Transparency in Public Policy: Great Britain and the United States

This volume is dedicated to William Plowden to honor his commitment to sharing ideas across nations

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Contents Foreword by Nicholas Deakin

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Acknowledgments

xiii

Notes on the Contributors

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1 Introduction: Transparency in Public Policy Neal D. Finkelstein

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2 The Transparency of Health Policy Decisions Steven H. Woolf

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3 Transparency in Education Policy Neal D. Finkelstein

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4 Decision-making Processes in Environmental Policy Robin L. Juni

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5 Rationing Human Organs for Transplant Jeffrey Prottas

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6 Opaque Markets and Firearm Regulation Jim Leitzel

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7 Emerging Issues in Emergency Medical Rescue Thomas Judge

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8 Power and Influence in the Making of British Budgets Lynda Edwards

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9 Measuring Quality in Health Care Paul G. Shekelle and Martin Roland

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Index

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List of Tables and Figures Tables 2.1 Justification for excluded services in selected health authorities 2.2 Most commonly excluded services in 1996/7 health authority purchasing plans 2.3 Prioritization schemes in selected health authorities 2.4 Top ten priorities mentioned by purchasers (1993/4) 7.1 Attributes of event-driven medical problems 7.2 Attributes of emergency versus urgent care 7.3 Practical and organizational reasons for increased demand

15 17 18 19 121 124 125

Figure 7.1 Total expenditure on health as a percentage of GDP, 1996

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Foreword Comparisons ought to specify . . . which Britain . . . is being compared. They should not assume that what holds good for one type of institution necessarily holds good for others. Nor should they assume that similarity necessarily means amity or that mutual hostility is a sign of dissimilarity. The majority of violent crimes, after all, are committed not against strangers but against close relatives.

Thus Marcus Cunliffe, a British specialist on American history and politics, wrote (quarter of a century ago) on Anglo-American comparisons. The contributors to this volume have not made the mistake against which Cunliffe warns the unwary. Rather, they have each taken a specific policy topic and submitted them to close examination, using as their basis for comparison the issue of the degree of openness practiced by each institution in the policy area they have chosen to explore. Their opportunity to do so in some depth stems from the time they have spent in Britain as Atlantic Fellows: and the interest and variety of the topics they have chosen speaks well for both the program and those selected to take part in it. As it happens, transatlantic comparisons on public policy issues are especially modish at the moment. Some of this is froth: the assumed common agenda of the ‘radical centre’, as represented by Prime Minister Blair and President Clinton is likely to be of no greater long-term significance than the preceding entente between their respective predecessors, Thatcher and Reagan. Once the personalities pass from the scene, much of the substance in those comparisons will evaporate. But the development of a common approach to issues of public management is an altogether different matter. This agenda, which our fellow Europeans are currently inclined to label as ‘Anglo-Saxon’, has a common point of origin in attitudes towards state bureaucracies and a shared agenda in the so-called ‘New Public Management’. Some of the measures introduced in both Washington and London have shared both content and purpose. The notion that, in order ix

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x

Foreword

to justify the continued commitment of public resources, public bureaucracies have to become more responsive to the interests and preferences of those whom they serve has now become firmly rooted. And the introduction of reforms based on this presumption is no longer a matter of political dispute on either side of the Atlantic. A vital part of the package of reforms that address the issue of responsiveness has been the opening up of bureaucracy through making information more freely available, both to taxpayers and to service users. This has become in some respects an easier objective to achieve, with the introduction of new information technology and the resources of worldwide communications systems now readily at the disposal of the individual citizen. Yet cultures change slowly, even under the impact of technical modernization, and one of the fascinating features of the Atlantic Fellows’ explorations has been to show the slow and uneven pace at which the coming of greater transparency has moved – further confirmation of the soundness of Marcus Cunliffe’s insight. Britain now stands at last on the verge of a Freedom of Information Act – lagging in this respect some way behind the United States. It will be fascinating to see what effects this legislation, if enacted, will have on both the culture of public bureaucracies and the attitudes and expectations of the public itself. Will greater exposure of the inner workings of bureaucracy and the consequences of its activities lead to greater pressure for change, for more efficient and effective regulation, for better measurement of outcomes, both comparative and absolute? Or will greater understanding lead citizens to turn their backs on transparency, preferring to put their faith in professionals, allowing them to continue to operate according to their best judgment without vexatious (possibly litigious) scrutiny? Perhaps another generation of Atlantic scholars can be persuaded to revisit the scenes that their predecessors in this volume have explored, and assess the extent of change. Meanwhile, this group of authors brings the freshness of a new perspective to the exploration of issues that are of fundamental importance to all users of public services. The approach may occasionally be a touch eccentric, as when using Oxford college porters as the voice of the oracle – perhaps in honor of President Clinton’s well-known preference for those functionaries over the dons. But that is no more than many distinguished journalists have done, with the traditional taxi-driver as the vox populi. Virginia Woolf once famously refused to write a foreword for a

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Foreword

xi

collection of essays on the grounds that a well-made book should be like a table, able to rest on its own four feet without a prop. These essays stand very solidly by themselves; but if they do require a gentle push to reach the wider audience that they deserve, I am very happy to provide it. University of Birmingham, UK

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N ICHOLAS D EAKIN

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Acknowledgments This book represents the collective efforts of the 1996–7 Atlantic Fellows in Public Policy, a group of American researchers who had the opportunity to examine public policy questions in the United Kingdom during the course of an extended stay. The program was established by the British government in partnership with the private sector in June 1994, to commemorate the fiftieth anniversary of D-Day and the contribution of the United States of America to the liberation of Europe. The program is administered in the United States on behalf of the British government by the Commonwealth Fund, a New York City-based private independent foundation. We gratefully acknowledge the support of the British government and the Commonwealth Fund and thank them for their commitment to international cooperation through educational exchange. The chapters that follow reflect the enormous support and insight that was provided to the Atlantic Fellows for their work by researchers, practitioners, and citizens alike across Britain. Each of the Fellows had an institutional host – often a university – that allowed for daily access to mentors, libraries, and professional alliances that were fundamental to the success of this research undertaking. We are grateful to these institutions, and to the many colleagues we met over the year, who provided guidance and friendship. Similarly, many of the insights we made reflect, in intangible ways, the friendships of neighbors from small villages and cities alike. The Atlantic Fellowship mirrors in design the Harkness Fellowship program which, for decades, sent British researchers to the United States to examine wide-ranging public policy questions. As a result, the Harkness alumni network in Britain provided endless opportunities for professional and personal interaction. We would like to thank the people in the Harkness network who hosted us, shared insights, and engaged us in complex international comparative analysis about specific policy questions. In addition, we wish to thank several Harkness fellows for their thoughtful review of early drafts of chapters in this book. The enormous energy behind the Atlantic Fellowship allowed for important seminars and discussions on the topics that are considered in the following pages. Keith Kirby in New York provided constant xiii

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xiv Acknowledgments

support for this effort. From the Atlantic Fellowship office in London, Sarah Keeton arranged all of the logistics and answered our endless questions as we acclimated to life in Britain. William Plowden, also based in London, was our anchor as he provided unstoppable support for our work and this book by organizing our year, and by providing countless introductions to colleagues and professionals who enabled our thinking to progress. The production of this book has been made possible by encouragement and extraordinary assistance from commissioning editors Sunder Katwala and Alison Howson. Keith Povey provided excellent editorial assistance for which I am terribly grateful. Robin Juni, a friend and colleague, and a contributor to this volume, also played a substantial role in the editorial and production details. Robin’s support for this work, from the first mention of this project, until the last page was printed, cannot be overstated. Finally, on a personal note, I would like to thank my colleagues at the University of Warwick – John Tomlinson, Jim Campbell, and Martin Merson – who provided support throughout the year and encouraged me to complete this effort. My wife, Rebecca, listened to the idea of a collective writing effort while sitting in Beaconsfield overlooking a mature English apple orchard. From that moment until now, she has provided encouragement and support for this work. Oakland, California

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Notes on the Contributors Lynda Edwards is a political analyst who lives in Washington DC. Her work includes the examination of the budget processes in the United States and Britain. As an Atlantic Fellow, she was in residence at Balliol College, Oxford. Neal D. Finkelstein is an education policy researcher, with expertise in school finance and management. He is based at the University of California Office of the President. From 1997 to 1999, he was a Senior Program Officer with the National Academy of Sciences in Washington, DC, and worked on an extensive study of the financing of American primary and secondary education. In Britain, he was based at the Institute of Education, University of Warwick. Thomas Judge is a practicing paramedic, currently serving as Chief Executive Officer for Meridian Mobile Health in Bangor, Maine. He has been involved in emergency medical policy design across the United States and the United Kingdom. He currently serves on the editorial board of the British Medical Journal Pre-hospital Immediate Care Journal. While an Atlantic Fellow, he was based at the Medical Care Research Unit, University of Sheffield. Robin L. Juni is an attorney with the international law firm of Jones, Day, Reavis & Pogue, and formerly with the Environment & Natural Resources Division of the US Department of Justice. She teaches as an adjunct professor at the George Washington University School of Law. Her research was conducted at the Centre for Socio-Legal Studies, Wolfson College, Oxford. Jim Leitzel is a senior lecturer in public policy in the undergraduate college of the University of Chicago. He has written extensively on issues of public policy, including the economic considerations of gun control. As an Atlantic Fellow, he was based in the Department of Economics, University of Essex. Jeffrey Prottas is a research professor and deputy director of the Institute for Health Policy, Heller Graduate School of Social Welxv

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Notes on the Contributors

fare, Brandeis University. He is an expert on health policy issues regarding human organ transplantation. He was based in Britain at the Radcliffe Hospital, Oxford, and Brunel University. Martin Roland is Professor of General Practice at the University of Manchester, and Director of Research and Development at the UK National Primary Care Research and Development Centre. He has conducted research on back pain, referrals from primary to secondary care, the use of time in consultations, and the assessment of quality in primary care. Paul G. Shekelle is a physician and a Research Associate at the West Los Angeles Veterans Affairs Medical Center. He is also a Senior Natural Scientist with the RAND Corporation. As an Atlantic Fellow, he was based at the UK National Primary Care Research and Development Centre, University of Manchester. Steven H. Woolf is a physician and Professor of Family Medicine, Medical College of Virginia, Virginia Commonwealth University. He is a specialist in family practice and preventive medicine with an interest in evidence-based health policy and health services research. He was based at the University of York while in Britain.

