Case studies have become, arguably, the predominant method by which much of social science is conducted. With its own long pedigree, health policy (allied to public and social policy) has not been immune to this trend. Yet, case study methods comprise inherent problems for designing and conducting research. They suffer from abuse and misuse, both in theory and in practice, in analysis and in application. In this book, we thus seek to recover and re-invigorate the case study as a valuable technique for researchers and practitioners. We do so in the context of health policy, a field which, sitting astride...

This introduction attempts to set the health policy case study within a general academic context, tracing methodological discussions and debates in relevant disciplinary fields. In particular, the use of case studies within the political sciences, as well as sub-disciplinary factions, has no small bearing. Initially, the case study was popularised by American academics working in specialist sub-fields of political science, especially in public administration (see Stein, 1952). By the 1970s, American political scientists were using the case approach to explore policy decision making. One notable example was Allison’s (1971)Essence of Decision, which used the Cuban missile crisis of October...

The first foray into our case studies covers the period from the inception of the NHS in 1948 until the 1980s. The starting point is, naturally, the creation of the NHS. We do not consider the political or organisational antecedents of the NHS; we take these for granted in our analysis. (For analysis of pre-NHS healthcare, see Powell, 1997, chs 2–3.) However, the end-point is less clear cut. The 1980s reflected the erosion of the post-war welfare state consensus and the emergence of ‘new public management’. A specific date is somewhat arbitrary, though the 1979 general election (bringing Margaret...

This chapter focuses on the creation of the NHS. It examines contributions from different times, perspectives, academic disciplines and approaches that yield some different conclusions. However, the extent to which all these contributions are ‘case studies’ is not fully clear. The definition of a case study is far from certain, and case studies come in all shapes and sizes (Yin, 2009, see also Chapters One and Two). Yin (2009, pp 8–14) sets out three conditions of the case study method: the type of research questions used, the extent of control that an investigator has over actual behavioural events, and...

Researchers probably will not know what their cases are until the research, including the task of writing up the results, is virtually completed. Whatit is a case ofwill coalesce gradually, sometimes catalytically, and the final realization of the case’s nature may be the most important part of the interaction between ideas and evidence. (Ragin, 1992, p 6; italics in original)

In 1962 the Conservative Minister of Health, Enoch Powell, launched what he characterised as an exercise in planning not previously attempted this side of the Iron Curtain. This was the Hospital Plan for England and Wales (Ministry of...

This chapter argues that by exploring case studies from the NHS’s past, we can gain insights into the dynamics of its organisation and policy in the present. To this end, a classic paper examining conflict in the 1970s, Rudolf Klein’s ‘Ideology, class and the National Health Service’, will be explored in terms both of what it tells us about the NHS in the 1970s and also of what it can tell us about the dynamics of health organisation today. First, we will explore Klein’s original case study in depth, bringing out its key messages and themes. We will then explore...

The notion that hospitals can do harm as well as good was not a new one when John Martin publishedHospitals in troublein 1984. Contemporary accounts of conditions in 18th-century hospitals talked of the high mortality and infection rates, the unhygienic conditions and the fact that they frequently ‘killed’ rather than ‘cured’. Later, in 1863, Florence Nightingale, in herNotes on hospitals, declared that ‘it may seem a strange principle to enunciate, as the very first requirement in a hospital, that it should do the sick no harm’ (p iii). She went on to explain that people who were...

Healthcare delivery is inherently complex, and we know that people make mistakes in every health service every day. Mistakes can and do harm patients, and we should be concerned to learn from them in order to ensure safer care in the future. There is a large and rapidly growing literature on errors and their prevention and no shortage of practical guidance, suggesting that there is indeed a desire to learn (see Higgins, Chapter Six). But closer inspection reveals a puzzle. Most research and guidance focuses on the avoidance of errors made by individual clinicians, and on the need to identify...

