America, he said needs "fresh blood in there." He insisted he was not singling out Biden. But there's no denying the obvious: Biden has held elective office for most of the last half-century. Further, these three structural dimensions come together in an institutional environment shaped by a set of three external contextual factors that further constrain effective management and reform of public hospitals. Kingdon JW. Agendas, Alternatives and Public Policies. 2nd ed. Reading: Addison-Wesley Educational Publishers; 1995. Schwarzenegger was in Sacramento over the weekend for events marking the 20th anniversary of his swearing-in after the historic 2003 California recall campaign. Interviewed on stage by journalist Carla Marinucci, he fielded a question about Republican presidential front-runner Donald Trump’s remark likening political adversaries to “vermin.” Degeling P. Mediating the cultural boundaries between medicine, nursing and management – the central challenge in hospital reform. Health Serv Manage Res. 2001;14:36–48.

The third and last contextual limitation is the unique problem of generalized and localized anxiety , which accompanies the delivery of medical services, and which suffuses decision-making on the part of patients, medical staff, hospital management, and political actors alike. Helpful comments from the journal’s three reviewers and Ruth Thorlby at the Nuffield Trust are greatly appreciated. Funding Saltman RB. The rise of pragmatism in state/market debate. Health Econ Policy Law. 2009;4(4):509–11. It was absolute insanity,” he said of the late 1960s. “People all over the world said to me, ‘Do you think they will recover?’ They did. America eventually climbed out of this hole. And this is why — I’ve seen it personally — America can get out of this hole, also.” Saltman RB. National planning for locally controlled health systems: the Finnish experience. J Health Polit Policy Law. 1988;13:27–51.Hall PA, Taylor RCR. Political science and the three new institutionalisms. Political Studies. 1996;44:936–57. Alvarez A, Duran A. Spain. In: Saltman RB, Duran A, Dubois HFW, editors. Governing Public Hospitals: Recent Strategies and the Movement Toward Institutional Autonomy. Observatory Studies Series 25. Brussels: European Observatory on Health Systems and Policies; 2011. p. 241–60. Business models: Michael Porter argues that health care has the wrong sort of competition [ 33]. Similarly, Clayton Christensen argues that current business and operating models do not fit the nature of the work to be done [ 34]. Data sharing is not applicable to this article as no datasets were generated or analysed during the current study. Authors’ contributions

Saltman RB, Bankauskaite V, Vrangbaek K, editors. Decentralization in Health Care: Strategies and Outcomes. European Observatory on Health Systems and Policies Series. Berkshire: Open University Press/McGraw-Hill Education; 2007.Economics and markets: The problem of poor performance is due to the absence of appropriate financial incentives and the effective operation of market mechanisms such as competition, the threat of bankruptcy and new entrants at the individual and institutional level. Building out a set of useful and implementable responses to this analysis will require a carefully choreographed mix of regulatory and managerial activities, particularly in the current difficult environment for public hospitals generally [ 85]. As Dixon-Woods [ 86] noted earlier of quality programs, there is a danger that too much technical complexity can overwhelm the ability to successfully implement reforms in practice that on paper had appeared to be effective interventions. Dixon-Woods’ antidote of practical wisdom and small politics, the notion of “humble inquiry” at the center of Edgar Schein’s recent work [ 87], and also the strategy at successful medical centers like Virginia Mason whose Chief Executive Officer has called for “authentic relationships built on trust and respect” offers some answers. Footnote 2 There may be little alternative to hard work, the use of data, attention to detail, the deployment of a method and a clear vision set from above [ 88]. Chinitz D, Wismar M, Le Pen C. Governance and (self) regulation in social health insurance systems. In: Saltman RB, Busse R, Figueras J, editors. Social Health Insurance Systems in Western Europe. Berkshire: Open University press/McGraw-Hill Education; 2004. p. 155–70. Dahlgren G. Why public health services? Experiences from profit-driven health care reforms in Sweden. Int J Health Serv. 2014;44:507–24.