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1 Introduction: Transparency in Public Policy Neal D. Finkelstein

This book is a collection of discussions about public policies that are of interest to most citizens: health care, education, gun control, the environment, and the mechanisms by which public money is budgeted. In various ways, the chapters address the question of policy transparency. We use transparency to describe those policies that are easily understood, where information about the policy is available, where accountability is clear, and where citizens know what role they play in the implementation of the policy. The book seeks to describe and analyze aspects of transparency using a comparative approach: each author discusses his or her policy field by contrasting policy structures between Great Britain and the United States. A primary assumption that underlies this discussion is that transparent policies are better than those that are opaque. From the outset, it should be understood that this remains an unproven and significant point. In practical terms, while proxies can illuminate some aspects of transparency, we do not know exactly how to test whether a policy is transparent, and the extent to which the transparency of the policy contributes to the intended outcomes or consequences of the policy. For example, the extent to which citizens are treated professionally, fairly and equitably in health care are all matters related to transparency, and yet we are reluctant to connect transparency to the outcomes of medical practice. Nevertheless, the authors assert in their chapters that polices that have transparent characteristics are preferable to those where they are missing. For instance, as Jeffrey Prottas points out in his chapter in this volume, the criteria that determine who receives a kidney transplant ought to be clear because we are concerned about fairness, 1

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and as a society want to protect ourselves from decisions that are capricious in any way. Many of the conclusions that are made come back to themes of fairness and equity, and impose a high level of expectation on the democratic process. In the chapters that follow, the authors have tried to untangle particular public policies and explain, analyze and critique them with attention to how transparent characteristics of public policies avail themselves. What is known about a policy as the effects are felt by citizens each day, with greater and lesser interest and skill in working within complex public and governmental systems? What has changed over time, as the result of political negotiation, technology, or economic conditions that have made transparency matter? This discussion comes at a time when calls for freedom of information are among the priorities of the British government. To be sure, the traditions of secrecy that have characterized policy development, particularly in Britain, are being reconsidered. With greater demands by the public to gain access to information the government holds, greater concern over public accountability, and new technological mechanisms for accessing information daily becoming available, considerations of the benefits of transparent policies are highly relevant.

Transparency and policy design The following chapters discuss four strategies regarding policy design. Each of the four has implications that affect the extent to which policies are transparent: regulatory structures; market-based mechanisms; standards of professional judgment; and litigation strategies. In both Great Britain and the United States, the combination of these approaches can be seen in most public policies. The balance among these often competing strategies, and changes on the margin that tend to favor one strategy over another, are of particular interest to us in this book. Partly as a result of Margaret Thatcher’s and John Major’s governments, Britain is often characterized as moving increasingly towards market-based strategies in many areas, although new and complex regulatory mechanisms have also been developed. In the United States, it is the courts that rule, time and again, on the legality and validity of statutes that have been put in place by elected officials. Each of the four strategies, and their interactions, have implications for policy transparency. Regulations, in the sense that they codify law, are necessary but

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not sufficient conditions for transparent policies. To be sure, regulatory structures dictate process and set safeguards, but they may or may not allow the citizenry to understand, much less observe, the ways policies operate. For example, as described in Chapter 3, schools in Britain are inspected within a strict regulatory structure, and the frequency of school inspection is a decision that is made at the very highest levels of government. Further, the terms of the inspection and what the inspectors will do is made available to schools and their governing boards. These components are transparent. And yet the actual inspection is a fairly closed process, whereby inspectors evaluate the schools using somewhat subjective standards. Outsiders are seldom admitted to the actual inspection of a school, and the tabulation of findings by inspectors is done in near secrecy. Another example comes from the discussion of public budgeting. Lynda Edwards explains that even though regulations guide the timing of decisions on the national budget, the decisions themselves are made in complete isolation of public scrutiny. The conclusion from these examples is that regulatory structures explain some, but not necessarily all, of the subtlety that surrounds policy implementation; moreover, the extent to which regulations are well understood by the public varies enormously. In both Great Britain and the United States there is an ongoing, often ideological, debate around the use of markets as an instrument in policy design. In health care, education, public housing, public utilities, and transportation policy, we can find countless examples of policy designs that depend on some form of competition to improve efficiencies in the ways in which public money is spent. Many of the policy strategies that utilize markets have been encouraged in recent years by ‘transatlantic borrowing’ of what have been advertised as best-practice solutions to extremely complicated social problems; specifically in health care, education, and welfareto-work programs, market-based practices have been included in policy structures seeking to enhance productivity and efficiency. The benefits, supporters explain, can be felt by the consumer, who can exercise personal choices. In several instances in this volume, authors point out the complicated relationship between market-based principles and transparency. The most natural connection has to do with access to information, and the interpretation of that information by consumers. One aspect of inefficient markets is the way in which

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Introduction: Transparency in Public Policy

information is unavailable or misleading to the consumer. As a result, governments in both countries have sought to help consumers by providing useful and timely information. Transparent policy depends on information being accessible, and similarly available to all requesters. However, we know that access to information is highly variable. Certain suppliers and consumers of information may be more able to provide and interpret information than others, and the subsequent choices made with that information may depend on idiosyncratic tastes. In Great Britain, for example, an extensive network of ‘charters’ forms the basis of a relationship between producers and consumers. A charter exists to explain what public expectations ought to be for railway service, for telecommunications service, for health care, and for other public services. Indicators of quality are made available; posters hang on railway station walls, leaflets litter seats on London buses, and brochures fill public offices with information about the performance of public agencies. Do these information mechanisms make policy transparent? Of course, the answer is ‘yes and no’. As Paul Shekelle and Martin Roland explain in their chapter on measuring quality in health care, the indicators that are being measured matter. Indeed, indicators are potentially highly misleading, because the measurement of particular indicators may be at odds with best practice. Information and markets play a central role in the discussion presented by Jim Leitzel concerning the control of firearms. In his chapter, Leitzel explains the dilemmas of establishing public policy regarding the black market for guns, when information in the public domain is deliberately sheltered. Transparency, an enviable characteristic of public policy, is made particularly difficult in this area as proponents of personal freedom are at work against the regulation of firearms, using valid arguments about the connection between crime and the black, unregulated markets. In all policy design, there is an almost inevitable dependence on professional judgment. Where regulations end, individuals make professional decisions to carry out the responsibilities of their work. These judgments are generally well-intentioned, and there should be no reason to believe otherwise. To be sure, discussion about the investment in training of workers is highly relevant; a professional can only make decisions within his or her expertise and the development of that expertise is the responsibility of employers and employees alike. The examples are plentiful. Airline pilots, physicians, school teachers, police officers, to name just a few, ultimately

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rely on their professional training to carry out their work. What they do and how they do it, while guided by professional norms and legal regulations, is a matter of judgment. These professional judgments are typically not transparent. We simply do not always know, as a community or as individuals, about the judgments that are being made on our behalf. It is a matter of faith, to a large degree, that the professionals we empower do work that is of a high quality. Steven Woolf, in his discussion of the National Health Service, draws us into a debate about the extent to which physicians ought to be able to make decisions based on professional medical judgments, and the extent to which those decisions ought to be mediated by concerns over cost. Woolf asks us to consider who is best situated to make decisions about the well-being of individual patients, and, by implication, all patients, in complicated judgments about the rationing of medical services consistent with the objectives of increased transparency. Even more contentious, how many of these decisions ought to be disclosed to the patient where emotional considerations take the place of rationality during times of ill-health? Thomas Judge provides a history of medical rescue in his chapter. Again, it is the decisions made by the trained paramedic at an accident scene that we depend upon for saving lives. Judge argues that these professionals’ judgments are being constrained within a system that has evolved over time and now must systematically be improved. In a world where the public expects new technology to play an increasingly important role in all services, Judge explains how organizational impediments have restricted the best use of technology by medical professionals. Finally, policy design does not depend upon litigation as a feature, but the public depends on litigation as a way of protecting rights that can be, and sometimes are, violated during the enforcement of public policies. Litigation is a mechanism that for the most part improves transparency surrounding public issues, but litigation has both real and implied costs. Robin Juni takes us through a discussion of environmental policy in Great Britain and the United States, and explains that environmental consultation processes are a component of transparency in both countries. That said, she explains that the threat of litigation influences the mechanisms by which decisions are made. Consensus-based approaches to decisions about limiting damages to the environment, particularly between industrial polluters and regulating agencies, have appeared in both countries.

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But because the stakeholders are backed by litigative tools, there are incentives to negotiate outcomes before taking the matter to the courts. Litigation has enormous costs; the benefits of more transparent environmental policies and decisions are therefore mediated by these costs. This example illustrates the dilemmas of engaging the public explicitly in policy decisions, even though some individuals may be directly, and arguably, entitled to such involvement.