Patient and public engagement has been an enduring theme in UK health policy and practice for many years. Concern about whether the NHS sufficiently considers patient experiences and views began to emerge in the 1960s, with the first patients’ organisations being established in the early years of the decade (Lupton et al, 1998; Wood, 2000). Yet in the 1970s Klein refers to the patient as the ‘ghost in the machinery’ (Klein, 1996). The introduction of Community Health Councils in 1974 was the first formal attempt at patient engagement. But by the 1980s, concerns about the representation of patients’ interests remained...

The second group of case study chapters deals with the period of the 1980s and 1990s. To a large extent, this period shaped most clearly the configuration of interests, ideas and institutions that we see in the NHS today. Thatcher’s assertion that the NHS was ‘safe in our [that is, the Conservative government’s] hands’ (http://news.bbc.co.uk/1/hi/1888158.stm) reflected a political pragmatism in the 1980s that recognised the saliency of the NHS among the electorate. Nonetheless, Thatcher never quite escaped the claim that the Conservative government had ‘damaged’ the NHS, a charge that David Cameron sought to nullify ahead of the 2010 general...

Managers now appear to be a permanent fixture in the NHS landscape but they are relatively recent recruits into the NHS ‘family’. It is now just over 25 years since they first appeared, having either been transformed from NHS administrators or recruited from outside the service. Nowadays, managers account for 2.7% of the 1.3 million-strong NHS workforce (NHS Confederation, 2008).

The seminal moment for the NHS was the Griffiths Inquiry report (DHSS, 1983), which introduced general management at all levels within the service. This arguably provided a turning-point at which NHS management was transformed. Indeed, without ‘Griffiths’, it is fair...

What is a case study in British health policy? Like other authors in this volume, I pondered this question when invited by the organisers to suggest a case study to discuss at the symposium that led to this book. It was clear to me that there was no simple definition or set of criteria that I could apply. So I reflected on those examples of policy analysis of specific ‘cases’ that had contributed to the development of my own understanding of the complexities of the policy process. Among several texts I considered, Andrew Pettigrew and colleagues’ (1992)Shaping strategic change...

On 19 January 2011 the UK’s Coalition government presented to Parliament the Health and Social Care Bill (DH, 2011a), which contained plans for health service reform so radical in scope that an editorial inThe Lancetclaimed that they would spell ‘the end of the NHS’ (Lancet, 2011). Central to the proposed reforms was the plan to delegate responsibility for commissioning ‘the great majority of NHS services’ to local GP consortia, announced in a White Paper six months prior to the Bill. Both critics and supporters were keen to compare it with the GP fundholding model that flourished between 1991...

The chapter discusses David Hunter’s classic case study of resource allocation after the 1974 NHS reorganisation,Coping with uncertainty: Policy and politics in the National Health Service(Hunter, 1980). Hunter’s research follows the well-established sociological tradition of basing case analysis on the longitudinal study of social processes in one or more formal organisations, in this instance following the activities of key participants in two Scottish health boards over two financial years. A shorter account of the same study appeared in the inaugural issue of the journalSociology of Health & Illness(Hunter, 1979).

Hunter’s book takes us back to a time...

Shaping strategic changeby Andrew Pettigrew, Ewan Ferlie and Lorna McKee was published in 1992, a period when the combined effect of managerialist and marketising reforms was creating high turbulence in the history of the NHS. The Thatcher government’s implementation of the Griffiths managerial reforms in the NHS had been under way for the past eight years (Macfarlane et al, Chapter Nine), and the introduction of quasimarkets heralded by the publication of the 1989 White PaperWorking for patients(Secretary of State for Health, 1989) was starting to take effect (Allen, Chapter Eighteen). Both these reforming movements were born of...

Ostensibly, the final section deals with the latest period of the NHS ‘story’. It takes its title from the 1997 White PaperThe new NHS: Modern, dependable(DH, 1997) and the moniker of the ‘New’ Labour government (1997–2010). Much of the institutional legacy of the health policies introduced by the Labour government is still apparent in the NHS, although the 2010 Coalition government plans offer a radical policy reform.

