Prospects for progress on health inequalities in England in the post-primary care trust era : professional views on challenges, risks and opportunities

Background - Addressing health inequalities remains a prominent policy objective of the current UK government, but current NHS reforms involve a significant shift in roles and responsibilities. Clinicians are now placed at the heart of healthcare commissioning through which significant inequalities in access, uptake and impact of healthcare services must be addressed. Questions arise as to whether these new arrangements will help or hinder progress on health inequalities. This paper explores the perspectives of experienced healthcare professionals working within the commissioning arena; many of whom are likely to remain key actors in this unfolding scenario. Methods - Semi-structured interviews were conducted with 42 professionals involved with health and social care commissioning at national and local levels. These included representatives from the Department of Health, Primary Care Trusts, Strategic Health Authorities, Local Authorities, and third sector organisations. Results - In general, respondents lamented the lack of progress on health inequalities during the PCT commissioning era, where strong policy had not resulted in measurable improvements. However, there was concern that GP-led commissioning will fare little better, particularly in a time of reduced spending. Specific concerns centred on: reduced commitment to a health inequalities agenda; inadequate skills and loss of expertise; and weakened partnership working and engagement. There were more mixed opinions as to whether GP commissioners would be better able than their predecessors to challenge large provider trusts and shift spend towards prevention and early intervention, and whether GPs’ clinical experience would support commissioning action on inequalities. Though largely pessimistic, respondents highlighted some opportunities, including the potential for greater accountability of healthcare commissioners to the public and more influential needs assessments via emergent Health & Wellbeing Boards. Conclusions - There is doubt about the ability of GP commissioners to take clearer action on health inequalities than PCTs have historically achieved. Key actors expect the contribution from commissioning to address health inequalities to become even more piecemeal in the new arrangements, as it will be dependent upon the interest and agency of particular individuals within the new commissioning groups to engage and influence a wider range of stakeholders.</p

Analysing the present: drawing on the legacy of Vere Foster in public policy debate on futures of schools

This paper sets out a framing analysis for a public policy debate on the future of schools that resonates with practitioners in teaching and teacher education on the island of Ireland, north and south, but also in other countries. This is informed by a democratic impulse to facilitate public policy debates, particularly on the ways schools and higher education institutions are directed and constrained by budget cuts and the shrinking of public funding in this age of austerity and gross inequalities. This is also informed by a need for policy learning about global neoliberal agendas, free-market capitalism and its push towards profit-making schools in systems that are deregulated but experience tighter centralized control, which can result in the domination and control of teachers’ work by politicians, corporate-funded think-tanks, entrepreneurs and business managers. Even though Ireland boasts checks and balances in the form of current structures and education legislation in both jurisdictions, the global financial crisis and the collapse of the ‘Celtic Tiger’ together with the ‘troika’ bail-out and Ireland’s exit from the troika in tandem with the unravelling of the common economic model built up over the last three decades have troubled the constituent social and political settlements with regard to teaching and teacher education. The authors also take inspiration from Vere Foster (1819–1900), an Anglo-Irish gentleman, philanthropist and ‘social worker’ with the poor in post-famine Ireland, as well as a significant social campaigner renowned for his contribution to emigration and education. His ideas, generated at a time of great social upheaval, can be reworked to be appropriate in the Ireland of today to address the neoliberal agenda that has brought the Republic of Ireland economy to the brink of disaster. It is argued that imaginative responses about future possibilities for teaching and teacher education, their form, regulation and accountability are but a few of the terms needed for public policy debate that engages the profession on the type of schooling that would best meet the needs of Irish society now and into the future

The idea of policy design: Intention, process, outcome, meaning and validity

While policy design is a relatively recent term in the social science literature, the concept itself is ancient. The modernist incarnation, from the mid-20th century onwards, is grounded in the applied social sciences: the systematic calculation of problems, values, practices and outcomes. But in many ways, the confidence of the faith in systematic design was not borne out by experience. It became clear that rather than finding expert designers advising authoritative decision-makers and perhaps monitoring the activities of subordinate ‘implementers’, the world of policy was populated by multiple participants in distinct organisational locations, with divergent framings, continuing negotiation on practice, and ambiguity in the understanding of outcomes. There is clearly a tension between the image of policy design and the experience of the activity. The response to this tension in the literature on policy design has largely been aimed at reconciling the experience of practice with the norms of instrumental rationality. It has tended to give little attention to the interpretive significance of ‘design talk’ in the process of governing. This paper argues that ‘policy design’ is an exercise in giving meaning – framing activity in a way that makes practices and outcomes appropriate and valid – and develops a more comprehensive analysis of ‘policy design’ as a concept in use in both policy practice and the analysis of that practice. </jats:p

Stocktake and future agenda

Bridgman and Davis recognised the problem and offered several putative accommodations of their own: one, that AIC was a normative ideal which practitioners could aim for but might never reach, or another, that the ‘policy cycle’ was a simple model which newcomers would find helpful in making sense of the policy process, but in time, they could discard it in the light of their experience. There are many voices in the policy conversation, and both analysts and participants need ways to ascertain which are the most significant ones. It is important to recognise that how the people discuss policy today can reinforce or challenge how they make sense of governing, as well as how governing takes place in the present, and into the future. That is not to say it is wrong, but it is important to be cognisant of its limitations and critically question its taken-for-granted status.No Full Tex

Introduction

The policy process is seen as an exercise in problem-solving in which an issue is identified as ‘a policy problem’, information is gathered, people are consulted, possible approaches are analysed and compared, and advice is provided to those in positions of authority. There are multiple organising models associated with ‘policy’, but two tend to stand out: the dominant AIC and the collective managing of the problematic (CMP). The collection starts by acknowledging that what is to be governed is the current outcome of a process of problematisation – sometimes conscious, sometimes so buried in the taken-for-granted that it seems ‘only sensible’. Scholarly writing tends to formally recognise both accounts, but some give more attention to instrumental action – the selection and pursuit of goals – and some puts more stress on the number and diversity of ‘stakeholders’, the complexity of the interaction, and the difficulty of achieving a mutually satisfactory outcome.No Full Tex

Comparative Analysis of Central Aspects

It is well known that schools and their work are highly dependent on and influenced by the societal values, history and political situation in the specific country where they are located (Ärlestig et al. 2016). School agencies and their role are not as well described in research as school districts and the impact of school communities. One reason for this disparity might be the considerable variation between different countries, with respect to the earlier little-studied aspects of school agencies and their role.</p