Chris Sirrs, Research Assistant on the ‘Health Systems in History: Ideas, Comparisons, Policies’ project.
“The Governance of Health: Historical Perspectives on Medical, Managerial and Economics Influence on Health Policy-Making” 11-12 July 2017, Liverpool Medical Institution (LMI), Liverpool.
In the highly complex health systems of the early twenty-first century, professional expertise and power is not merely wielded by the organised medical profession. A variety of interests and specialisms influence policymaking, from economists and management consultants, to accountants, administrators and regulators. The increasing intricacy of expert and professional relations in the health sector has created important new power dynamics and sites of political conflict. In relation to ‘the public’ too, and the ways in which patients, health campaigners and other stakeholders exert political influence, these developments prompt renewed focus on the governance of health and the various pressures that shape health policy.
Organised by Professor Sally Sheard’s Wellcome Investigator Award team at the University of Liverpool, this two-day conference brought together a range of academic and non-academic experts to explore the ways these new forms of expertise entered health policy. The conference began with a provocative keynote presentation by Professor Scott Greer (University of Michigan), who analysed the geopolitical dimensions of Brexit and its potential implications for British health policy. Suggesting that political elites will ultimately reassert their authority when the full consequences of Brexit are felt, he highlighted the enormous problems that confront negotiators, for example maintaining systems for the evaluation of medicinal products, and the trade in clinical radioactive isotopes.
The first panel drew upon perspectives from history and political science to examine discourses of health reform. Peder Clark of LSHTM’s ‘Placing the Public’ team presented the latest findings from his PhD research on the history of cardiovascular disease epidemiology. Focusing on the 1976 publication ‘Prevention and Health’, he outlined a major shift in the expert approach to public health in Britain, one that attempted to engage the public more fully in decisions about health. Dr Ewen Speed (University of Essex) exposed the nebulous and opaque dynamics of accountability and responsibility at work in the allocation of power to arm’s length bodies such as NHS England. Professor Martin Powell (University of Birmingham), meanwhile, drew upon a fascinating corpus linguistics methodology to examine discourses around ‘crisis’ in the NHS.
Panel 2 explored the health policymaking process. Dr Michael Lambert, a new recruit to the University of Liverpool’s Governance of Health project, presented findings from his PhD on the issue of ‘problem families’. Maria Teresa Ferazzoli (University of Sheffield) explored the discourse of community mental health care, while Dr Phil Begley (University of Liverpool) analysed how management consultants evolved from being mere ‘arm’s length vendors’ to effective ‘branches of government’, with considerable influence over the NHS. Between 2010 and 2014, spending on management consultants in the NHS doubled!
The evening’s keynote speech was by Frank Dobson, the Labour Secretary of State for Health between 1997 and 1999. In an entertaining and candid presentation, he reminisced about the challenges he faced as Health Secretary, from the licensing of Viagra and the provision of an anthrax vaccine to British troops, to the fallout from the MMR scandal and the establishment of the National Institute for Clinical Excellence (NICE). Dobson’s speech was a stark reminder that even in times of relative plenty (health spending increased under the Labour government), the NHS – and those in charge – have come under pressure. However, the question raised by Martin Powell’s presentation – whether NHS ‘crises’ are merely rhetorical devices (or media hyperbole), or articulations of ‘real’ underlying problems with the health system – remained unanswered.
The second day began with a panel on supranational influences. Dr Chris Sirrs of the LSHTM ‘Health Systems in History’ team presented his research on the history of international health accounting – how experts in international organisations such as the Organisation for Economic Co-operation and Development (OECD) have measured and compared how much countries have spent on health care, and the political implications of these calculations. Janelle Winters, Wellcome Fellow at the University of Edinburgh, explored the first direct health project undertaken by the World Bank in the 1970s: The West African onchocerciasis (river blindness) control project.
The fourth panel explored the growing influence of health economics. Dr Ulrike Thoms (Max Planck Institute, Germany) analysed the emergence of health economics in Germany, a crucial influence that has been neglected by Anglophone scholars. Dr Eleanor Mackillop (University of Liverpool), then told of the blossoming influence of economics in the British government, especially under the leadership of Harold Wilson in the 1960s. Perhaps surprisingly, however, there was no economist working on health in the DHSS until 1967, despite the influential work of special advisers such as Brian Abel-Smith. Angela Stainthorpe (University of Liverpool) concluded the panel with a fascinating – and much needed – discussion on the practicalities of being a health economist, explaining NICE’s technology appraisal process.
The final panel widened the discussion to explore the crucial influence of the public. Dr Jenny Crane, a member of the University of Warwick’s Cultural History of the NHS team, told of the shift in NHS campaigning over the 1980s and 1990s away from left-wing activist groups to individual-oriented campaigns. Dr Ellen Stewart (University of Edinburgh) presented on the controversial topic of hospital closure in the Scottish NHS, raising the intriguing question of whether well-intentioned public activism and narrow political self-interest is actually inhibiting modernisation. Last but not least, Dr Pam Carter (University of Leicester) explored the role of public relations in the English NHS, including under the new Sustainability and Transformation Partnerships (STPs).
The conference as a whole underlined that history can play an important role in shedding light on contemporary health policy problems. The common themes raised by the presentations – issues such as transparency and accountability – showcase how historical case studies provide an invaluable store of empirical experience which policymakers can draw upon. Plans are underway to disseminate this exciting research; updates will be posted on the History Centre website once these plans are finalised.