The five chapters in this section explore the health policy process in terms of major planks of policy (Patient Choice and the internal market) and associated developments (viz, the rise...

This chapter aims to explore the use of a case study approach to a specific policy and how the use of narrative approaches to analysis provides both a way of understanding how policy evolves and also a framework for the analysis of policy. Drawing on the findings of a study that sought to examine the content and operationalisation of the different policies in respect of patient choice in the four countries of the UK, this chapter explores how (often ill-defined) policies can be examined in a case study approach. The chapter is divided into three sections. The first section discusses...

When we consider the aims of ‘health promotion’ it would be difficult to argue against the apparent central premise, which is that it is a stated policy objective to, quite simply, promote health. Its assertions are presented as ‘obvious’, ‘self-evident’, ‘common sense’ or ‘what observer could possibly deny?’. Or perhaps, ‘what observer could possibly object?’. This case study looks at the work of Petr Skrabanek both in a broad context and also with particular reference to his bookThe Death of Humane Medicine(1994). He was highly critical of the aims and objectives of the ‘new’ public health and sought...

The subtitle of this study borrows from Pressman and Wildavsky’s (1973)Implementation, moving Washington to Whitehall, and Oakland to Stoke. The title genuflects to Sir Christopher Meyer’s (2005) memoirsDC confidential– for the separate, longer version of this case study (available from the author) ‘spills the beans’. This study is one of failed policy as well as of failed implementation. But an endemic ‘implementation deficit’ is one reason why the lessons extend beyond both the NHS and (arguably) New Labour.

There is merit in the late (Speaker of the US House of Representatives) Tip O’Neill’s dictum that ‘all politics...

The case described here is a research study in which the authors were participants between 1998 and 2002. The study sought to evaluate the effect of a particular approach to implementing clinical guidelines in primary care in the English NHS. Although an account of the aims, methods and findings of the study must necessarily be given, the aim of this chapter is somewhat broader. We attempt to use this research as a vehicle for understanding something about the policy, organisational and academic context in which it took place, and the manner in which this subsequently developed. The chapter is divided...

Since 1948, the British NHS had been a tax-financed healthcare system that is free at the point of delivery to all patients (Webster, 2002). On the establishment of the NHS in 1948, virtually all hospitals had become state owned and all clinical staff (except for general practitioners [GPs]) had become employees of the state. General practitioners remained independent contractors, with a complex system of payment involving a mixture of capitation and incentive payments for carrying out certain health-screening tasks. The contract for paying GPs was negotiated at national level between the government and GP representatives.

In order to understand why...

Health inequalities have long been totemic of the way in which public policy has addressed complex, ‘wicked’ issues (Graham, 2009; Exworthy and Hunter, 2011). These inequalities reflect the persistent and systemic variations in the social determinants of health, access to care, service provision and health status. Such inequalities are stratified by socio-economic status, education, gender, ethnicity,inter alia. Health inequalities have long been recognised as a ‘policy problem’, dating beyond the inception of the NHS in Britain to the work of, among others, Edwin Chadwick in the 19th century (Lewis, 1952).

At periodic moments in the NHS, inquiries have been...

The chapters in this book provide a range of observations about health policy in the UK. Each contribution presents a ‘policy’ case study but there is enormous variation in the scope, focus and methods of each case study. This chapter examines how practitioners and researchers can learn from these case studies, and indeed how we understand the learning process itself.

The first aim of this chapter is to trace the interconnections between case studies and policy learning in the context of health policy. We pose a series of questions concerning how the learning from case studies can be and is...

In Chapter One, we set out the aims of the book. In this chapter, we review those aims in the light of the intervening chapters, enabling us to draw conclusions about the role of case studies in health policy and the methodological and analytical challenges that they present. At the outset, we sought to explore the conceptualisation, design, practice and impact of case studies in health policy in the UK. In more detail, these aims were: to raise awareness of case study as a technique for scholarly inquiry; to provide an accessible resource; to identify the value of exploring health...