Introduction

Policy-makers seem to find the urge to reorganise healthcare almost irresistible. Doing so, however, as governments across the world have repeatedly found out, is expensive and time-consuming. In the UK, the National Health Service (NHS), after experiencing relative stability between its founding in 1948 and its first substantial reorganisation in 1974, has been subject to substantial changes with increasing frequency. In the 1980s the NHS Management Inquiry (DHSS, 1983) led to changes attempting to make the service better run. In the 1990s, an ‘internal market’ was introduced (HM Government, 1989) that attempted to create a dynamic where a split between purchasers and providers would generate improvements to services. After their election to power in 1997, Labour engaged in an almost hyperactive series of changes to the organisation of the NHS in England (with devolution taking other UK countries down a different path). Such a period of intense policy-making offers us significant opportunities for learning, both in terms of the NHS, and for health policy more generally.

While it is relatively straightforward to try and draw lessons from individual, specific policy changes, trying to disentangle the effects of one change from another, especially because they came with such frequency under Labour, is a more significant challenge. Finding a method of achieving this is a difficult but important task. To try and address these challenges, this chapter adopts an approach based on Pawson's realism, especially in the context of realist review (Pawson et al, 2005; Pawson, 2006, 2013), in trying to extract contextually sensitive programme theories from Labour's reorganisation to learn lessons from the changes between 1997 and 2010 for policy today.

In contrast to more conventional approaches to evaluation and review, Pawson suggests that we need to consider not only evidence about what appears to have worked in specific instances, but also the context within which those changes occurred, the theory that they appear to draw from and the outcomes that resulted as a consequence. The patterns between context, mechanism and outcome can be used to compare evidence of what happened in each case with both policy-makers’ expectations and existing theories to generate learning that we might be able to use to inform future policy.