Posts Tagged ‘healthcare’

How involved is the public in changes affecting the devolved NHS?

Ellen Stewart, Angelo Ercia, Scott Greer, and Peter Donnelly compare how the public is involved in major service changes across the UK’s four health systems. They find some clear differences between the four systems’ processes, including the extent of central government oversight and guidance.

Of the issues that have dogged health politics since the creation of the NHS, the closure of hospitals has proved one of the most intractable. What decisionmakers describe as service ‘reconfigurations’ or ‘redesigns’, but many campaigners perceive simply as cuts, highlight central-local faultlines that have been evident in the NHS for 70 years. They outplay any other local issue in causing national political ructions; with local clinicians elected to Westminster, Stormont, and Holyrood on single-issue ‘save our hospital’ campaigns. Health policy debates have long exhibited impatience with such campaigns, and the result is that the bricks and mortar of the NHS is remarkably slow to change.

Recent research has argued that genuine processes of public involvement – how organisations consult and engage local populations in decision-making – may be key to enabling healthcare organisations to make the changes that they argue are clinically, and oftentimes also financially, necessary as health systems manage ageing populations with increasingly complex health needs. However what constitutes ‘meaningful’ (or ‘successful’) involvement processes remains contested.

In our research, we seek to understand how the NHS is involving the public in contentious service change comparatively, drawing on the remarkable natural experiment that is devolved health policy in the UK’s four health systems: England, Northern Ireland, Scotland, and Wales. It’s a task complicated by increasing divergence in both terminology and structures between these evolving systems, but one which provided intriguing insights into their priorities. All four systems have a stated, in most cases statutory, requirement for NHS organisations to involve the public in changes to services. However beyond that there are significant differences.

Public involvement and NHS England

England is both by far the largest of the UK health systems and also the one which has been most subject to radical reorganisation – or what has been described as redisorganisation – and fragmentation in alternating pursuit of competition or collaboration. Change – including closures – seemed most frequent in the English NHS compared to the other health systems. Central government actively seeks to distance itself from local service changes:

If your starting point here is who’s responsible for NHS service change … it doesn’t take place in this building [the Department of Health] anymore. Government, central government is not responsible for service change in the NHS. (Official, England)

As well as the Department of Health’s distance from change plans, NHS England, the behemoth agency-come-policymaking body, also emphasises that it advises but does not take responsibility for local decisions on approach. English policy guidance to local NHS organisations encourages involvement but in very general terms, and based on broad principles, not prescription.

Public involvement and the Northern Irish NHS

Northern Irish policy, by contrast, mandates a somewhat rigid and legalistic approach to public involvement. The focus is very much on pre-defined ‘consultation schemes’ which set out with some precision who will have a say and exactly how, and the approach to engagement was broadly, and with good reason, risk averse.

Say for example there was a service change and I thought I’ll have a focus group… we’re likely to be challenged… If it’s controversial and somebody doesn’t like our decision, which quite often happens, we would be challenged on the process. (NHS manager, Northern Ireland)

Not helped by prolonged periods without a functioning Government, hospital closures are vanishingly rare in the Northern Irish NHS, and even ostensibly minor changes to services provoke significant concern. As in the all the devolved system, Government civil servants play an active role in brokering solutions where controversy develops over proposed changes, but the overwhelming impression from our Northern Irish research was of frustration from both NHS staff trying to improve services and from campaigners, tired of repeated consultations on even very minor changes.

Public involvement and NHS Scotland

In Scotland, Health Boards redesign services with an extensive and prescriptive set of policy guidance which sets out how involvement should proceed. Perceived by some interviewees as excessively thorough, others felt that the detailed guidance gave Boards a degree of protection:

…incredibly nitpicky… it was absolutely exhausting… [But] you’re much more certain to be able to make the change if you’ve gone through the process, you’ve got a fighting chance. (NHS manager, Scotland)

A team of service change specialists within the Scottish Health Council (an NHS agency) provide advice and also assurance on the quality of involvement. Distinctively, current Scottish health policy additionally mandates the approval of the Minister in every service change which is deemed ‘major’. This contrasts sharply with the other three health systems where government politicians are generally shielded from the often febrile politics of hospital changes, and has kept hospital closures firmly on the Scottish political agenda.

Public involvement and the Welsh NHS

Welsh policy ambitions in this area are the most distinctive by some distance. Welsh health policy directs Local Health Boards to focus on continuous engagement with its population, with far less attention to a discrete process of consultation when a change is proposed. This emphasis on building trust, and therefore dialogue, between an organisation and its population seems closest to longstanding accounts of best practice. However this ambition for culture change towards transparent, responsive organisations was less evident in local practice, and had seemed to become embroiled in extant entrenched battles over particular hospitals.