Examining public policy: is it transparent? Transparency is a characteristic of those policies that are easily understood, where information about the policy is available, where accountability is clear, and where citizens know what role they play in policy implementation. As indicated earlier, the authors in this volume assert that these are characteristics that serve citizens well. But with such broad objectives, how will we know whether public policies are transparent, or how components that are transparent are being shrouded by more powerful design features? There are inherent difficulties in applying a consistent framework to these questions. Perhaps the most complicating feature is the context within which each policy exists. The context of gun control policy is so different than that of environmental decision-making; and the context of health care is different again from that of education. For this reason, the researchers in this volume have taken a fairly broad view of their respective policy areas and considered transparency alongside greater policy objectives and system constraints. Consistent themes are emphasized to highlight the extent to which policies are transparent. In several of the chapters that follow, there is a discussion of rationing. Rationing is an almost forbidden word for many government officials, but illustrates important policy complexities. Rationing of any kind forces difficult decisions. Not only are rationing decisions made within education, and within health care, but the public system in total rations resources: education against health care, for example. Of course, rationing is about investigating and making trade-offs; there are winners and losers in any allocation. Identifying the criteria by which these trade-offs were made is one mechanism through which we can examine transparency. Who makes these decisions is important. There is no particular governmental body or structure that is necessarily predisposed to make better or worse decisions. Rather, we are interested in the

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extent to which we can identify by whom decisions are made. In several of the chapters that follow, changes in power and jurisdiction are discussed. To what extent have these changes made the policy-making process more or less transparent? Are citizens involved now where they had not been before or, alternatively, has a series of changes excluded local decision-making in favor of more centralized control? Again, the effects are difficult to tease apart, but the policy implications are significant. For example, even though education policy in Britain has been designed around a system of individual choice, the system has undergone a strengthening of centralized control. This seemingly paradoxical arrangement is in fact fairly straightforward: allow individual discretion within a highly proscribed set of conditions set by central government. The point is that changes in the location of decisions about public issues can shed light on matters of transparency. It is not that decisions made centrally are more or less transparent than those made locally. Rather, the changes in policy illustrate where power has been gained, and where it has been lost; these changes are often consistent with changes in who makes important decisions. Public accountability is related to this point. The ongoing interest in understanding how government is accountable to the citizens it serves can be examined from two perspectives. First, is it clear where the accountability for decisions resides? Is it the doctor, or the local health authority, or the National Health Service that is ultimately responsible for good and bad decisions? Second, have accountability mechanisms shifted in ways that citizens find more or less opaque? Again, changes in power and jurisdiction can provide insight into increasing or decreasing access to information regarding these issues.

Are transparent policies optimal policies? We would like to understand the extent to which policy outcomes are improved if the citizenry understands and participates in the system of governance. As indicated at the beginning of this chapter, this remains an important but elusive goal. It is simply not possible to untangle the relationship between transparent policy and lower crime rates, increased reading and mathematics aptitude, or improved health outcomes. But there are proxies that ought to be considered as a set of alternatives. There is a lot to be said for healthy debate about public services and about the performance of governmental agencies. Beyond the

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Introduction: Transparency in Public Policy

debate, however, there is a role for strong analytical work to support our decisions in the future. While political considerations remain central, the role of analysis is essential to appropriate policy design. Analytical work to support better governmental decisions cannot proceed without data of the highest integrity. Trustworthy policy analysis cannot be conducted with skewed information. Transparent policies must consider the collection, storage, and availability of information, for research and other purposes. Many of the chapters that follow make this point within the discussion of specific policy areas: we must collect information carefully, and do so without adding bias to the provision of public services. Voting behavior is another proxy worth considering. In both Britain and the United States, national leadership is flourishing under unprecedented approval ratings. At the same time, voter turnout in local elections continues to fall. The connection between voting behavior and participation in the system of governance is fundamental. At the same time, transparent policy need not depend on voter participation. But as a proxy for understanding the involvement of citizens in policy, voting behavior is one important practice to observe.

Conclusion The chapters that follow reflect a particular type of investigation and comparison. Researchers with significant expertise in US policy made extended visits to Great Britain researching policy and observing practice. For example, the medical researchers shadowed doctors, the education researcher shadowed teachers, and the environmental lawyer shadowed environmentalists; and we all shadowed government officials. The nature of the research allowed for detailed investigations of subtle policy components. These observations, coupled with analytical work, are the basis for the discussions that follow. International comparisons allow a particular type of lens to be applied, one that examines simultaneously the policy area and the overarching political and economic systems. The strengths aside, we must be cautious about drawing conclusions about policy design, and in particular in our ability to exchange policy designs across countries, from this type of comparative work. As the chapters that follow clearly illustrate, history, culture, and political infrastructure cannot be replicated between countries, much less simulated.

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It is not to say for a moment that there are not insights to be gained from exploring, and comparing, policy systems between countries. Much of what this group of researchers found while conducting their comparative work reinforced the power of the most fundamental forces that shape policy: history, political culture, competing stakeholder demands, and the complicated dynamics of organizations. Continued exploration of these forces enhances our understanding of how governmental systems operate, and how they might be improved. This book attempts to contribute to that understanding.

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The Transparency of Health Policy Decisions

2 The Transparency of Health Policy Decisions Steven H. Woolf

To what extent are decisions about British health policy transparent? Do members of the public, including patients, have access to information to understand what choices are made and the underlying rationale? Recognizing that there are other aspects of health care delivery and public health programs in which transparency is also important, this chapter examines the most important decision area in British health care, the allocation of resources and health care services. In the cash-limited health care delivery system of the National Health Service (NHS), the process by which government officials and health care providers determine which services to provide, and which to ration, is of critical public concern. Like other aspects of British public policy, health care does not have a strong tradition of transparency. Historically, the reluctance of government to shed light on the process has been a subject of derision: Rationing in Great Britain has been implicit . . . It is a silent conspiracy between a dense, obscurating bureaucracy, intentionally avoiding written policy for macroallocation (rationing), and a publicly unaccountable medical profession privately managing microallocation so as to conceal life and death decisions from patients. (Cramshaw, 1990) In recent years, however, the sun has begun to shine on health care in Britain and an interest in improving transparency and public accountability has permeated the NHS and medical community (Smith, 1991). Although some question whether transparency is necessarily a good worth pursuing (see below), most agree that public 10

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policy and accountability would be improved by greater clarity. Transparency, like other aspects of current health policy in Britain, cannot be discussed without noting the recent reforms to the NHS over the past decade. These reforms, launched in 1990 under Working for Patients, (Department of Health, 1989) have dramatically reshaped the organizational structure of the service and have given new, unfamiliar roles to managers and providers. The most important changes include the devolution of decision-making authority from central government to local health authorities (including the removal of the middle tier of NHS regional management) and the creation of an internal market built around the ‘purchaser–provider split’ (Levitt et al., 1995). NHS trusts and clinicians, previously employees of the NHS, are now provider–contractors who must compete with each other to win contracts with local purchasers (health authorities and fundholding general practitioners). The reorganization of the NHS followed the idealogical agenda of the Conservative party, which launched the reforms to reduce the size of government and to encourage privatization of previously nationalized industries. The reforms hoped, under this competitive arrangement, to offer incentives to health care providers to maximize quality and cost-effectiveness, but whether this strategy will succeed remains to be seen. Disaffection with the emerging ‘twotiered’ system, in which patients in certain settings appear to enjoy different levels of care, and escalating financial crises threatening the viability of hospitals, have prompted the recently elected Labour government, which came to power in 1997, to introduce initiatives to scale back the internal market scheme. The impact of the reforms, and the historical context of what preceded them, must be kept in mind in the discussion that follows. For example, it is noted below that the allocation of resources by health authorities is meant to be based on the health needs of the local population. This was not the case before the reforms, when purchasing decisions were driven by provider demands, (that is, the services local doctors considered necessary). Indeed, the reforms were largely undertaken because the older paradigm gave providers few incentives to limit utilization. As we turn now to examine the transparency of health care policy in Britain, it is useful to view the process at three levels: (i) decisions made at the national level about funding for the NHS, restricted services, and waiting lists for elective procedures; (ii) decisions made by local health authorities, trusts, and practices regarding the health

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The Transparency of Health Policy Decisions

care services they will provide their catchment area; and (iii) decisions made by individual clinicians and patients regarding available testing and treatment options.

Decisions made by central government A major factor affecting the health care services patients receive in the UK is the amount of money spent on the NHS. Britain spends 6–7 per cent of its gross national product (GNP) on health care, about half the proportion spent by the United States, with obvious implications for the range of services and extent of rationing seen by the public (Ham, 1991). Although the amount allocated is transparent – the NHS budget and how it ranks against other spending priorities is laid out each autumn in the Cabinet’s public expenditure review (Chancellor of the Exchequer, 1995) – the process by which the figure is determined is not available to the public. The committee hearings at which decisions are made are not broadcast (as they might be on the C-SPAN television network in the United States), or reported in the press. Departmental documents outlining the rationale for budgetary requests are neither made available to the public (for example, through a ‘Freedom of Information’ equivalent), or sought with much fervor by the media. Even if the public had insight into the process, it would not find it to be consistent or explicit. No formula is used to determine an appropriate funding level for health care (although Committees of Inquiry and Royal Commissions have tried unsuccessfully to derive one). The very nature of the services to be offered by the NHS are a subject of debate (New and Le Grand, 1996). Overarching goals such as equity and need are mentioned in speeches and documents, but the real influences are more likely to be political expediency, whether there is an upcoming general election, the current status of the economy, the potential impact on economic performance, and the perceived need of the target population (Klein et al., 1996). Moreover, there is little information about the extent to which allocations for health care meet the needs and demands of the population or receive adequate priority (Klein et al., 1996). Several political considerations argue against making the process explicit, not least the desire of politicians to distance themselves from any association with the highly unpopular notion of rationing. When a random group of 2012 people was asked, ‘Do you think the NHS should have unlimited funding, or do you think

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that budgets should be set even if that means some treatments will have a higher priority than others?’, 51 per cent called for unlimited funding (Heginbotham, 1993). Politicians prefer to maintain the façade that there is no rationing. Instead, they are happy to devolve responsibility for such decisions to local authorities. As stated by one former Secretary of State: We can set only the framework in which local decisions are made: clinicians and managers must determine the health needs of the local population and how they are best met . . . It is not the government’s role to lay down local priorities or make local decisions; local purchasers and providers of health care are best placed to do that (Bottomley, 1994). That such decisions are not made by the central government is in keeping with public sentiment. According to one survey, only 6 per cent of Britons want national politicians to decide which treatments should take priority (Heginbotham, 1993). On the other hand, the public is likely to hold central government accountable if, at the point of service, doctors attribute their inability to provide care to limitations set by the center (Klein et al., 1996). Although central government passes most resource allocation decisions on to health authorities, it does make some central health policy decisions for which there is some degree of public transparency. It sets targets for waiting times that are specified in public documents (and sometimes the subject of boasting in campaign speeches and other venues as elections approach). According to NHS documents, ambulances must respond to calls within 14–19 minutes; patients must be allocated to a general practitioner with two days; and in-patient treatment must be provided within eighteen months (NHS Executive, 1996). It sets prescription charges and publishes a list of drugs that doctors cannot prescribe. It devises geographical allocation formulae for funding health authorities, and sets broad purchasing priorities for them (NHS Executive, 1996). But specific decisions affecting how health care services are paid for are shunted to the authorities themselves.

