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

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.