Hybrid healthcare governance for improvement? Combining top-down and bottom-up approaches to public sector regulation

Aoife M. Mcdermott, Lauren M. Hamel, David Steel, Patrick C. Flood, Lorna McKee

Research output: Contribution to journalArticle

17 Citations (Scopus)


Improving healthcare governance is an enduring challenge for policy-makers. We consider two national healthcare regulators adopting novel 'hybrid' regulatory control strategies in pursuit of improvement. Hybrids combine elements usually found separately. Scotland's and Ireland's regulators combine: (1) top-down formal regulatory mechanisms deterring breaches of protocol and enacting penalties where they occur (e.g. standard-setting, monitoring, accountability); and (2) bottom-up capacity building and persuasive encouragement of adherence to guidance by professional self-determination, implementation, and improvement support (e.g. training, stimulating interventions). We identify socio-historical contextual factors constraining and enabling regulatory hybridity, whether and how it can be re-created, and circumstances when the approaches might be delivered separately. Using our findings, we develop a goal-oriented governance framework illustrating distinct, yet complementary, national and local organizational roles: (1) ensuring the adoption and implementation of best practice, (2) enabling and (3) empowering staff to adapt and add to national mandates, and (4) embedding cultures of improvement.

Original languageEnglish
Pages (from-to)324-344
Number of pages21
JournalPublic Administration
Issue number2
Early online date19 Jan 2015
Publication statusPublished - Jun 2015


ASJC Scopus subject areas

  • Public Administration

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