Decisions made by local authorities There are currently 100 health authorities throughout England, and each has responsibility for purchasing health services for the resident

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population through contracts with local trusts (hospitals) and general practitioners (Levitt et al., 1995). Health authorities receive their funds from the Department of Health. These are derived from a weighted capitation formula that reflects the local population size and health status. Although the NHS Executive does set broad priorities and place limited restrictions on how the money is spent (NHS Executive, 1996), it is the health authority’s remit to decide which services are provided in its area. Under the recent NHS reforms, the process by which health authorities make these decisions was designed to reduce provider demand as an influence on how services are allocated, and to make decisions more responsive to local needs, evidence of effectiveness, and public input (Levitt et al., 1995). In theory, the new paradigm would provide greater accountability and transparency to the decision-making process, and the following observations would suggest that the model has had some success: The priorities of health authorities are explicit. The service aims to achieve equity, efficiency, and responsiveness, according to guidance from the NHS Executive and from the House of Commons (NHS Executive, 1996; Health Committee of the House of Commons, 1995). Recent priorities of the NHS Executive have included the development of a primary-care-led NHS, mental health services, improved clinical and cost effectiveness, public input, long-term care, and corporate health (NHS Executive, 1996). Some health auth– orities have set more explicit priorities (Cochrane et al., 1991). In an approach used by the City and Hackney Health Authority, for example, a specified number of points were awarded for proposals that were prioritized by the Community Health Council or local general practitioners that contributed to equity, that enhanced effectiveness or efficiency, or that promoted collaboration with primary care (Klein et al., 1996). The reasons for excluding services are well-defined. Health authorities are directed by the NHS Executive to base their decisions on explicit analytic criteria: a careful assessment of local needs, current service levels, and a comparison of the relative clinical and cost effectiveness of competing options for improving outcomes (Coast and Donovan, 1996). The Department of Health has published guidelines on needs assessment (Department of Health, 1992) and has disseminated bulletins, electronic databases, and other resources to help health

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Steven H. Woolf 15 Table 2.1

Justification for excluded services in selected health authorities

Health authority

Excluded/disinvested service

South Lancashire

Reversal of sterilization

South Lancashire

Sex-change operations (counseling covered, surgery excluded)

Portsmouth and South East Hampshire

Surgery and x-rays for back pain

Portsmouth and South East Hampshire

Frequency of elective cesarean

Newcastle and North Tyneside

High-cost hip prostheses

Newcastle and North Tyneside

Diagnostic arthroscopy

Wigan and Bolton Wigan and Bolton

Bone density screening Cholesterol screening in low-risk persons

Rationale Probability of success is low A minority of patients who receive counseling undergo surgery, which is costly Very few episodes of back pain show radiological abnormalities and in less than 1% is surgery indicated Evidence that vaginal birth after cesarean section is safe Switching to low-cost prostheses could be applied to waiting lists for orthopedic procedures Replacement with MRI is cheaper and less invasive Poor predictive value Poor predictive value; treatment may be ineffective or harmful, and is expensive

Source: Redmayne, S. (1996) Small Steps, Big Goals: Purchasing Policies in the NHS (Birmingham: National Association of Health Authorities and Trusts), box, p. 21.

authorities to improve their assessment of existing evidence of effectiveness (NHS Executive, 1996). With these reforms, the public now has access to more explicit criteria for decisions to exclude services (see Table 2.1) (Redmayne, 1996). With increasing frequency, the absence of evidence of effectiveness is the cited reason for not covering services. Dilation and curettage in women under the age of 40; insertion of grommets for glue ear; wisdom tooth extraction; hysterectomies; some antenatal services for low-risk mothers; treatments for sleep apnea; and bone densitometry screening are examples of services commonly excluded for this reason (Redmayne, 1996). Inadequate cost-effectiveness is

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another exclusion criterion. The reason cited by most health authorities for not covering beta-interferon, a drug for multiple sclerosis, is its estimated annual cost of £10 000 per patient and £380 million nationwide (Walley and Barton, 1995; Redmayne, 1996). Explicit criteria are also cited for setting limits on the delivery of covered services. In vitro fertilization, for instance, is often restricted based on likelihood of benefit (for example, restricting to women under the age of 40), need (no living children), and desert (evidence of a stable relationship) (Klein et al., 1996). Purchasing plans are public. All health authorities must publish an annual purchasing plan, which often includes an explanation of excluded services, such as those listed in Table 2.2. Some health authorities take extra steps to ensure public access to the details. They organize public meetings, roadshows, announcements in local newspapers and radio broadcasts, and household distribution of information (for example, in local free papers) to explain the plans (Redmayne, 1996). In at least one health authority, measures to improve attendance at public meetings included access for wheelchairbound patients, services for the hearing-impaired, and a sitting service for persons with dependents (Redmayne, 1996). Policy-makers respond to public input. Encouraging public involvement in setting priorities is part of the official policy of the Department of Health (NHS Management Executive, 1992), a position reinforced in 1995 by the Health Committee of the House of Commons: ‘Health authorities must be able to demonstrate . . . that input from local people has influenced change to the purchasing agenda and the planning of services’ (Health Committee of the House of Commons, 1995). Health authorities must ‘give greater voice and influence to users of NHS services’ (NHS Executive, 1996, p. 5). Health authorities have responded to this remit by conducting population surveys, public meetings, focus groups, and interactive television programs to assess public preferences and priorities (Klein et al., 1996; Bowling, 1993; Ham, 1993; Redmayne, 1996). Some health authorities have experimented with more creative approaches: telephone hotlines, distributing with purchasing plans a booklet (How You Can Make a Difference) that explains how to give views on commission priorities, attaching tear-off slips or reply coupons to purchasing plans to allow the public to register views, sponsoring ‘Have Your Say Day’ in local shopping centers, and con-

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Steven H. Woolf 17 Table 2.2 Most commonly excluded services in 1996/7 health authority purchasing plans (N ⫽ 26) Procedure

Number of plans with contract exclusion

Reversal of sterilization Assisted fertilization Sex-change operations Reversal of vasectomy Breast augmentation Rhinoplasty Cosmetic varicose vein surgery Tattoo removal Pinnaplasty Liposuction Dilation and curettage in women under 40 Complementary therapies Dental implants Aesthetic orthodontics Blepharoplasty Abdominoplasty Mastopexy Buttock lift Facelift

15 11 11 10 10 10 8 8 6 6 5 5 5 5 5 4 4 4 3

Source: Redmayne, S. (1996) Small Steps, Big Goals: Purchasing Policies in the NHS (Birmingham: National Association of Health Authorities and Trusts), table 1, p. 19.

vening citizens’ juries which hear the evidence on important health questions (Redmayne, 1996). One health authority has established a research panel consisting of 2500 representative persons from the local population to provide feedback on programs (Redmayne, 1996). Public input appears to have influenced policy in a number of health authorities, such as in Essex, City and Hackney, Oxfordshire, Southhampton, South West Hampshire, and Wandsworth (Ham, 1993). Some health authorities complete the feedback loop by reporting back to the public which policies they have changed based on public input (Redmayne, 1996). Public comments led to increased coverage for single-sex wards in hospitals in Kensington, Chelsea and Westminster; respite care and transport services to the mainland on the Isle of Wight; and more extensive community nursing services in Cambridge and Huntingdon (Redmayne, 1996). A closer examination of the above process reveals, however, that its purported transparency may be illusory.

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Table 2.3

Prioritization schemes in selected health authorities

Health Authority

Prioritization criteria

Barnsley Health

Improves people’s health or their home or social circumstances, distributes resources or services more fairly, or contributes to the target for increased health service activity. Exeter and North Devon 10–point scale reflecting the severity of the condition the intervention is likely to relieve, qualified by other factors: community necessity (number of people likely to benefit, potential for prevention, potential to achieve swift return to employment), degree of effectiveness, efficiency, and responsibility. Sandwell Cost utility index weighted by health gain, common ailments, strength of public feeling, proven effectiveness, and waiting times. Ayrshire and Arran First round: effectiveness, equity, quality, strategic fit, efficiency. Second round: relatedness, affordability, business plan fit. Source: Redmayne, S. (1996) Small Steps, Big Goals: Purchasing Policies in the NHS (Birmingham: National Association of Health Authorities and Trusts), box J, p. 17.