Despite a proliferation of generic best practice guides and the availability of technical advice from organisations which cross national boundaries, processes of public involvement in contentious service changes were overwhelmingly shaped by factors endogenous to the four health systems. This supports other studies which have criticised organisational change management models for neglecting the highly politicised context in which UK healthcare organisations operate: put simply, in the UK, NHS change projects are deeply entrenched in their national politics. Taking an explicitly comparative approach to understanding British health politics – still too often assumed to refer only to English health politics – enriches debates on the relationship between the NHS and the British public. While calls for more comparable quantitative performance data are commonplace, qualitative comparison remains well-placed to handle the complexity of our increasingly divergent NHS(s).


Note: the above draws on the authors’ published work in Health Economics, Policy and Law.

About the Authors

Ellen Stewart is Chancellor’s Fellow in Social Studies of Health & Medicine at the University of Edinburgh.

Angelo Ercia is Research Associate in Health Informatics at the University of Manchester.

Scott Greer is Professor in Health Management and Policy at the University of Michigan.

Peter Donnelly is Professor at the Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto.


All articles posted on this blog give the views of the author(s), and not the position of LSE British Politics and Policy, nor of the London School of Economics and Political Science.

Becoming ‘prevention ninjas’: Rethinking leadership and political will in preventive health

John Boswell, Paul Cairney, and Emily St Denny examine agencies with responsibility for preventive health policy in Australia, New Zealand, and England. They find that building and maintaining legitimacy for such agencies may come at the expense of quick progress or radical action in service of the prevention agenda.

Most public health advocates bemoan the current balance of resources in health spending and attention. They complain that far too much money is wasted on acute services, when people are already sick, rather than on preventive measures, which stop them getting sick in the first place. The problem—in this view—is low political will to do what is necessary: divert resources away from the high-profile services which dominate media attention (e.g. hospital waiting times) and towards difficult policy initiatives that might bring government into conflict with ideological commitments (think, ‘the nanny state’) and powerful industry interests (especially Big Tobacco, Big Alcohol, Big Food).  The solution, in this view, is to offer bold leadership, to coordinate action, and provide a bulwark against political interference.

One particular formula, which advocates have promoted in recent times, has been an executive agency devoted to public health and prevention. Executive agencies are dedicated bodies which enjoy operational autonomy from government departments and (usually) direct access to the executive. They are integrated within government (to help coordinate policymaking functions) but operate sufficiently autonomously to ensure that their objectives are not necessarily affected by changing political context and elected policymakers’ fluctuating attention. The hope among public health advocates is that executive agencies with responsibility for preventive health can provide that missing leadership and political will. They are akin to the caricature of bold warriors, speaking truth to power fearlessly, challenging vested interests, and facing down public opposition for the sake of the greater good.

However, agencification is not a simple solution for the preventive health movement. In fact, the evidence suggests that most executive agencies falter and fail. In our research, we explore the actual effect of attempts to ‘institutionalise’ the prevention agenda in practice. We compare the trajectories of recently established agencies with responsibility for preventive health in Australia, New Zealand, and England.

We find that these agencies struggle to provide the sort of bold advocacy expected of them. On the one hand, being bold and brash brings the risk of generating too much conflict with powerful interests inside and outside government. In the Australian case, for instance, the newly formed agency made powerful enemies with the food and alcohol lobby, and failed to be seen as sufficiently useful to win bipartisan political support. It was little surprise it was de-funded within months of Tony Abbott’s Coalition government taking office.

On the other hand, being too timid also brings risks. The New Zealand agency ended up courting controversy for the opposite reason—seen as too close to industry interests and the concerns of the ruling government. The agency survives but with its reputation as an advocate for preventive health severely diminished (although recent developments, after we conducted our research, suggest this may change).

Instead, it was in the English case that we observed agency officials best managing this tension. They did so by foregrounding the relatively uncontroversial benefits that public health could provide, and backgrounding their more challenging prevention work. One official we spoke to even described himself as a ‘prevention ninja’. He argued that, rather than providing outright leadership for preventive health, it was more profitable to pursue this agenda by stealth, building and leveraging good will with other powerful actors:

So, for example, what would be the point of doing something which upset the NHS, if you want them to deliver some evidence-based interventions which are likely to have an impact on public health? So we’ve got to play canny. It’s about using our relationships.

The implications of these reflections are important. We confirm that creating agencies cannot solve the prevention problem, as the viability of agencies depends on a complex configuration of factors which shift over time. We learn that such agencies may actually serve this agenda better by emphasising technical public health programmes and sneaking prevention in the back door rather than by offering the allegedly ‘bold’ advocacy many envisage. Building and maintaining widespread legitimacy for such agencies, and their work, may come at the expense of quick progress or radical action. However, it ensures that agencies can walk before they try to run.


Note: the above draws on the authors’ published work in Social Science & Medicine.

About the Authors

John Boswell is Associate Professor in Politics within the Department of Politics & International Relations at the University of Southampton.



Paul Cairney is Professor of Politics and Public Policy at the University of Stirling.



Emily St Denny is a Lecturer in Politics at the University of Stirling.




All articles posted on this blog give the views of the author(s), and not the position of LSE British Politics and Policy, nor of the London School of Economics and Political Science. Featured image credit: Pixabay (Public Domain).



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