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About this book

Systematically updated throughout, the 6th edition of this leading text takes the story of health policy to the end of the Blair era and into the early years of the Brown premiership. It offers a clear and thorough introduction to the history of the NHS, its funding and priorities, and to the process of policy making.

Table of Contents

Introduction

Abstract
This book provides an introduction to health policy in the United Kingdom covering both the substance of health policy and the process of health policy-making and implementation. Its aim is to offer an introduction to the organisation of the National Health Service (NHS), its history and development and to the way in which policies for NHS services are made and implemented in central government and in NHS bodies. The book also examines the auditing and evaluation of health policy, and considers which groups have power over policy-making. The main concern of what follows, then, is the politics of health care: who decides, who benefits and who controls health services.
Christopher Ham

Chapter 1. The Development of Health Services and Health Policy

Abstract
Health policy in Britain today is a legacy of decisions taken by public and private agencies over many hundreds of years. These decisions have shaped the organisation and financing of health care and the part played by government, voluntary or third sector organisations and private interests. The aim of this chapter is to trace the development of health services and health policy in the period leading up to the establishment of the National Health Service, and in the first 30 years of its existence. As well as providing a context for the rest of the book, the chapter illustrates the dynamics of health policy formulation and raises a number of questions explored in more detail in subsequent chapters.
Christopher Ham

Chapter 2. Health Policy under Thatcher and Major

Abstract
If health policy between 1948 and 1982 was characterised by successive adjustments to the original design of the NHS and a focus on fine tuning its administrative structure, in the following 15 years events took a different turn. The election of the Conservative government under Margaret Thatcher in 1979, coupled with the emergence of major funding pressures, led to the consideration of more radical alternatives. Of particular importance was the introduction of the reforms set out in the White Paper, Working for Patients, published in 1989 (Secretary of State for Health and others, 1989a). These reforms in turn followed from the introduction of general management and the implementation of a range of efficiency initiatives. The aim of this chapter is to trace the development of health policy under Thatcher and Major, and in the process to examine the various influences on policy-making and implementation.
Christopher Ham

Chapter 3. Health Policy under Blair and Brown

Abstract
The election of a Labour government under Tony Blair in 1997 brought to an end 18 years of Conservative government under Margaret Thatcher and John Major and appeared to offer the prospect of a return to quieter times for the NHS. In practice, this was not to be as the Blair government developed its own policies for the reform of the NHS and in the process published proposals which were just as radical as those contained in Working for Patients. These proposals centred on what ministers described as a ‘third way’ of reform, different from both the internal market of the Thatcher government and the application of centralised planning by previous Labour governments. The process of reform continued when Gordon Brown succeeded Tony Blair as Prime Minister in 2007. The aim of this chapter is to analyse this third way under Blair and Brown and to explore its evolution.
Christopher Ham

Chapter 4. Financing Health Services and the Rediscovery of Public Health

Abstract
The aim of this chapter is to describe key issues in the financing of health services and the Wanless reviews of the long-term funding of health care and of public health. The rationale for considering the financing of health services alongside policy on public health derives from the assessment in the Wanless review of the long-term funding of health care that concerted action was needed on public health to ensure the financial sustainability of the NHS. The chapter begins with an analysis of trends in NHS expenditure and an assessment of the sources of funding and its distribution. This leads into a discussion of the Wanless review of the long-term funding of health care and its argument that the NHS spending should increase significantly. Policy on public health since the 1970s is then reviewed including the Wanless review of public health and its impact. The chapter concludes by assessing what has been achieved in the area of public health.
Christopher Ham

Chapter 5. Policy and Priorities in the NHS

Abstract
The aim of this chapter is to describe the policies that successive governments have adopted in seeking to improve different aspects of the NHS. Issues covered in the chapter include access and standards, primary care, acute hospital services, cancer, heart disease and stroke, mental health, learning disabilities, older people, children’s services and maternity care, and health and social care integration. In developing policies for the NHS, ministers have sought to ensure greater consistency in the availability and funding of services in different areas. Sixty years after the establishment of the NHS, there are still wide variations in expenditure on different services between areas, and there is no certainty that government policies will be implemented at a local level. Alongside the challenge of policy implementation, both government and NHS bodies have to determine the priority to be attached to competing claims on resources. The way in which priorities are set is considered in the final section of the chapter in the context of the changing balance between national and local responsibilities. After 1999 the governments of Northern Ireland, Scotland and Wales developed their own policies in relation to a number of the issues covered in this chapter, and the impact of devolution on health policy is discussed further in Chapter 7.
Christopher Ham

Chapter 6. Policy-making in Westminster and Whitehall

Abstract
The chapter begins with a definition of policy. The focus then shifts to the organisation of central government. At the core of the chapter is a description of the role of Parliament, the Prime Minister and Cabinet, ministers, civil servants, and special advisers, and relationships between government departments. This is followed by an analysis of the role of outside interests and pressure groups. The increasing part played by these groups requires that we look beyond the formal institutions of government to the role of policy networks and policy communities. The final part of the chapter assesses whether central government is best described as pluralist or corporatist in character. In exploring these issues, the chapter focuses particularly on the Blair government and the argument that power has become more centralised around the Prime Minister in the period since 1997.
Christopher Ham