Priority setting Although some health authorities do use sophisticated schemes for setting priorities (Table 2.3), most do not have the time or resources to do so, and fall back on targets set by the center (Klein et al., 1996). Goals emphasized in circulars from the national government – efficiency, responsiveness, and targets set in Health of the Nation – are useful platitudes, but are difficult to operationalize in practice at the health authority level (Klein et al., 1996). The very definitions of the terms are uncertain; experts debate the true meaning of ‘equity’ and of ‘need’ (Doyal and Gough, 1991). How best to measure them is even more controversial. Some favor measuring efficiency, for example, in terms of quality-adjusted life years, whereas others resist this trend (Harris, 1997). Aside from these methodologic concerns, most health authorities lack the resources to achieve the goals outlined by central government (Klein et al., 1996). For these reasons, the stated priorities of health authorities often have little meaning. In a 1993 survey of health authorities, Redmayne found that stated priorities did not correspond with how funds were appropriated (Table 2.4) (Redmayne et al., 1993). Mental health, for example, was the most frequently mentioned priority of health

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Steven H. Woolf 19 Table 2.4 Top ten priorities mentioned by purchasers (1993/4) Number of purchasers citing as priority (n ⫽ 100)

Service Mental health Heart disease Learning difficulties Cancer Community services Children Maternity Accident prevention HIV/AIDS Elderly

74 56 54 54 51 51 49 49 49 48

Distribution of expenditure (1993/4) Service Acute Community Other (miscellaneous) Mental health Elderly Learning difficulties

Amount (£ million)

Proportion of total (%)

35.5 10.6 6.8 4.9 2.6 1.3

58 17 11 8 4 2

Source: Redmayne, S., R. Klein and P. Day (1993) Sharing Out Resources: Purchasing and Priority Setting in the NHS (Birmingham: National Association of Health Authorities and Trusts).

authorities, yet it received only 8 per cent of the funds. Moreover, the public is not given sufficient information about local needs and resources to judge whether the stated priorities are appropriate. The Centre for the Analysis of Social Policy at the University of Bath, which studied the purchasing plans of all health authorities in four surveys during 1992–6 (Klein and Redmayne, 1992; Redmayne et al., 1993; Redmayne, 1995; Redmayne, 1996), found that they did not provide enough information about baseline conditions and financial commitments to evaluate their appropriateness: Analysing the plans is therefore an exercise in tin-opening, and some of the tins turn out to be extremely resistant to efforts to prise out information from them . . . There is still a long way to go before the hope that the 1991 reforms would force health authorities to be transparent about the distributional consequences of their choices is realized (Klein et al., 1996, p. 56).

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Managers themselves often have little insight into the broader context of their priorities. ‘There is little sense of authorities addressing the larger – and therefore even more difficult – question of whether the priorities implicit in their existing commitments are the right ones’ (Redmayne, 1996, p. 17). Analytic Procedures Health authorities encounter both methodological and practical problems in attempting to operationalize an evidence-based approach to needs assessment and to evaluating the effectiveness of interventions. Although the Director of Public Health in each authority is expected to produce an annual report of the health of the district, the best way to define ‘need’ and perform needs assessment is uncertain (Coast et al., 1996). Epidemiological data to characterize the extent of local health problems are lacking in most communities. National efforts are under way to fill this gap, such as the work of the Department’s Central Health Outcomes Unit, but the data will not be available for some time. Evidence regarding the effectiveness of interventions, although well summarized in a growing number of publications and electronic databases on evidence-based health care, is available for only a minority of healthcare services. Health authorities are often forced to rely on expert opinion or the claims of local practitioners to judge whether interventions are effective (Klein et al., 1996), and most interventions are effective to some degree, or for some patients, thus making blanket exclusions infeasible (Klein, 1997). Practical barriers to an evidence-based approach stem from the lack of time and resources to scrutinize data, and from political pressure. Budget decisions must be made quickly to complete annual contracting rounds, and chief executive officers often cannot wait for their public health directors to conduct careful scientific analyses of local health needs, or to consult systematic reviews of the evidence (Levitt et al., 1995). Moreover, the pressures of local advocacy exert considerable influence on the process, independent of the science. Decisions to eliminate services that are popular with the public or medical profession may falter when they meet with forceful local opposition. Community constituencies can be highly effective in maintaining the status quo by mobilizing health professionals, the press, and the public to oppose the plans (Klein et al., 1996). Conversely, services that lack local support are easier to eliminate. Whether in vitro fertilization is covered by a health authority, for

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example, often depends on whether there is a vocal champion for the service in the community (Klein et al., 1996). Public input In practice, the quality of the information given to the public is more limited than official policy would suggest. The list of what is covered by the health authority is not universally available in most communities. The inclusion criteria for determining coverage, although publicized by some health authorities (see Table 2.1), are elsewhere undeveloped or undisclosed. Even when coverage policy and purchasing plans are known, the public is rarely given the additional background details to judge the extent to which existing resources are being used and local needs are being met. Based on one survey of all health authorities, an investigator concluded that, ‘with few exceptions, the plans still fail to give much of the information about the adequacy (or otherwise) of existing services that is required for an informed public debate about priorities’ (Redmayne, 1996, p. 4). ‘This reflects as much ignorance as a deliberate attempt to veil the decision-making process’ (Klein et al., 1996, p. 123). More importantly, health authorities face obstacles in responding to public concerns. ‘There is a question over the real willingness of purchasers to incorporate the views and opinions of the public, and, if this is achieved, how far they will go in changing existing services to meet the priorities expressed by “the public”’ (Coast and Donovan, 1996, p. 29). Managers have different priorities than do the public in how to fund the health service (Klein et al., 1996; Bowling, 1993) and have little compelling interest to respond to public sentiments. Under the new NHS structure, managers are more likely to feel accountable to their superiors in central government than to the public. There are also concerns about the wisdom of setting health policy based on lay views, which can be influenced by ignorance, misconceptions, prejudices, sensational press reports, opposing perspectives, and disease-specific biases, as well as by measurement errors (for example, through selection bias, incorrect framing of questions, or difficulties in addressing sensitive or emotional topics) (Klein et al., 1996; Heginbotham, 1993; Coast and Donovan, 1996; Whitehorn, 1993; Pollock, 1992). Perhaps for these reasons, the role of public consultation on health policy has regressed in recent years. In most health authorities, the public voice serves mainly as a resource for

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consumer research (for example, patient satisfaction surveys) (Klein et al., 1996), ‘to legitimize decisions already taken’, (Klein et al., 1996, p. 59) or to help leverage providers in contract negotiations (Coast and Donovan, 1996). These limitations were addressed explicitly in a purchasing plan from the Isle of Wight: [The public may] also express views which may be difficult to support and there is a risk of raising expectations which cannot be met. Given the size of the national agenda, there is a limited potential for immediate response and impact on the determination of local priorities and this may lead to disillusionment with the consultation process. (Redmayne, 1996, p. 9) Devolution to providers In the end, the public’s limitations in influencing health authorities may have little bearing on the NHS services they receive, given the more important role played by the medical community. Of the 100 health authorities in England, specific services are excluded by only twenty-six (Redmayne, 1996). Those services that are excluded (see Table 2.2) are of marginal importance, mainly involving cosmetic surgery and uncommon procedures. Health authorities leave untouched the hundreds of health services that dominate care. ‘Historic levels of service provision are rarely questioned but just taken for granted’ (Redmayne, 1996, p. 32). Managers have little desire to attract political disfavor by rationing these services (Beecham, 1992). According to one survey, managers are more likely than the public to want general practitioners to decide how to prioritize treatments (71 per cent versus 49 per cent), or to defer such decisions to national politicians (36 per cent versus 6 per cent) (Heginbotham, 1993). Providers, rather than health authorities, decide which health services are provided to the public. Health authorities adjust how resources are used within a service area (for example, cancer treatment), rather than shifting resources from one service to another (Klein et al., 1996). Contracts with providers devolve the detailed decisions to the point of service. The recent emphasis on clinical practice guidelines (see below) may help to bridge the roles of health authorities and providers in selecting services (Klein et al., 1996; Ham, 1993). In a recent survey, the purchasing plans of 14 per cent of health authorities linked coverage to compliance with guidelines (Redmayne, 1996).

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Decisions made by individual clinicians and patients Ultimately, the most important resource allocation decisions in British health care are made at the point of service, where doctors and other health professionals select diagnostic tests and treatments: ‘Despite all the changes in the structure of the NHS, decisions about which patients should be treated, when and how, remain the prerogative of the health care professions. It is the way in which doctors, nurses, and others organize and allocate the resources at their disposal that determines micro rationing at the point of service delivery’ (Klein et al., 1996, p. 83). In large measure, the criteria by which such decisions are made are clinical: the patient’s history, physical findings, laboratory results, and an assessment of which choice will produce the best outcome. How these criteria are applied is rarely ‘transparent’. Most doctors do not spell out for the patient the detailed rationale behind their recommendations. This is partly because of the entrenched paternalistic traditions of medicine and partly because the decision-making process occurs on a subconscious level that makes such explication difficult. Klein terms this the ‘secret garden’ in which doctors make decisions (Klein et al., 1996, p. 83). Although these opacities in the process are common to most physicians, in Britain and elsewhere, two important characteristics of practice in the NHS influence the decision-making process of British doctors: (i) implicit rationing; and (ii) evidence-based medicine. These characteristics may help to explain the tendency of British physicians to be more conservative than their American counterparts, ordering fewer diagnostic tests, recommending less aggressive treatments, and being more at ease with monitoring patients without treatment (Aaron and Schwartz, 1984). Implicit rationing British doctors understand the limited resources of the health care system in which they practice, and this knowledge appears to influence their clinical advice. Doctors ‘internalize resource constraints’, (Klein et al., 1996, p. 90) influencing, consciously or unconsciously, the treatment options they propose, and their decisions to refer patients to consultants. Knowing the likely waiting time a patient would face before undergoing an operation may, for example, prompt a doctor to recommend treatment with medication. ‘General practitioners may, in other words, incorporate hospital rationing practices

