Introduction

This book focuses on the nature of health policy making in the United Kingdom. In the first part of the book we examine the importance of rationality in policy making and the ways in which core policy makers try to make their policies rational. We start by looking inside the policy process, considering the factors that shape the rationality of health policy. We start chapter 1 with a discussion of the modern conception of policy and its grounding in the Enlightenment concept of human progress and modernisation. We argue that in modern democracies policy makers need to justify their policies in terms of instrumental rationality: the measurable benefits which their policies have for citizens and the ways in which their policies will create a better future for all citizens. We consider the implications of this for health. We note that, in the United Kingdom, health is a relatively recent area of government interest, and policy making. Premodern governments lacked both the technology to improve health and an overall interest in the health of the population. In the nineteenth and early twentieth century, developments in public health and medicine provided the means for increased state intervention, and the development of social democracies with their commitment to enhancing the welfare of their citizens provided the stimulus and rationale for government involvement in health care, making health a major policy area. The formation of the NHS in 1948 can be seen as part of the ‘Enlightenment’ programme in which government has taken on responsibility for an important aspect of the welfare of its citizens and, as such, can be seen as both rational and progressive. However, we show through a discussion of the changing focus of health policy since 1948 that there have been major changes in focus, and what is considered rational has changed, reflecting the specific circumstances of the time.

In chapter 2 we start to explore how core policy makers – ministers and their advisers – seek to make policy making rational through using knowledge about the nature of health issues and the best way of addressing them. We start with the major paradox of policy making in the UK system, ministers’ knowledge deficit. Ministers are senior and usually skilful politicians but they are not expected to have special interest in or knowledge of the policies for which they are given responsibility. They overcome this deficit through the use of confidential advisers, special political advisers and civil servants. The ways in which these advisers support the making of rational policy and the continual pressure to increase access to knowledge can be seen in and through the development of ministries that support health and related policy making.

In chapter 3 we concentrate on a key aspect of policy making and one which should reflect and facilitate rationality, the allocation of resources – particularly money – to health and related programmes. Money is concrete, objective and measurable and therefore is an ideal medium for thinking about the means/ends relationship that underpins instrumental rationality. However, as we will show, the complexity of predicting the changes in the cost of programmes and changes in prices means that it is impossible to achieve rationality, which would require a review of all past decisions. There is rationality in public expenditure decisions but it is very much in the margins of overall allocations, in the decisions about which policies will receive additional or reduced funding. There are the practical limitations to full rationality – especially the limitations of time, knowledge and resources – and the pressure of external events, and core policy makers deal with these limitations by making decisions which are good enough in the circumstances, although not the best.

In chapter 4 we explore the ways in which core policy makers – Ministers and their civil servants – draw on external expertise through policy communities and networks. We examine the ways in which policy communities provide core policy makers with a cost-effective way of overcoming some of the practical problems of accessing knowledge. By building up trustworthy relationships with a range of individuals and groups with expertise in particular aspects of policy, core policy makers – especially civil servants – can expand the quantity and quality of knowledge which informs decision making. In health policy making, such trusted groups have traditionally included those closely involved in the provision of health care, such as health professionals, health authorities and drug companies. However, other groups also have expertise, for example those representing alternative practitioners or particular groups of health service users. These groups are often not perceived as trustworthy and their knowledge and beliefs may challenge those of the insider core of policy makers. Thus these outsider groups may be perceived as a threat and only involved in the policy process when there is no alternative. We note in chapter 4 that there has been a major change in the ways in which core policy makers interact with other groups. During the early period of the NHS, there was a club culture in which medical groups such as the British Medical Association (BMA) were co-opted into health policy making. As the scale, complexity and cost of health and related care increased so did the range of groups consulted. The BMA lost its privileged insider status as core policy makers moved to a more open system of consultation with an emphasis on involving patients and the public in all aspects of decision making.

In chapter 5 we move on to consider the pressure of events, especially disasters, on health policy making. Rational policy making needs time and resources for the dispassionate analysis of issues and the selection of the best policies to address them. Events such as disasters reduce the scope of rational action. They often create an emotionally charged atmosphere in which there is pressure for immediate action by core policy makers. Ministers can buy time by appointing independent inquiries but only at the cost of acknowledging that routine policy making has failed and the risk that the inquiry will recommend unacceptable policy changes. We examine the increasing importance of disasters in health and social care policy making. We note the ways in which, in the immediate post-war period, the NHS and related services were protected and, while major service failure could result in serious harm to service users and others, this harm tended to remain a private misfortune and did not become a public disaster. However, for a variety of reasons, this protection was reduced, and disasters and associated inquiries have become almost a routine part of policy making.

In the second part of the book we shift the focus of attention from the policy making process and the core policy makers to a broader societal context. This involves a move beyond rationality – i.e. the view that objective knowledge about health problems and their solutions exists independently of policy makers – to a more socially grounded perspective that acknowledges and examines the political and social processes that structure knowledge of health and related problems and their solutions. Indeed, we reconsider several of the cases from Part 1 using this perspective. Since these processes are interconnected, the structure of the second part of the book is to some extent arbitrary and the themes overlap. Thus, when we deal with the processes of claims making in ‘creating’ social problems (chapter 6), we acknowledge that the openness of social democracies facilitates the articulation of competitive claims (chapter 7), that ideologies contribute to the definition or framing of such claims (chapter 8) and that the media provide a major forum for the articulation of claims (chapter 9).

While in chapter 5 we emphasise the way in which an apparently rational bureaucratic formalism can be disrupted and ruptured by disasters and unforeseen events, chapter 6 goes on to peer into the processes by which seemingly obvious concerns for policy makers are made into ‘problems’. We draw upon claims-making and constructionist approaches to policy – to develop an account of how interested parties are involved in bringing certain issues to the attention of policy makers, as well as reasons why certain claims-makers and their claims are more successful than others. Here, notions of power become strongly evident in terms of the mechanisms by which certain interests are able to influence policy-making while other significant interests and social conditions remain ‘unarticulated’. Amidst this tension between competing interests, policy-making comes to be seen more as a disjointed amalgam of conflicting notions.

In chapter 7 we develop a broader understanding of the context of this claims-making and, more particularly, the nature of health policy within a modern democracy. Both the nature of democratic accountability and, moreover, the way this format manifests itself within late-modern environments have implications for how policy makers reach policy decisions and justify these to a diverse audience. The pragmatic policy formats which emerge in this context raise important questions regarding whether the influence of the public in the complex and highly technical business of running healthcare systems is a positive or negative phenomenon. We also draw attention to various ways in which suspicions regarding a democratic deficit have been addressed and the tensions that emerge...