & Management, 20: 1319.Google Scholar
Mays, N. (2006), Use of Targets to Improve Health System Performance: English NHS Experience and Implications for New Zealand, Wellington: New Zealand Treasury.Google Scholar
Mcdermott, A., Hamel, L., Steel, D., Flood, P. and McKee, L. (2015), ‘Hybrid healthcare governance for improvement? Combining top-down and bottom-up approaches to public sector regulation’, Public Administration, 93(2): 324344.Google Scholar
NHS Tayside (2011), LDP Risk Management Plan 2011/12, Dundee: NHS Tayside.Google Scholar
Noonan, K. G., Sabel, C. F. and Simon, W. H. (2009), ‘Legal accountability in the service-based welfare state: lessons from child welfare reform’, Law and Social Inquiry-Journal of the American Bar Foundation, 34: 523568.Google Scholar
Patton, M. (2002), Qualitative Research & Evaluation Methods, Thousand Oaks, CA: Sage.Google Scholar
Pires, R. (2011), ‘Beyond the fear of discretion: flexibility, performance, and accountability in the management of regulatory bureaucracies’, Regulation & Governance, 5: 4369.Google Scholar
Pollitt, C., Harrison, S., Dowswell, G., Jerak-Zuiderent, S. and Bal, R. (2010), ‘Performance regimes in health care: institutions, critical junctures and the logic of escalation in England and the Netherlands’, Evaluation, 16: 1329.CrossRefGoogle Scholar
Power, M. (1999), The Audit Society: Rituals of Verification, Oxford: Oxford University Press.CrossRefGoogle Scholar
Quality and Efficiency Support Team (QuEST) (2014), Annual Report 2013: Reporting on the Quality and Efficiency Support Team, Edinburgh: The Scottish Government.Google Scholar
Rittel, H. W. J. and Webber, M. M. (1973), ‘Dilemmas in a General Theory of Planning’, Policy Sciences, 4: 155169.CrossRefGoogle Scholar
Sabel, C. (2004), ‘Beyond principal-agent governance: experimentalist organisations, learning and accountability’, in E. Engelen and M. Sie Dhian Ho (eds), De staat van de democratie. Democratie voorbij de staat, Amsterdam: Amsterdam University Press, 173196.Google Scholar
Sabel, C. and Zeitlin, J. (2012), ‘Experimentalist governance’, in D. Levi-Faur (ed.), The Oxford Handbook of Governance, Oxford: Oxford University Press, 169183.Google Scholar
Sabel, C. F. and Zeitlin, J. (2008), ‘Learning from difference: the new architecture of experimentalist governance in the EU’, European Law Journal, 14: 271327.CrossRefGoogle Scholar
Scottish Executive (2005), The Unscheduled Care Collaborative Programme, Edinburgh: Scottish Executive.Google Scholar
Scottish Executive Health Department (2002), Performance Assessment Framework, NHS HDL 78, 1 November 2002.Google Scholar
Smith, P. (1995), ‘On the unintended consequences of publishing performance data in the public sector’, International Journal of Public Administration, 18: 277310.CrossRefGoogle Scholar
Smith, P. C. and Busse, R. (2010), ‘Learning from the European experience of using targets to improve population health’, Preventing Chronic Disease, 7(5): A102.Google Scholar
Solberg, L. I., Mosser, G. and Mcdonald, S. (1997), ‘The three faces of performance measurement: improvement, accountability and research’, Joint Commission Journal on Quality Improvement, 23: 135147.Google Scholar
Steel, D. and Cylus, J. (2012), ‘United Kingdom (Scotland): health system review’, Health Systems in Transition, 14: 1150.Google Scholar
The Scottish Government (2009a), Improving Outcomes by Shifting the Balance of Care, Edinburgh: The Scottish Government.Google Scholar
The Scottish Government (2009b), Long Term Conditions Collaborative. Programme 2008-2011, Edinburgh: The Scottish Government.Google Scholar
The Scottish Government (2010), Reshaping Care for Older People. A Programme of Change 2011-2021, Edinburgh: The Scottish Government.Google Scholar
Wismar, M., McKee, M., Ernst, K., Srivastava, D. and Busse, R. (2008), Health Targets in Europe: Learning from Experience, Copenhagen: World Health Organisation, on Behalf of the European Observatory on Health Systems and Policies.Google Scholar