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into their own referral policies’ (Klein et al., 1996, p. 85). Researchers have attempted to identify the criteria doctors use in implicit rationing. Older age appears to exclude patients from renal dialysis and coronary care services (Wing, 1984; Dudley and Burns, 1992; Evans, 1993), but because the rationing is implicit other factors may also be involved (for example, life expectancy, likelihood of benefit, or ability to cope with treatment) (Coast and Donovan, 1996). Women and working-class patients also seem less likely to receive certain services (Baker, 1992). In addition to resource constraints, attitudes about effectiveness, safety, and social justice limit the use of health care services by British physicians. Compared to their American counterparts, British physicians tend to be more skeptical about the health benefits of aggressive medical interventions and worry more about their potential adverse effects. They also appear to have a greater awareness of the societal implications of resource consumption and a deeper commitment to ensuring equity in health care. An expensive treatment of unproven value, used with little hesitation by American doctors in the hope of helping patients, is more likely to be deferred by British doctors on the grounds that it might draw resources away from more effective services or from health care for others in the population (Goldstein et al., 1997). Though the need to consider resource issues is acknowledged, and indeed encouraged, by the medical profession – the British Medical Association code states that ‘it is the doctor’s ethical duty to use the most economic and efficacious treatment available’ (British Medical Association, 1988, p. 72) – there is a desire to keep the process implicit: If services are to be limited, I would rather see it done implicitly – unstated, unwritten, unacknowledged – in the curious and not inhumane way in which such matters are managed in the United Kingdom. (Sir Raymond Hoffenberg, Harveian oration, as cited in Smith, 1991) Some believe that it is easier psychologically for physicians to think of such decisions as being ‘clinical’ judgments rather than as rationing. British doctors ‘seek medical justification for decisions forced on them by resource limits’ (Aaron and Schwartz, 1984). Managers and politicians, who have devolved rationing to providers largely for political reasons, are happy to collude in viewing these

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decisions as being medical (Smith, 1991). As recent reforms have moved doctors from the role of NHS contractors to purchasers, however, British physicians have come to resent their long-standing responsibility for rationing. Some would rather have the government place an absolute embargo on services than leave it to individual doctors to decide who receives care (Hoffenberg, 1993). Decisions by doctors are not the only factors that influence care at the point of service. Beyond overt rationing by denial (for example, transplant denial), Klein et al. (1996) note that rationing also occurs by selection, deflection (encouraging the use of another agency), deterrence (cost, inconvenience, or language barriers), delay (waiting lists), dilution (reducing quality to spread out resources), and termination (Klein et al., 1996). For example, subtle rationing by dilution is evident in how time is allocated: delays in getting an appointment or in the waiting room, or the length of time afforded to meet with the doctor (Klein et al., 1996). Administrative decisions also affect the quality of care, such as the staff and budget a hospital assigns to a ward, equipment, and food service. This ‘hidden iceberg of rationing’ (Klein et al., 1996, p. 85) lacks transparency. The most well-known example of administrative point-of-service rationing, the waiting list, would seem to be highly transparent. Most hospitals classify cases as immediate, urgent, or non-urgent (West, 1993). As already noted, the maximum number of months a patient can wait for treatments is specified by the NHS Executive (NHS Executive, 1996). But how the criteria are applied in practice is often inexplicit: ‘Waiting lists veil the discrepancies between what is offered and what can be done’ (Frankel and West, 1993). In summary, to the extent that implicit rationing occurs, the public and patients have little way of knowing the specific criteria for treatment decisions at the point of service. The reason a diagnostic procedure or treatment is offered or denied – whether it be the doctor’s beliefs about efficacy, resource constraints, waiting lists, or administrative factors – may be impossible to determine. ‘Clinical judgment’, the most common and convenient explanation, may obscure the real determinants: Rationing in the UK is carried out by physicians who are aware of budgetary limits, but who ration care by telling the patient that they are unable to do anything to help them, rather than explicitly stating that the resources are not available for treatment. (Coast and Donovan, 1996, p. 12)

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Evidence-based medicine To the extent that doctors base clinical decisions on research evidence of effectiveness, the public can find in science a more explicit accounting of how tests and treatments are selected. The growing emphasis on evidence-based medicine in the British medical community (for example, clinical practice guidelines) is a recent phenomenon, encouraged by a special program of the NHS (NHS Executive, 1996), but also one that fits comfortably with the conservative practice philosophy of British physicians. British doctors appear more willing to set aside personal beliefs about the effectiveness or ineffectiveness of tests and treatments and to rely instead on findings from well-conducted clinical research. Reliance on evidence from randomized controlled trials and the critical appraisal of evidence carries a much lower profile in American medicine. The growing number of clinical practice guidelines, a recent outgrowth of evidence-based medicine intended to improve the consistency, quality, and efficiency of care, further improves the transparency of decisions by providers who use them. The practice guideline movement gained momentum in England and Scotland in 1993–5, following a similar upsurge of interest in practice guidelines in the United States. The NHS Executive has encouraged the Royal Colleges and other professional societies to develop guidelines that explicate, preferably based on evidence, the best way to treat specific conditions or to perform procedures. Community-based programs have been established to encourage clinicians to implement these recommendations. To the extent that doctors follow practice guidelines, the documents give patients a tangible reference for understanding the basis for treatment decisions and recommendations. Shared decision-making The ability of patients to play an active role in decisions about their health care has an obvious influence on the transparency of medical decisions. The reasons for decisions can be no more transparent than if patients receive information about the benefits and harms of available choices and make informed decisions about which option they prefer. However, British patients may not receive this information unless they ask for it. British doctors feel less compelled than do Americans (and face less medico-legal pressure) to initiate such discussions

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with patients, preferring the more paternalistic practice of advising patients what to do. British patients are accustomed to this arrangement and thus do not expect to engage in shared decision-making. American patients, perhaps because of their cultural orientation toward self-empowerment and consumerism, take a more active role in expressing preferences and making decisions. That said, a trend towards more active decision-making by patients is evident in the UK. Privatization of health care and other industries has led to a great emphasis on customer (patient) satisfaction. In the NHS, the trend is reflected in The Patient’s Charter (Secretary of State for Health, 1991), a key element of recent health care reforms that, among other things, has committed the government to providing a better service to the public and to better accommodating patients’ preferences. An outgrowth of patient-centered care has been the move to develop practice guidelines for patients, not just for providers. A practice guideline on low back pain, for example, developed by the Royal College of General Practitioners, included a ‘consumer version’: a leaflet that summarized the recommendations in lay language. Evidence summaries on maternity and child care, prepared for clinicians and payers by the NHS Centre for Reviews and Dissemination, also included a patient information series (Entwistle et al., forthcoming). More involved efforts to engage patients in the decision-making process are currently under study. Based on similar products in the United States, the King’s Fund has developed interactive videodiscs that allow patients to learn more about their options and make choices that reflect their personal preferences.

Discussion This chapter has made the assumption that transparency in health policy is a good worth pursuing, a notion that has been debated (Mechanic, 1995; Coast and Donovan, 1996; Coast, 1997). There are several arguments for keeping the process implicit: in making decisions that may determine who lives and dies, opacity may ‘have a useful social function by taking some of the pain and collective guilt out of such “tragic choices”’ (Klein et al., 1996, p. 121). According to Coast (Coast, 1997), transparency brings pain to the patient, clinician, and society. Explicit methods cannot accommodate the heterogeneous nature of health care. These and other methodologic problems, combined with the moral implications, make

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rationing impossible to resolve to everyone’s satisfaction (Rationing Agenda Group, 1996). Explicit acknowledgment of this fact could damage public trust in the medical profession and in the NHS. For reasons outlined earlier, it is in the self-interest of many politicians, NHS managers, and clinicians to keep the process opaque (Klein et al., 1996). Some have argued that the potential conflict between these parties engendered by explicitness could undermine efforts to change the system and ultimately serve to reinforce current patterns of delivery (Hunter, 1993). There appears, however, to be a growing feeling in Britain that improved transparency is desirable in public policy. The new Labour government has made this an explicit priority. Several arguments for enhancing the transparency of health policy have been advanced: in a democracy, citizens must be allowed to influence decision-making. If rationing is ‘messy’ it is better to be open about this than to risk the consequences of deceiving the public (Rationing Agenda Group, 1996). Explicitness provides the information base for ensuring distributive justice (Doyal, 1997), discourages special interests from making decisions on the basis of tradition, prejudice, or advocacy, and prevents politicians from passing responsibility and blame to others (Klein et al., 1996). It makes public the gap between societal need and available resources. At the clinical level, it helps to inform patients of when decisions are based on uncertainty, arbitrary criteria, or other ‘veiled’ factors. Here it is worth distinguishing between transparency and accountability in health policy. Political, organizational, public pressure, and normative measures provide some degree of accountability in Britain (Rationing Agenda Group, 1996). Political structures include legislative (review of funding and statutory instruments, Health Select Committee, Public Accounts Committee, Health Service Commissioner and National Audit Office); executive (fiscal powers, Social Services Inspectorate, Health Advisory Service, Audit Commission, and personnel appointments); and judicial (Mental Health Review Tribunal, and judicial review). Organizational methods include improved internal management, opening government to public and media scrutiny, and citizen juries. Public pressure is provided by organizations (for example, Patients Association, NHS complaints procedure), and statutory bodies (Community Health Councils). Normative methods include the public service ethos, clinical audit, and other forms of self-accountability (Rationing Agenda Group, 1996). Critics note that the current level of accountability could be

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improved. For example, Klein et al. (1996) have recommended making the Department of Health more accountable to Parliament by reporting regularly to the House of Commons Health Committee on how the department ensures that decisions about priorities are taken with regard to equity, efficiency, and responsiveness. Specific questions should be answered: how are these principles interpreted when assessing the performance of health authorities, and what action is taken if they fail the test? Many believe that central government should assume responsibility for making these decisions (Lenaghan, 1997). At the local level, a new role for local government in administering community health care services (Harrison and Hunter, 1994), making rationing decisions (Harrison, 1997), or evaluating health authority priorities (Klein et al., 1996) has been advocated. The NHS reforms, by removing the previous scheme, in which local officials representing the public had a dominant role in health authorities, and replacing them with individual consultation with the public, have in many ways weakened public accountability (Pollock, 1992). Currently the members of health authorities are appointed by the Secretary of State and as such are not elected or accountable to the public (Lenaghan, 1997). Improving transparency requires going beyond accountability to provide more accurate and meaningful information to the public. This should include better information on population health status, health care requirements, degree of need (ill-health deficit), capacity to benefit, cost, and current levels of service provision (Rationing Agenda Group, 1996). British health policy cannot be evaluated by the public without an understanding of current supply (accessibility and availability of existing services) and demand (shortfall from national norms, local needs) (Klein et al., 1996). The practice of selectively providing attractive information to the public, such as shortened waiting times for a given type of surgery, is politically expedient but often misleading. Although there is room for improvement in the transparency of British health policy, public accountability for resource allocation is still further along in Britain than in the United States. We know more about how British pounds are spent on health than we know about the expenditure of US health care dollars. Because the NHS is a single-payer system with a defined budget, there is order and accountability to resource allocation that is impossible to achieve in America, where care is paid for and provided by hundreds of

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private, independent health care systems (managed care organizations, insurance companies) and governmental programs (Medicare, Medicaid). Compared to the British, Americans know far less about how their money is appropriated to acute care, hospitals, technology, longterm care, administration (for example, managers’ salaries), and about how rationing decisions are made. In the United States, this information is often proprietary (the antithesis of transparency) and, even when available (as in the case of Medicare data), provides little insight into how health care dollars are spent nationwide across the population. Under its ‘effectiveness initiative’, the NHS is improving its ability to demonstrate to the public its efforts to improve quality and clinical effectiveness, maximize efficiency, and document the results through improved data collection. Americans are unlikely to obtain such information from their own managed care organizations, and certainly not for the country as a whole, and in this sense operate under a considerably less transparent health care system. Note The author thanks Professor Trevor Sheldon (director of the NHS Centre for Reviews and Dissemination) for his support during this research and Dr Andrew Farmer for reviewing an early draft of this manuscript.

