Introduction

This chapter brings together the literatures on policy-learning and lesson-drawing on the one hand, and intra-crisis learning on the other, in order to examine the UK's response to the COVID-19 pandemic. The policy-learning literature explores issues such as what lessons were learned by whom. The lesson-drawing literature examines the content and process of policy transfer, focusing on the fungibility or transferability of lessons. However, most existing work is based on ‘ordinary’ policymaking rather than ‘extraordinary’ or ‘crisis’ policymaking characterised by elements of threat, urgency and uncertainty such as that during the pandemic.

We critically examine three different ‘real time’ lenses, drawing on three main sources: political (government documents, and Hansard debates); scientific (minutes of advisory groups such as the Scientific Advisory Group for Emergencies, SAGE) and media (national news media). These three sources provide different perspectives on the rapidly evolving government agenda. Political sources provide a record of what was being discussed by policymakers, who often claimed that they were ‘following the science’, as well as debates between the government and opposition, providing an insight into the scientific sources they were making use of in their deliberations. The scientific sources explore the extent to which the advisory bodies were looking at emergent research from their own countries, from the past or from abroad. The news media provide a rapid (daily) commentary on issues, giving a contemporary record of what was happening in other countries and material from the past that could inform learning about the virus. As Wolfe et al (2013) suggest, which issues are on the agenda, which ones are not, when and why, are the central questions that drive agenda-setting in communications and policy studies, and become even more important during a period of extraordinary policymaking. Our study cannot trace the links between policymaking and media reporting, but it can throw light on how the media aims to influence the public and policymaking. In particular, we focus on the lessons that the media suggest the pandemic offers to policymakers.

The chapter focuses in particular on the early stages of the pandemic, especially during January to April 2020 when key decisions were being made about policy in respect of testing, lockdown and border controls – the three elements highlighted by prominent public health advisors such as Edinburgh University's Chair in Global Public Health, Devi Sridhar (see Appendix 2: articles on 15 March and 4 May) as being crucial to pandemic response.

Introduction

It has been claimed that the first half of the 2010–15 Coalition government was taken up with debate on the Health and Social Care Bill 2012 (HSCB), which was introduced by Conservative Health Secretary Andrew Lansley, while the second half was devoted to limiting the damage caused by the Bill and dealing with the effects of growing financial and service pressures in the National Health Service (NHS) (Ham et al, 2015: 1; Powell, 2016). This chapter examines the longer period of the cold climate of a decade of austerity in the English NHS, focusing on two broad moves. First, there was a broad move from the optimism of the NHS's 60th anniversary to the greater pessimism of its 70th anniversary. Second, there was a similar game of two halves based on the argument of Timmins (2018) of the rise and fall of marketisation and privatisation, with the Health and Social Care Act 2013 (HSCA) perhaps being the high-water mark of faith in ‘competition and choice’ as the key drivers of NHS reform, and the period since then seeing efforts to ‘work around’ the Act. However, in addition to the ‘constant’ of austerity, some things stayed the same, such as the continuation of inquiries into failings in the NHS, continuing inaction on social care and ‘policy retreads’ on issues such as prevention and integration.

A tale of two birthdays

This section focuses on the move from the optimism of the NHS's 60th anniversary in 2008 (under the Labour government of 1997–2010) to the greater pessimism of its 70th anniversary in 2018. In 2008, some ‘official’ accounts entered the celebratory birthday spirit, for example, according to then NHS Chief Executive David Nicholson: ‘the NHS is performing extremely well’. He continued that the NHS was on course to achieve the historic 18-week maximum waiting time by the end of 2008, and to meet challenging targets for reducing rates of health-care-associated infection. Mortality rates for cancer and cardiovascular disease had been substantially reduced, while access to GP and other primary care services was quickly improving. In its 60th anniversary year, public confidence in the NHS and patient satisfaction with the quality of NHS care were both at their highest level for years (DH, 2008a: 3).

Introduction

There does not appear to be a dominant approach to conceptualising or measuring change in health systems (Beland and Powell, 2016; Powell 2016), which makes it difficult to differentiate evolution from revolution. In other words, there is no clear dependent variable of change, but rather multiple and sometimes incommensurate criteria that defy attempts to come to neat conclusions.

There are many possible ways to examine these issues (Beland and Powell, 2016; Powell 2016), but this chapter draws on the influential account of Hall (1993) which differentiates between first, second and third order change. It views policymaking as a process that usually involves three central variables: the overarching goals that guide policy in a particular field, the techniques or policy instruments used to attain those goals, and the precise settings of those instruments. Hall regards change in settings as first order change; changes in instruments and settings as second order change; and changes in all three components – instrument settings, the instruments themselves and the goals – as third order or paradigm change. There are, however, a number of problems with this approach. First, it is not clear that first order change is always necessarily less important than second order change. For example, if the level of health spending was doubled or halved, this large first order change may be more important than a second order change in instruments. Second, it does not really capture outcomes, and so cannot explore the impact of ‘change’, which is complicated by issues of time lag and of causality and attribution.

This chapter tracks some of the main policy measures introduced by the Coalition's Health and Social Care Act (HSCA) of 2012 backwards to the Conservative government of 1979, which introduced market mechanisms into the NHS, using the framework of orders of change (Hall, 1993).

Orders of change: the challenge of evaluation in a complex service

This section explores some of the main changes since the Conservative government of 1979 (for details see, for example, Klein 2013a; Timmins, 2012; Powell, 2003, 2015a) in terms of first, second and third orders of change. Table 2.1 sums up the main points, which are developed in more detail below.

This Chapter takes retrospective and prospective perspectives on health reforms in English NHS. Retrospectively, we offer a precis of the preceding chapters, taking stock of the cumulative lessons from the significant body of evidence that has been presented in this book. Moreover, we seek to explain the ‘how and why’ of these reforms, using a specific conceptual model (multiple streams approach (MSA)). Prospectively, we consider the direction of health policy in the English NHS, and the research agenda which might inform this process.

What have we learnt so far?

We have presented 16 chapters of evidence across a diverse range of policy or thematic topics. Some of these (such as commissioning) have been standard topics in previous collections of evidence (Robinson and Le Grand, 1994; Le Grand et al, 1998; Mays et al, 2011) although the more recent emphasis has been upon ‘clinical’ commissioning (Chapter 8). Other topics are either novel to such collections of evidence (for example, equity, staffing and PPI: Chapters 12, 13 and 15) or are specific to the temporal context of the first and second decade of the twenty-first century (for example, fiscal austerity: Chapter 3). To organise the evidence (and to aid the reader), we grouped these chapters into three thematic sections: national health policy, commissioning and service provision, and governance.

National health policy

Over the past 25 years, the NHS has been the subject of a massive ‘natural experiment’ in reorganising, seeking to install the tenets of new public management (NPM). Specifically, this has entailed markets, competition, decentralisation and managerialisation. While the effects of these multiple reforms continue to play out, they have been overlain by the recent reforms since 2010. Archetypes such as the ‘bureaucratic’ NHS have been sedimented by newer ones (such as marketisation) which may distort and reinforce the effects of any single reform (Addicott et al, 2007).

The financial crisis of 2008 precipitated the conditions for fiscal austerity during the Coalition government (2010–15). Charlesworth and colleagues (Chapter 3) discuss the recent period of NHS austerity with reference to different sectors within the NHS, specific elements (such as agency pay), comparisons between the four nations of the UK, and wider international comparisons.