Although community care has been the professed policy of successive governments over three decades, according to the Prime Minister's own adviser, Sir Roy Griffiths, ‘in few areas can the gap between political rhetoric and policy on the one hand or between policy and reality in the field on the other hand have been so great’. This paper examines the extent and causes of this ‘implementation gap’ in respect of services for people with mental handicaps—a consistent priority group for national policymakers. We examine centre–periphery relations in the health and personal social services in the light of Rhodes' power–dependence framework and his concepts of policy networks and policy communities. The NHS has been described as the archetypal professionalised policy network but we conclude that it is possible to account for implementation failures in community care only partly in terms of the dominance of the medical professions' values and interests and the deficiencies of accountability and control due to clinical autonomy. Such failures are due also to the inherently limited power of the centre. Sub-central units are not merely its meek agents. Moreover, the centre must explicitly structure local environments by itself providing a coherent framework of service and resource policies compatible with the national objectives it is seeking to achieve.

It has never been easy to conduct research into currently sensitive policy issues, but there is now accumulating evidence to indicate that various forms of resistence to scholarly investigation are on the increase. Such a climate handicaps all social policy research, but may have the greatest impact on ethnographic projects. Yet, it is argued, ethnography is increasingly widely recognised among academics as having a particularly valuable contribution to make to the study of the policy process. Unfortunately, many policy practitioners (and occasionally some academic colleagues) perceive ethnographic research as being of questionable validity and low helpfulness. This behoves policy-oriented ethnographers to demonstrate that they do indeed have procedures for assuring validity, even if their style of investigation is never likely to be popular with government.

The core of this paper is a case study of how a District Health Authority (Paddington and North Kensington, now Parkside DHA following a recent merger with Brent DHA) in Inner London responded to a major new health care issue of the 1980s—Aids, but the paper also seeks to locate this case study material within wider debates. What theories are there of organisational change which could be used to illuminate policy and service change in the health care sector? How, indeed, do we best study change in health care organisations? The paper is thus in three parts. In the first section we identify some streams of literature which act as a frame of reference defining our initial research question and discuss implications for methodology. The second section presents the case itself, while the last section discusses some emerging findings.

A changing socio-economic environment and competition have led trade unions to extend their role and become service providers. This paper examines some of the issues of service delivery which arise. Four central implications are discussed: the trade union's need (1) to adapt to the competitive service provider's market, (2) to enlarge its consumer body, (3) to become an employer of workers, and (4) to expand its interests with business establishments and authorities over non-union matters. The paper focuses on the General Federation of Labour in Israel (the Histadrut), and its comprehensive health insurance scheme (Kupat Holim). The scheme is provided to all union members and their families as part of union membership. Nonetheless, alternative service systems seem sufficiently attractive for many union members to consider ‘deserting’ their union. The union depends on its members—consumers—to secure its broad base, universalistic image, source of income and legitimacy. Trying to attract consumers causes the union to bend some of its principles. Ultimately, service provision forces the union to adopt characteristics alien to, and even contradicting, its traditional, militant role as an organiser of labour.