In recent years the pace of reform in health policy and the NHS has been relentless. But how are policies formed and implemented? This fully updated edition of a bestselling book explores the processes and institutions that make health policy, examining what constitutes health policy, where power lies, and what changes could be made to improve the quality of health policy making. Drawing on original research by the author over many years, and a wide range of secondary sources, the book examines the role of various institutions in the formation and implementation of health policy. Unlike most standard texts, it considers the impact of devolution in the UK and the role of European and international institutions and fills a need for an up-to-date overview of this fast-moving area. It features new case studies to illustrate how policy has evolved and developed in recent years. This new edition has been fully updated to reflect policies under the later years of New Labour and the Coalition government. Although written particularly with the needs of students and tutors in mind, this accessible textbook will also appeal to policy makers and practitioners in the health policy field.
In recent years, political scientists have taken a greater interest in the relationship between government and industry. This article examines the specific relationship between the government and the tobacco industry in a structured fashion, so as to facilitate comparisons with other industries. Three factors which have shaped this relationship are examined: the pressures on government to intervene in the affairs of the industry; the complexity of the machinery of intervention; and the government’s dependence on the industry’s co-operation. Finally it is argued that the tobacco industry is in many respects similar to other industries and that consequently several points made during this article may well have wider significance.
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).
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.
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.
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.
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).
As noted in Chapter One, health policy can be seen as a developing within policy networks, which include various organisations and individuals from outside government. The rationale for such networks is that government lacks the capacity to govern alone. It needs external people and organisations to provide expertise, knowledge, research and ideas about policy. They are also useful as partners in the implementation of policy. They can inform sections of the community and the wider public about policy changes, and can even mobilise their resources to make policies work. External individuals and organisations are also needed as a means of strengthening the legitimacy of a policy. Their support can help convince public opinion and the media of the merits of government policy.
The roles of organisations and individuals are now examined in this chapter, along with the various lobbying tactics they use, and the resources that help them to exert influence over policy.
Over the past century, the medical profession has exerted strong influence over health policy. Its influence increased during the second half of the 20th century, due in part to the ‘concordat’ between the profession and the state on the NHS (Klein, 1995; Salter, 1998). Healthcare was nationalised, and the medical profession given both autonomy to practice and strong influence within the decision-making process. Doctors secured this position due to their political resources, including specialist expertise and knowledge, high social status, excellent political contacts and strong representative institutions. Indeed, with regard to the latter, the doctors’ ‘trade union’, the BMA, gained a reputation as one of the most effective pressure groups in the country, while the prestigious Royal Colleges of Medicine, which represent specialists, could rely on the ‘old boy network’ to gain access to the highest levels of government.
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).
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.