Reform of the English NHS: Insights from the Programmatic Action Framework

• In Event: Health Policy Elites in a Populist Age: Comparative Perspectives

Abstract

Between the publication of “The NHS Plan” in 2000 and passage of the Health and Social Care Act of 2012, change in the National Health System for England has been virtually continuous (this paper does not discuss the autonomously managed systems of Scotland and Northern Ireland). Each reform has followed on the heels of the last before the consequences of its predecessor could be assessed, let alone formally evaluated. This dynamic poses a puzzle both from the perspective of standard models of policy analysis and that of received visions of British policy making. Reform did not generally emerge from the established policy-making machinery or electoral program of the parties, from the professional civil service, or from high status social groups such as the medical profession. Indeed, the marginalization of these traditionally influential actors was central to many of the reform episodes throughout this period.

This paper mobilizes the analytic tools of the Programmatic Action Framework (Hornung and Bandelow, 2018) in an effort to produce a more coherent analysis of this dynamic. At the heart of the PAF is the premise that competition for authority among policy professionals within the state is an important and understudied explanation both for the ongoing dynamic of policy change and for the content of reforms. Reform proposals, the PAF suggests, are typically structured around pre-existing programs with which are associated “programmatic groups,” defined as an informal coalitions of policy professionals whose social identity in the medium term is significantly informed by their adherence to the program’s content and purpose. For these, gaining authority is the end to which imposing a reform provides the means. Reform is thus explained by an endogenous theory of action, rather than by exogenous problem pressure or electoral competition.

In the English NHS, we identify two such programs: one centered on arms-length regulation through autonomous agencies, and the other on competitive forces acting through the “internal market.” While both were present in the first Blair-era reforms between 2000 and 2003, we propose that they have become increasingly distinct, and that each forms the programmatic core of a competing group of policy professionals. These competing programs can be seen most distinctly in the various attempts to resist or redirect the measures found in the 2012 Health and Social Care Act, which is unique among measures of this era for having genuinely exogenous origins.

We propose that these programmatically-based efforts of resistance can be traced to the action of “programmatic groups” that emerged in the late 2000s. Each of these derives legitimacy by importing ideas from a broader policy domain. Associated with the regulatory option, which seeks to depoliticize health policy-making through delegation to agencies, is the faith in targets and indicators consistent with the heritage of New Public Management. Associated with the internal competition option is the faith in effectiveness gains from consumer choice consistent with the privatization and “marketization” initiatives of the Thatcher and Blair eras. While each can loosely be identified with the “neoliberal” critique of the 20th century welfare state, both their intellectual justifications and the instruments they mobilize are distinct and, we argue, increasingly incompatible. Each program provides the means through which associated actors engage in the competition for legitimate authority over the broader health sector.

We trace the origin and development of the competing programs and identify the key policy-making actors associated with each. A strong hypothesis of the Programmatic Action Framework is that the coalescence of such actors into competing programmatic groups will be encouraged not only by shared ideas but also by shared professional trajectories. The paper provides, among other things, an initial empirical test of this hypothesis in the English case by tracing back the careers of the individuals who presently hold key decision-making positions, and whose action identifies them with one or the other competing groups. We are particularly interested in the subsequent careers of individuals who were involved in the key reform-producing loci of the early 2000s, of which the most important was the strategy unit of the Department of Health whose director, Simon Stevens, is currently chief executive of NHS England. To this end, we combine content analysis of programmatic texts with biographical data and the results of two campaigns of elite interviews carried out ten years apart, one in 2007-2008 and the second beginning in 2018 and currently ongoing.

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Hornung, Johanna and Nils Bandelow. 2018. “The Programmatic Elite in German Health Policy: Collective Action and Sectoral History.” Public Policy and Administration (published on-line 13 September 2018

Authors

• Marc E. Smyrl, Universite de Montpellier

• Anne Laure Beaussier