References Aaron, H. J. and W. B. Schwartz (1984) The Painful Prescription (Washington DC: The Brookings Institution). Baker, R. (1992) ‘The Inevitability of Health Care Rationing: A Case Study of Rationing in the British National Health Service’, in M. A. Strosberg, J. M. Weiner, R. Baker and I. A. Fein (eds), Rationing America’s Medical Care: The Oregon Plan and Beyond (Washington, DC: The Brookings Institution), pp. 208–29. Beecham, L. (1992) ‘Health Authorities are Reluctant to Ration’, British Medical Journal, vol. 305, p. 1049. Bottomley, V. (1994) ‘Rationing in Action’ (letter), British Medical Journal, vol. 308, p. 338. Bowling, A. (1993) What People Say About Prioritising Health Services (London: Kings Fund Centre). British Medical Association (1988) Philosophy and Practice of Medical Ethics (London: British Medical Association). Chancellor of the Exchequer (1995) Financial Statement and Budget Report, 1996–97 (London: HMSO). Coast, J. (1997) ‘The Case Against’, British Medical Journal, vol. 314, pp. 1118–22. Coast, J. and J. Donovan (1996) ‘Conflict, Complexity and Confusion: The Context for Priority Setting’, in J. Coast, J. Donovan and S. Frankel (eds) (1996) Priority Setting: The Health Care Debate (Chichester: John Wiley), pp. 3–34.

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Steven H. Woolf 31 Coast, J., G. Bevan and S. Frankel (1996) ‘An Equitable Basis for Priority Setting?’ in J. Coast, J. Donovan and S. Frankel (eds.), Priority Setting: The Health Care Debate (Chichester: John Wiley), pp. 141–66. Cochrane, M., C. Ham, C. Heginbotham and R. Smith (1991) ‘Rationing: At The Cutting Edge’, British Medical Journal, vol. 303, pp. 1039–42. Cramshaw, R. (1990) ‘Health Care Rationing’, Science, vol. 247, pp. 662–3. Department of Health (1989) Working for Patients, Cm. 555 (London: HMSO). Department of Health (1992) Population Needs Assessment: Good Practice Guidance (London: Department of Health). Doyal, L. and I. Gough (1991) A Theory of Human Need (London: Macmillan). Doyal, L. (1997) ‘The rationing debate: rationing within the NHS should be explicit’, British Medical Journal, vol. 314, pp. 1114–8. Dudley, N. J. and E. Burns (1992) ‘The Influence of Age on Policies for Admission and Thrombolysis in Coronary Care Units in the United Kingdom’, Age Aging, vol. 21, pp. 95–8. Entwistle, V. A., I. S. Watt, H. Davis, R. Dickson, D. Pickard and J. Rosser (forthcoming) ‘Developing Information Materials to Present the Findings of Technology Assessments to Consumers: The Experience of the NHS Centre for Reviews and Dissemination’, International Journal of Technology Assessment in Health Care. Evans, J. G. (1993) ‘This Patient or That Patient?’, in R. Smith (ed.), Rationing in Action (London: British Medical Association), pp. 118–24. Frankel, S. and R. West (eds.) (1993) Rationing and Rationality in the National Health Service: The Persistence of Waiting Lists (London: Macmillan). Goldstein, L. B., A. Farmer and D. Matchar (1997) ‘Primary Care Physicianreported Secondary and Tertiary Stroke Prevention Practices: A Comparison between the United States and the United Kingdom’, Stroke, vol. 28, pp. 746–51. Ham, C. (1991) The New National Health Service Organization and Management (Oxford: Radcliffe Medical Press). Ham, C. (1993) ‘Priority Setting in the NHS: Reforms from Six Districts’, in R. Smith (ed.), Rationing in Action (London: British Medical Association), pp. 59–71. Harris, J. (1997) ‘The Case Against: What the Principal Objective of the NHS Should Really Be’, British Medical Journal, vol. 314, pp. 669–72. Harrison, S. (1997) ‘The Case Against’, British Medical Journal, vol. 314, pp. 970–73. Harrison, S. and D. J. Hunter (1994) Rationing Health Care (London: Institute for Public Policy Research). Health Committee of the House of Commons (1995) Priority Setting in the NHS: Purchasing, Fifth Report, Session 1994–5 (London: HMSO). Heginbotham, C. (1993) ‘Health Care Priority Setting: A Survey of Doctors, Managers, and the General Public’, in R. Smith (ed.), Rationing in Action (London: British Medical Association), pp. 141–56. Hoffenberg, R. (1993) ‘Letter to the Editor’, in R. Smith (ed.), Rationing in Action (London: British Medical Association), pp. 198–200. Hunter, D. (1993) Rationing Dilemmas in Healthcare (Birmingham: National Association of Health Authorities and Trusts). Klein, R. (1997) ‘The Case Against’, British Medical Journal, vol. 314, pp. 506–9.

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Klein, R. and S. Redmayne (1992) Patterns of Priorities: A Study of the Purchasing and Rationing Policies of Health Authorities (Birmingham: National Association of Health Authorities and Trusts). Klein, R., P. Day and S. Redmayne (1996) Managing Scarcity: Priority Setting and Rationing in the National Health Service (Buckingham: Open University Press). Lenaghan, J. (1997) ‘Central Government Should Have a Greater Role in Rationing Decisions’, British Medical Journal, vol. 314, pp. 967–70. Levitt, R., A. Wall and J. Appleby (1995) The Reorganized National Health Service, 5th edn. (London: Chapman & Hall). Mechanic, D. (1995) ‘Dilemmas in Rationing Health Care Services: The Case for Implicit Rationing’, British Medical Journal, vol. 310, pp. 1655–9. New, B. and J. Le Grand (1996) Rationing in the NHS: Principles and Pragmatism (London: King’s Fund). NHS Executive (1996) Priorities and Planning Guidance for the NHS: 1997/98 (Leeds: NHS Executive). NHS Executive (1996) Promoting Clinical Effectiveness: A Framework for Action In and Through the NHS (Leeds: NHS Executive). NHS Management Executive (1992) Local Voices: The Views of Local People in Purchasing for Health (London: Department of Health). Pollock, A. (1992) ‘Local Voices’, British Medical Journal, vol. 305, pp. 535–6. Rationing Agenda Group (1996) The Rationing Agenda in the NHS, B. New (ed.) (London: Kings Fund). Redmayne, S. (1995) Reshaping the NHS: Strategies, Priorities and Resource Allocation (Birmingham: National Association of Health Authorities and Trusts). Redmayne, S. (1996) Small Steps, Big Goals: Purchasing Policies in the NHS (Birmingham: National Association of Health Authorities and Trusts). Redmayne S., R. Klein and P. Day (1993) Sharing Out Resources: Purchasing and Priority Setting in the NHS (Birmingham: National Association of Health Authorities and Trusts). Sabin, J. E. (1992) ‘“Mind the Gap”: Reflections of an American Health Maintenance Organisation Doctor on the New NHS’, British Medical Journal, vol. 305, pp. 514–6. Secretary of State for Health (1991) The Patient’s Charter (London: Department of Health). Smith, R. (1991) ‘Rationing: The Search for Sunlight’, British Medical Journal, vol. 303, pp. 1561–2. Walley, T. and S. Barton (1995) ‘A Purchaser Perspective of Managing New Drugs: Interferon Beta as a Case Study’, British Medical Journal, vol. 311, pp. 796–9. West. R. (1993) ‘Joining the Queue: Demand and Decision-making’, in S. Frankel and R. West (eds), Rationing and Rationality in the National Health Service: The Persistence of Waiting Lists (London: Macmillan). Whitehorn, K. (1993) ‘Surely You Aren’t Going to Ration Me!’, in R. Smith (ed.), Rationing in Action (London: British Medical Association), pp. 107–10. Wing, A. J. (1984) ‘Why Don’t the British Treat More Patients with Kidney Failure?’, British Medical Journal, vol. 287, pp. 1157–8.

