The task of defining health policy is difficult, largely because both ‘health’ and ‘policy’ are open to different interpretations.

Health can be interpreted in different ways (Aggleton, 1990; Blaxter, 2004). In a narrow, negative sense it can mean the absence of disease or illness. This conventional biomedical approach interprets health as a state of normality disrupted by illness and disease. However, health can be defined in a positive sense, as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ (WHO, 1946, p 100). The distinction between positive and negative definitions is important for the study of health policy. If one adopts a positive definition, health policy analysis extends beyond health services policy and organisation, incorporating a much wider range of social, economic, environmental and political processes affecting public health and wellbeing.

Policy is also a contested term (Parsons, 1995; Hudson and Lowe, 2004; Cairney, 2012; John, 2012). In broad terms, it refers to a position taken by an organisation or individual in a position of authority. It might refer to a statement, a decision, a document, or a programme of action. A policy is not always the result of positive action, however. It may take the form of inaction or a deliberate attempt to block a decision. The primary focus is usually on public policy: how the authoritative positions of governing institutions are determined and how they are put into practice. However, public policy processes involve non-governmental actors, who can be influential. Therefore, their activities should fall within the scope of public policy analysis.

Central government (or ‘the executive’) comprises government departments and agencies as well as the core institutions – the Treasury, the Cabinet Office and the Prime Minister’s Office. Many of these organisations have an interest in health policy (see Box 3.2). Nonetheless, the best place to begin is with the department with overall responsibility for health and the NHS, the Department of Health.

The Ministry of Health was created in 1919 (Gilbert, 1970; Honigsbaum, 1970). Its principal duty, vested in the Minister of Health, was ‘to take all steps as may be desirable to secure the preparation, effective carrying out and coordination of measures conducive to the health of the people’ (Ministry of Health Act 1919). Prior to the NHS, the Ministry did not have responsibilities for a comprehensive health service. However, it possessed important public health responsibilities, including environmental health, housing, water supply and sanitation, as well as oversight of local government.

After the Second World War, the Ministry of Health acquired responsibility for the NHS, but lost control of important public health responsibilities when local government was ceded to the Ministry of Housing and Local Government in 1951. This negatively affected morale in the Department, and focused the Ministry’s attention on health services, in particular hospital services, to the detriment of public and community health (Webster, 1996). During the post-war period, the Ministry of Health was not a prestigious department. Its senior minister was not guaranteed Cabinet rank (and between 1945 and 1968 was more often outside rather than inside the Cabinet).

By exploring the role of key institutions and organisations and their involvement in various processes (such as agenda setting, consultation, policy advice and implementation), it has been possible to draw some broad conclusions, although a word of caution is perhaps needed. The analysis has been performed at a level of generality, albeit illustrated by particular cases. In any specific circumstance the balance of the institutions and forces described in this book will differ. The policy process is difficult to predict in advance, and one cannot simply ‘read off’ likely outputs or outcomes from a list of policy participants or the characteristics of a policy issue. What has been achieved here is a broad framework of analysis, which may be useful in investigating how specific policies have emerged and developed.

As shown in Chapter Two, party politics is important in setting the parameters and direction of health policy. However, there is considerable continuity between governments, irrespective of the party in power. There is also substantial policy change under governments of the same party. So party ideology does not automatically dictate what will happen in government. In practice, governments are more pragmatic than their rhetoric would suggest. Policy is shaped by party competition and the borrowing of ideas from other parties. Ideological policies may be discarded on grounds of ineffectiveness or impracticality, to be replaced by more pragmatic approaches. There is also a certain amount of path dependency in health, which limits the impact of new ideological policies. Political circumstances, internal party conflict and pressure group lobbying may also dilute parties’ ideologically based policies. But this is not to say that ideology has not had any impact on policy.

Implementation is a crucial part of the policy process (see Chapter One). In health policy, much of the task of implementation falls to the NHS. As this is a large and complex organisation, inhabited by conflicting and powerful interests, there is no guarantee that national policies will be implemented locally (Ham, 2004). This chapter explores policy implementation in the NHS and the activities of central government to ensure that policies are put into practice. When looking at policy implementation in the context of centralisation and decentralisation, one has to be aware of the multiple levers at the disposal of national policy-makers. This chapter explores the most significant of these, structure and organisation; priorities and planning; leadership and management; regulation; financial mechanisms and incentives; and culture and networks.

