In this feature authors discuss recent research findings that are of interest to readers of Beleid en Maatschappij.

Values like quality of life, efficiency of services, solidarity in finances and privacy of clients are being compromised continuously in daily practices, inspired by opinions and ideology of (groups of) individuals. Yet, systems like healthcare are dominated by technocratic procedures to enforce transparency and efficiency. This functional rationality pushes away the more fundamental debates on values. This doesn’t mean they are not being compromised, but it’s done in a hidden way. It’s the nurse taking decisions on the amount of time available for a patient. Although restricted by procedures nurses compromise differently. The same counts for healthcare executives in their boardrooms. Restricted by system requirements they take decisions differently, inspired by their convictions. It is all ‘hidden ideology’ in institutions, interactions and intuitions. Even the political arena is imprisoned by the self made technocratic way of debating and deciding on important societal issues. Political debates should be about the values behind procedures instead of technocratic in its essence. Critical checks and balances have to be reinstalled (or reanimated) in political decision making in order to do this and meet patients’ or citizens’ needs, instead of maintaining a procedural attitude that drives politics and ideology away from society.

Over the last decades an increasing number of mergers and acquisitions between Dutch healthcare organizations has taken place (up scaling). More recently there is a rise in the numbers of new small-scale healthcare organizations and small-scale care facilities (down scaling in the numbers). The wide variety of scales, each with its pros, cons and (historical) contexts, makes the existence of one optimal scale an illusion. Our research question is: when, and on the basis of which values, is scale of healthcare organizations legitimate? We answer this question by analyzing 650 newspaper articles from fourteen national newspapers. By using theory about legitimacy and values, we argue that five values underlie the public discussion on scale: governance, the human size, quality of care, market power and efficiency. We conclude that achieving legitimate scale involves dealing with those five values, which are not always commensurable and sometimes conflicting. With this article we contribute to the scientific debate about scale and values. We also give recommendations to policy makers and executives that can be used to improve the legitimacy of scale decisions.

There is probably no other sector of the welfare state where the gap between citizen's expectations and government's opportunities is deepening so intensely and has such a complex and politicized reform agenda as the health care sector. Health care is a critical case par excellence to study the relation between efficiency and legitimization of welfare state reform. The leading question of this special issue of Beleid & Maatschappij is: how does the Dutch health care system and the connected public policymaking accommodate the different and often conflicting goals (input), organizing concepts (throughput) and outcomes (output)? With these questions in mind the dominant governance principles of Dutch health care, especially the system of regulated competition, are scrutinized. One of the findings is, that 'second best' solutions are the highest achievable in this field, a notion that reform policies should take into account.

There is probably no other sector of the welfare state where the gap between citizen's expectations and government's opportunities is deepening so intensely and has such a complex and politicized reform agenda as the health care sector. Health care is a critical case par excellence to study the relation between efficiency and legitimization of welfare state reform. The leading question of this special issue of Beleid & Maatschappij is: how does the Dutch health care system and the connected public policymaking accommodate the different and often conflicting goals (input), organizing concepts (throughput) and outcomes (output)? With these questions in mind the dominant governance principles of Dutch health care, especially the system of regulated competition, are scrutinized. One of the findings is, that 'second best' solutions are the highest achievable in this field, a notion that reform policies should take into account.