Critical analysis of policy: The Darzi Review

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Critical analysis of policyThe Darzi Review

• David Evans
• 22 April 2009

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Why is understanding policy important for public
health?

• Health is significantly affected by decisions by
  a range of policy actors
• Policy decisions may be open and transparent
  but often are not!
• The relationship between research evidence and
  policy is complex and often not direct
• Policy is made (and unmade!) at different levels
  local, regional, national, international by
  governments and front line practitioners ...
• Understanding the role of policy is necessary to
  tackle major public health issues
• There are a range of frameworks and concepts
  useful for analysing policy

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Some definitions of policy

• Policy as stated intention
• Policy as a current or past action
• Policy as an organisational practice
• Policy as an indicator of the formal or claimed
  status of a past, present or proposed course of
  action.
• Levin (1997)

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The policy process

• Deciding to decide
• Deciding how to decide
• Issue definition
• Forecasting
• Setting objectives and priorities
• Options analysis
• Policy implementation, monitoring and control
• Evaluation and review
• Policy maintenance, succession and termination
• Hogwood Gunn (1984)

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Macro, micro and meso levels of policy analysis

• Macro
• Globalisation, political economy, changes in the
  world of work, technological change
• Meso
• Structures of power, policy networks,
  institutions, policy transfer
• Micro
• Decision-making and personality, implementation
  and delivery, evaluation and evidence
• Hudson Lowe (2004)

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Example

• Application of Hogwood Gunn (1984) framework to
  Acheson (1998) Independent Inquiry into
  Inequalities in Health

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Deciding to decide

• Long term impact of Black Report (1980)
• High political profile of health inequalities in
  1997 election - Labour critique of previous Tory
  failure to acknowledge existence of inequalities
• Large and increasing research activity/literature
• Persistence and expansion of inequalities in UK
  (and other developed economies)
• Pent up energy in Labour and public health
  movements to finally do something about
  inequalities

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Deciding how to decide

• History in UK policy making of independent
  inquiries
• Political symbolism of independent inquiry
• Credibility of great and good on committee
• Clear parameters of what aspects of policy were
  non-negotiable (within the broad framework of
  the Governments financial strategy)

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Issue definition

• Problems defined by public concerns fairness in
  access to services
• Problems defined by internal party concerns
  two tier Tory internal market
• Problems defined by policy communities evidence
  and effectiveness to tackle inequalities in
  health
• Problems defined by politicians addressing
  inequalities within mixed economy

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Forecasting

• No evidence of modelling different futures
  (unlike later Wanless Reports)
• No consideration of investing in NHS v wider
  public policy interventions
• Blurring of organisational/process indicators v
  health outcomes

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Setting objectives and priorities

• Broad recommendations and priorities rather than
  specific objectives and targets
• Resources required not specified
• Government followed up with specific targets
  but difficult to operationalise
• And dont necessarily map directly to action to
  reduce inequalities

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Options analysis

• No explicit options analysis
• No consultation Green Paper
• Assumption of functionality of new structures to
  deliver
• No comparison of upstream and downstream
  interventions

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Policy implementation, monitoring and control

• Implementation from above but with lots of
  local bottom-up activity
• Legislation and central command new central
  institutions and prescription of local
  organisational forms
• Contradictory central drivers financial balance
  v action on inequalities

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Evaluation and review

• Formal review of progress on policy in 2005
• But very positive slant put on essentially
  negative data
• Policy on inequalities fundamentally compromised
  by new policies from c. 2000 focus on health
  care, individual choice, return to market
• Continuing policy rhetoric masking fundamental
  policy shifts

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Policy maintenance, succession, or termination

• Underlying public policy/public health systems
  problems not resolved
• Wider shift in Labour government thinking towards
  market solutions to public policy problems
• Politically unthinkable to terminate policy on
  inequalities even if not working

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Issues not addressed by Hogwood Gunn (1984)

• Macro level - globalisation, migration, newly
  emergent infectious diseases, global economic
  competition, new technology, speed of IT
• Meso level policy networks, policy transfer,
  role of institutions, structures of power
• Micro level human agency and personality,
  diversity of local contextual factors, street
  level bureaucrats
• (Hudson Lowe, 2004)

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Exercise

• In small groups, analyse the Darzi review using
  aspects of Hudson Lowes (2004) framework
• Macro
• Globalisation, political economy, changes in the
  world of work, technological change
• Meso
• Structures of power, policy networks,
  institutions, policy transfer
• Micro
• Decision-making and personality, implementation
  and delivery, evaluation and evidence

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Macro level

• Globalisation Power and influence of
  international pharmaceutical industry and (mainly
  US) healthcare corporations internationalisation
  of medical research global illegal drugs trade
• Political economy Dominance of neoliberal
  economic ideology and policies growing national
  and international inequalities in health and
  wealth
• Technological change Growth of the internet and
  IT systems more generally increased potential
  for surveillance of population health in the
  home tele-medicine key-hole surgery.

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Meso level

• Structures of power Increased power of global
  corporations (but not explicit in policy)
  notional empowerment of patients/public (but no
  analysis of entrenched power of medical
  profession
• Policy networks Provider networks (special
  advisers, think tanks, corporations medical
  royal colleges, BMA, speciality groups) consumer
  networks (Patients groups, PPI forums/LINks ...)
• Institutions Role of the media, evidence-based
  medicine movement, European Union, World Trade
  Organisation
• Policy transfer Impact of US experience and
  policy on UK health policy

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Micro level

• Decision making and personality Impact of
  specific politicians (Brown, Darzi) and other
  policy makers (Le Grand, Stevens) local
  resistance to private sector providers/polyclinics
  aggregate passive resistance
• Implementation and delivery Gap between policy
  rhetoric and local implementation role of
  street level bureaucrats (local GPs, other
  clinicians, mangers) similarities to previous
  NHS quality initiatives
• Evaluation and evidence Diverse mixture of
  evidence-based policy (e.g. stroke units) and
  evidence-free policy (e.g. National Quality
  Board, Quality Accounts, best practice tariffs,
  legal duty to promote innovation (!)
  possibility (probability?) of unintended
  consequences (e.g. clinician/managerial gaming
  of monitoring

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References

• Acheson, D (1998) Independent Inquiry into
  Inequalities in Health A Report London The
  Stationery Office.
• Hogwood, B Gunn, L (1984) Policy Analysis for
  the Real World Oxford Oxford University Press.
• Hudson, J Lowe, S (2004) Understanding the
  Policy Process Analysing welfare policy and
  practice Bristol The Policy Press.
• Levin, P (1997) Policy and Social Policy Ch. 3
  Making Social Policy Bucks, Open University
  Press.
• Secretary of State for Health (2008) High Quality
  Care For All NHS Next Stage Review Final Report
  Cm. 7432 London The Stationary Office.