The NHS was originally constituted as a tripartite service: hospitals, owned and funded by the state, overseen by regional and local boards; state-funded family health services provided by independent contractors (such as GPs and dentists), administered by executive councils; and community and public health services run by local councils. The NHS in England has been reorganised many times (health service reorganisations in other parts of the UK are discussed in Chapter Nine). The original structure was reorganized in 1974. Public health and community health services were incorporated within the main NHS structure (Webster, 1996). The hospital boards were replaced by three tiers of health service management, at regional, area and district level, overseen by new regional and area health authorities. Executive councils were replaced by family practitioner committees (FPCs).

Differences in health policy between the countries of the UK existed before the introduction of devolved governance in the late 1990s (see Levitt and Wall, 1984; Webster, 1996; Stewart, 2004; Woods, 2004). The NHS in Scotland was governed by separate legislation and fell within the responsibilities of the Secretary of State for Scotland and the Scottish Office. Although broadly adopting the policies of the UK government, Scotland had some leeway in how it organised the NHS. In 1974, for example, it established unified health boards responsible for family health services as well as hospital and community health services. Wales, meanwhile, began to enjoy a measure of administrative devolution for the NHS in the late 1960s, extended further in 1974 when responsibility for all health services was delegated to the Secretary of State for Wales (Webster, 1996). Until the early 1970s, Northern Ireland had responsibility for health services under Home Rule arrangements. It had its own Parliament and government. These arrangements were suspended due to civil conflict in the Province (known as ‘the Troubles’). Northern Ireland was from then on subject to direct rule from the UK government. However, a high degree of administrative devolution was allowed in the field of health policy, under the stewardship of the Northern Ireland Office.

Political and cultural differences were also relevant prior to devolution. For example, Scotland is regarded as having powerful medical elites (Greer, 2009). Scotland and Wales both have strong socialist traditions, embedded within their political cultures. Such factors may explain discernible differences in policy implementation on issues where the UK government was not strongly committed or was disinterested (Woods, 2004).

Global influences on UK health policy can be seen as part of a broader process of ‘globalisation’. Although the precise meaning of globalisation is contested (see Lee and Collin, 2005; Koivusalo, 2006), it is often used as a convenient term for the growing interconnectedness of the world, and an increasing likelihood that decisions or events in one place will have a significant impact elsewhere (Giddens, 2002; Held et al, 1999; Labonte and Schrecker, 2004).

Health is affected by various global forces and trends from which individual countries cannot escape. The existence of such threats is not unprecedented, of course, as exemplified by the history of epidemics (Berlinguer, 1999). Rather, it is the combination of globalising forces in modern times that is unique, bringing new pressures for change across multiple policy arenas, including health. These forces are widely acknowledged (see Kickbusch and de Leeuw, 1999; Lee and Collins, 2005; Kickbusch and Seck, 2007), and include:

• climate change, pollution and damage to ecological and agricultural systems;

• population displacement and migration (and health tourism);

• war and terrorism;

• increasing levels of chronic disease related to lifestyle and ageing populations;

• the threat of new and highly resistant strains of infectious disease, and the spread of infectious disease through increased trade and travel;

• concentration of capital and economic power;

• the spread of the Western consumer culture across the world;

• trade liberalisation, privatisation and deregulation;

• the global trade in legal and illegal recreational drugs;

• the movement of health professionals from poorer to richer countries;

• increasing inequalities, both within and between countries.

The media is not easy to define (Torfing, 1999; Devereux, 2007). It is a catch-all term for the many ways in which communication takes place between people. The term ‘mass media’ covers means of communication with large groups of people, with traditional forms of mass media including television, radio and the print media. Much attention has been paid to these forms of media as they involve communication from one entity to many, giving rise to opportunities to manipulate public opinion. Traditional media are now accompanied by new media technologies that enable person-to-person as well as mass communication (such as the internet and mobile phone technology).

The mass media doesn’t just communicate news, views and information; it also has enormous political, cultural and economic significance (McQuail, 2005), conveying values, ideas and meanings. It is important in shaping shared identities and cultural environments (hence film and music are considered part of the mass media). And it has a crucial political dimension, as a channel of debate and as a means of exercising political influence.