Chapter 7. Policy-making in Scotland, Wales and Northern Ireland

Abstract
In this chapter, we describe the organisation, politics and policies of the NHS in Scotland, Wales and Northern Ireland. The chapter begins with a description of differences in organisation and management before devolution. This is followed by an account of the changes that came from devolution, both in NHS structures and in health policy. The challenges of comparing the performance of the NHS in the countries that make up the United Kingdom are then discussed, as is the possibility of regional devolution in England. The chapter draws extensively on policy documents from the Scottish government, the Welsh Assembly government and the Northern Ireland government as well as analyses of the impact of devolution to date (see particularly Greer, 2004; Jervis, 2007).
Christopher Ham

Chapter 8. Policy-making in the Department of Health

Abstract
The aim of this chapter is to examine the policy-making process in the Department of Health (DH). The chapter begins by describing the organisation of the Department and the way in which this has evolved. This leads into a discussion of the health policy community and the influence of different organisations and interests in policy-making. The chapter concludes by reviewing attempts to strengthen the Department’s capacity for policy analysis. Throughout the chapter the influence of different actors is explored in an attempt to illuminate the debate between advocates of the Westminster model, commentators who highlight the increasing power of the core executive and those who advance the governance narrative as alternative ways of seeking to understand the dynamics of policy-making in central government. The experience of the Blair and Brown governments is drawn on to understand the resilience of established institutions and the increasing role played by new actors, such as special advisers.
Christopher Ham

Chapter 9. Implementing Health Policy

Abstract
The aim of this chapter is to examine the implementation of health policy and the micro politics of the NHS. The chapter begins with a description of the organisation of the NHS and the role of NHS bodies such as health authorities and trusts. This leads into a discussion of the relationship between the Department of Health and the NHS and of policy-making within the NHS. The influence of the medical profession is reviewed and the chapter concludes by summarising the various factors relevant to an understanding of health policy implementation. During the lifetime of the NHS, the pendulum has swung back and forth between the Department and the NHS, and current moves to strengthen the grip of the centre over implementation need to be seen in this historical context. It is an open question as to whether the commitment made in the final report of the NHS Next Stage Review to promote further improvement in the performance of the NHS from the bottom up, and led by clinicians, can be realised in practice. While the chapter focuses mainly on the NHS in England, the changing balance of power between the centre and the periphery and the influence of doctors over implementation are also important features of health policy implementation in Northern Ireland, Scotland and Wales.
Christopher Ham

Chapter 10. Auditing and Evaluating Health Policy and the NHS

Abstract
The aim of this chapter is to examine how health policy is audited and evaluated and the way in which the results of audit feed back into policymaking. The chapter begins by tracing the evolution of interest in audit and evaluation, in particular the use of performance indicators and performance ratings. This leads into discussion of the audit explosion and the rise of the regulators, including the National Audit Office, the Audit Commission and the Care Quality Commission. This is followed by a review of changes to the regulation of the medical profession following the Kennedy Report and the Shipman Inquiry. The evaluations carried out by independent organisations and government itself are considered next, before the chapter moves on to assess the performance of the NHS. This is done in relation to health improvement and access to health care. The chapter makes use of evidence from various sources to draw up a balance sheet of the achievements of the NHS in relation to its original objectives.
Christopher Ham

Chapter 11. Power in Health Services

Abstract
Our examination of the auditing and evaluation of health policy and the NHS in Chapter 10 revealed various inequalities in health and health services. Explaining the distribution of benefits within health services requires us to ask: who controls those services and who influences the allocation of resources? A number of macro theoretical approaches have been developed in an attempt to answer these questions. These approaches range from pluralist theories that focus on the role of pressure groups through structuralist approaches that analyse the interests that systematically gain or lose from the organisation of health services to Marxist theories that emphasise class divisions within society.
Christopher Ham

Chapter 12. Looking Back and Looking Ahead

Abstract
In this chapter, we look back at the achievements of the NHS and look ahead to the challenges it faces in the future. The chapter begins by asking, how good is the NHS? A variety of data sources are used including information that compares the performance of the NHS with that of health care systems in other countries. This includes comparing population health outcomes as an indicator of the effectiveness of public health policies. The chapter then moves on to review information about patient and public attitudes. This leads into discussion of options for the future in relation to the organisation and management of services and the funding of health care. In this section, the role of hierarchies, markets and networks is considered, as is the contribution of private health care provision. The future funding of health care is also discussed in a context in which demand seems certain to increase as a result of demographic changes, rising public expectations and medical advances. This presents challenges in relation to priority-setting or rationing and the prospects for the NHS are considered against the backdrop of experience in other health care systems. The chapter concludes by turning to political futures and the policy options that have been advanced by the main political parties for the further reform of the NHS.
Christopher Ham

Chapter 13. Reflections on the Reform of the NHS: 11 Lessons for Policy-makers

Abstract
In this final chapter, I move beyond the analysis of the literature and evidence accumulated by myself and others to offer some personal reflections on the experience of NHS reform in the hope this will be of value to both students of health policy and those involved in policy-making. These reflections are brought together in eleven lessons for health policy-makers. The lessons focus mainly on the process of reform and the role of politicians, civil servants, managers and frontline staff in this process. The chapter is written in a deliberately pithy manner as I plan to return to these lessons at greater length in future work.
Christopher Ham
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