The media has experienced substantial changes over the past few decades (Dean, 2013; Richards, 2013), with the key developments as follows:

• Technological changes: these include the rise of the internet, mobile phone technologies and the means of communication linked to these new media (websites, blogs, email, messaging, Twitter and social networking sites). Technological changes have reduced the cost of traditional media and enabled their expansion into other formats (for example, print media and multi-channel TV becoming available through computers and mobile phones).

Over 30 years ago, Ingle and Tether (1981) argued that Parliament had minimal influence over health policy. They argued that Parliament was largely powerless when faced with a majority government, and that the House of Commons did not scrutinise health policy and administration effectively. The ability and commitment of MPs to raise issues of concern to their constituents was acknowledged, but the tools of the trade (debates and questions) were found wanting. Scrutiny by the House of Lords was rated as high quality, although the Chamber lacked ‘clout’ (Ingle and Tether, 1981, p 47). This chapter examines whether or not Ingle and Tether’s findings are still relevant today.

MPs’ interests are shaped by a range of background and personal factors (Richards, 1972). Some MPs have worked in healthcare, including, for example, Dr Richard Taylor, the former independent MP for Wyre Forest (2001–10), who was an NHS consultant. Medically qualified MPs in the 2010–15 Parliament included Dr Sarah Wollaston, who chaired the Health Select Committee (see below), and Dr Dan Poulter, who served as a DH minister. Other MPs have previously worked in the NHS as nurses, dentists or in other health occupations. Some MPs have an interest in health arising from personal or family experience of illness. Examples from the 2010–15 Parliament include Laura Sandys and Paul Maynard, both of whom have epilepsy and have been active in Parliament in raising awareness of the issues facing people with this condition. Others have health policy interests as a result of working with health charities, while some sit on NHS boards as non-executive directors.

Health policy is not a matter for the NHS alone. The implementation of health policies depends heavily on other organisations that provide health and social care services, support people with health problems, and promote health and wellbeing. These include local authorities, the private sector and voluntary organisations. This chapter examines the need to form effective partnerships with these organisations (see Chapter One). It also examines the role of patients and the public in health policy and implementation.

Historically, local government played a major role in the improvement of health and the provision of healthcare and related services (Snape, 2003; Baggott, 2010a). When the NHS was created, local councils ceded their hospital services but retained other health service responsibilities including ambulance services, school health services, home nursing and other community and public health services. Local authorities also kept their role in funding and providing social care. However, the interface between local authority social care and the NHS was, and has remained, problematic (Glendinning et al, 2005; Health Committee, 2012; Wistow, 2013). This led to poor coordination of services for those with multiple needs (including children, elderly people, people with mental illness, those with learning disabilities and people with long-term conditions).

There were regular calls for better working arrangements between local authorities and the NHS. These included recommendations to transfer health services to local government (Committee of Inquiry into the Cost of the National Health Service, 1956; Royal Commission on Local Government in England, 1969a, 1969b). Governments rejected these ideas and opted instead for reorganisation in 1974. Local government health responsibilities were transferred to the NHS, leaving local authorities with responsibility for social services and environmental health.

As noted in Chapter One, parties are important political institutions that can shape policy. However, there is disagreement about the extent of their impact. This chapter explores the role of political parties in health policy and assesses their influence. It focuses mainly on UK-wide political parties and health policy in England. Most health policy matters relating to Scotland, Wales and Northern Ireland are devolved to their national governments. The influence of party politics in these countries is explored in the context of devolution in Chapter Nine.

Health policy is often seen as a party political football. It is a major issue of debate between the political parties. Health issues are often prominent at election time, and have been a source of party political conflict (see Box 2.1). Issues relating to health and health services are a concern to most people, and so politicians must be ready to take a position and make commitments. Furthermore, the NHS is generally popular and is a major employer, both of which heighten political sensitivity. Moreover, health and the NHS are key areas of government responsibility and public expenditure. They are therefore important in judging the competence of governing parties seeking to retain office (and also in assessing the policies of opposition parties seeking office). Health and the NHS invariably appear among the most salient issues of public importance. This level of public interest is expressed and reinforced by media interest in health matters (explored more fully in Chapter Five). Another reason why health has been a key issue in party politics is that it has provided a focus for ideological conflict between the two main political parties.