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3 Transparency in Education Policy Neal D. Finkelstein

The 1988 Education Reform Act in England set in motion a series of far-reaching changes to English education policy with a firm and clearly articulated objective: to recast the education system by implementing centrally-controlled policy structures as the catalysts for improvements in educational services. The Thatcher Government began, and the Major Government continued, an overhaul of the education system that promoted at its very core the idea that educators, including those in government, ought to be accountable for the performance of pupils, and that parents ought to choose schools with this foremost in their minds. Many of the structures that have been put in place to stimulate competition and promote accountability are tied loosely to the concepts of markets, and market-based doctrine. While the Act introduced new educational curricula, it also addressed directly who should be accountable for the successes and failures of the education system, and where decisions about education policy should be made. This chapter discusses changes to accountability mechanisms from three perspectives within the system: central government, local government, and professionals at school sites. The significance of reviewing changes at each of the three levels cannot be overstated. The Act established an ironic juxtaposition of central government, with enormous central control, telling local school sites to have it their own way, albeit within a fairly predetermined scope. This separation of power between central government and the school sites left local government agencies in a precarious middle position – a position which is still notably unsettled today. A theme that has been prevalent in the rhetoric at all levels of the education system is that student performance needs to improve. 33

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Setting standards, and holding education professionals accountable to meet those standards has therefore been the primary focus of the education reforms. (Department for Education and Employment (DfEE), 1997) A natural extension of the debate is the somewhat intractable question of how policy-makers, and parents for that matter, will know when the targets of increased performance have been met. The discussion inevitably falls to information – is it accurate, is it without bias, is it accessible, and perhaps most importantly, does it matter? Does the behavior of government, teachers, parents, or students change because information has become available that in some way improves the score-keeping of the education system? At all levels of education system, there have been gestures to increase the transparency of policy as a way of encouraging the reforms. Whether the gestures are genuine or, alternatively, are overcome by the complexities of the education reform agenda, is explored in the following pages.

Accountability issues and decision-making by central government Education in England is centrally controlled. While the 1988 Act has a number of components that give the contrary impression, there is no mistaking that the major constraints on the provision of education are narrowly written and enforced by central government. The promise of school choice and the construction of markets in education are mediated by a set of policy structures at the central level (See Finkelstein and Grubb (forthcoming)). Briefly, four major policy structures guide how schools operate in England.1 The 1988 Act put into place the National Curriculum, increased the reliance on assessment systems as the basis for understanding the implementation of the National Curriculum, and recast Her Majesty’s Inspection (HMI) system into OFSTED (Office for Standards in Education) to ensure that particular standards were being met. With these three systems in place, a great majority of the decisions about how a school should operate have been made. A fourth policy change in 1988, the implementation of the Local Management of Schools (LMS), took significant responsibilities away from local government and devolved decision-making on some critical issues – including budgets – to head teachers at school sites. Each of these four major policy structures are described below.

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The National Curriculum The National Curriculum, for primary and secondary grades, details exactly what a child in each grade year ought to know. The curriculum exists across nine subject areas, and is complemented by teaching aids that suggest strategies for teaching that are consistent with content requirements. As a policy structure, the National Curriculum improves transparency – for better or worse. The arguments on both sides of the debate are well worn. For those who believe, almost philosophically, that the purposes of education can be transcribed into a particular set of curricular objectives, the creation of the National Curriculum satisfied the need to codify those objectives. The opponents argue that the very structure of a National Curriculum constrains the educational mission to be consistent with the views of those responsible for the design. In this particular case, the initial design and implementation of the National Curriculum is widely agreed to have been a fiasco, with rapid and overwhelming changes with unrealistic time frames being imposed on teachers. Either viewpoint in this debate supports the fact that discussion about what is taught in schools could allow increased public involvement. However, in England’s case, the design of the National Curriculum was done quickly, behind closed doors, and was delivered as a completed project. Subsequent revisions have been far more inclusive of a range of educators’ views. Nearly ten years after its introduction, and countless revisions later, head teachers’ anecdotal comments are that the National Curriculum has helped to raise standards, and when used imaginatively, need not restrict teachers’ creativity. Surprisingly, the research evidence in this area is woefully incomplete. The significance of the National Curriculum, as it relates to accountability, is that it establishes and documents a standard that applies to all schools for all children. The worthiness of curriculum standards has been widely debated for decades, but many policy specialists agree that curricular guidelines, of some kind, are essential; curriculum standards can protect students from schools that are performing at a substandard level. Alternatively, if used as a limit, curriculum standards can restrict that which might otherwise be taught by teachers with particular subject mastery or innovative ideas. School governors are legally responsible for ensuring that the National Curriculum is fully taught, and there is a wide variation from school to school as to how this is done. In fact, a similar

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range is notable in the way individual teaching professionals have gone about working within this policy constraint in their own schools. While some officials have suggested that schools have no choice but to follow the rigid curriculum structure, there are countless examples of teachers who have designed their own strategies and used the National Curriculum as a minimum standard from which to depart. The idea of a minimum standard was the original intention, which became overwhelmed by curriculum development at a highly specified level. For all the advantages and disadvantages of this approach, the implementation of the National Curriculum as part of the 1988 Act served to impose a structure on what was being taught in English schools. In addition, the nuts and bolts of the structure, in the form of a series of books that are found on every teacher’s bookshelf, are available for the public to read and scrutinize. Reacting to enormous pressure from the education community, the revision of the National Curriculum by the Qualifications and Curriculum Authority (QCA) is now to involve a broad array of educators. The debate on curriculum development was summarized recently by a series of questions that evolved during a professional conference on the topic: 1 How to build on the stability achieved through the five-year moratorium [on curricular changes] while recognizing the need for the curriculum to evolve over time – how much change, over what period of time? 2 Is the current balance right between central prescription and local determination of the curriculum? 3 How do we achieve the necessary focus on raising standards in literacy and numeracy, while retaining an appropriately broad, balanced and manageable curriculum? 4 Does the curriculum need to give greater emphasis to the spiritual, moral, personal and social dimensions of teaching and learning, and if so, how? 5 Is the structure of the National Curriculum and, in particular, its articulation in terms of discrete subjects, the most appropriate and effective way of setting out our expectations of primary schools? (School Curriculum and Assessment Authority (SCAA), 1997). The development of the curriculum will continue, as it should, with a debate on these types of topic. The extent to which the answers will be informed by a transparent process is less well known. What

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is clear, however, is that the overall education policy structure will continue to link curriculum design to the assessment of what students know. This segment of education policy, discussed next, forms a logical coherence – examine students on what they are to have learned as a way of understanding opportunities for improvement. Assessment In England, students are assessed formally four times during their schooling: at the ages of 7, 11, 14, and 16. Final examinations in specific subject areas for university entrance, the A-levels, are taken at age 18. Baseline assessment for pupils starting primary school at age 5 is being phased in. Year 4 assessment for 9-year-olds, optional at this point, in English and mathematics is being made available for schools who are interested. Government sponsored assessment is in vogue. The purpose of the assessment instruments is to provide evidence of attainment against the National Curriculum. Notably, the results of the assessment at year 16 – General Certificates of Secondary Education (GCSEs) – have been improving in recent years. The proportion of students who have scored grades of A to C in five or more areas of the National Curriculum has risen by 16 per cent since 1992 (Audit Commission, 1996a). A-level pass rates also continue to improve, continuing a thirty-year trend. But other assessment indicators for maths and reading, particularly in the primary years, have shown mixed results (Campbell, 1996). Independent of the actual assessment results, the justification for the process has been to improve accountability in education. With all the complications of the quality of assessment set to one side for the moment, the underlying motivation on the part of central government is to understand whether students are doing better or worse than they have done before, and if progress against the National Curriculum is being attained year by year. While perhaps a crude measurement technique for this purpose, the results of periodic assessments generate enormous amounts of data on how students, in particular schools, in particular socio-demographic areas perform on the same tests. The connection between more data and improved transparency is implied, but not proven. The fact that data has been generated has not necessarily meant that the connection to accountability has been improved, particularly for parents, who often find assessment issues daunting. The assessment results have been promoted

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as a way for parents to evaluate how their child is doing, and how their child’s school is doing compared to others in the area. Exactly how the information is used is much less certain. What is clear is that the motivation for reporting data on student progress is consistent with strategies to improve the competitiveness of schools through market-based principles. The actual reporting of comparative results has been made possible by the construction of league tables. Once a year, separately for primary and secondary schools, the tables are widely published in newspapers to compare the schools on the basis of the standard assessments. There is no adjustment made to the tables for the percentage of students enrolled who took the courses, took the exams, the socio-demographic characteristics of the school population, or the number of students who have special educational needs. As one might predict, the general pattern is that schools with students from middle-class homes in wealthy catchment areas do better than those schools serving children who live in more socioeconomically deprived areas. If the league tables serve to inform the notion of schools competing against one another, then it could be argued that the information is limited in its scope. Still, the league tables have evolved into a policy tool that most people seem to love to hate. Educators widely agree that the tables are misleading and distort the relative strengths and weaknesses of schools and their programs. They further agree that a ‘corrected table’ would be more useful if it could account for differences in socio-economic conditions and report more accurately a ‘value-added’ score for the educational programs that occur in schools. While these improvements are under development in England, and other countries, there has been no reporting of adjusted tables in England in the public domain. And ironically, at the same time that ministers have shown support for a value-added system to be in place by 1998, university researchers have insisted that more work still needs to be done to understand how ‘value-added’ scores could be developed. Still, head teachers do look at the scores. They are interested in the scores of their school compared with others nearby, and they reflect on the year-to-year changes. Technical distractions aside, the assessment programs that have been designed are another mechanism to improve accountability for outcomes in education. They are not perfect, and some would say that they are even destructive. But what seems as interesting as the debate over their accuracy is that there is no evidence that the

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assessment results are being used by parents in any systematic way. Research suggests that some parents use the information as part of the information they gather when choosing schools, but the interpretation of the results is far from systematic and uniform, and varies considerably among the socio-economic characteristics of families (Gewirtz et al., 1995). There is, however, plenty of evidence that the results are being used within the education establishment – by head teachers, LEAs, and central government. As it relates to accountability, the conclusion might be that the assessment information supports a process that is as much about educational change as it is political discourse. The fallibility of the information allows anyone to be critical, while at the same time the baseline information probably does produce some useful information about overall educational trends. Inspection Perhaps the most controversial of the four central government policies at this particular time is the inspection system operated by OFSTED. The ostensible objective, again, is to raise standards in education by making certain that the quality of the educational process, in each classroom, and in each school, is at least consistent with minimum standards as outlined in central government policy, and that it is disclosed. The inspectorate will have conducted a full one-week inspection of each school in England by the end of 1997 (6000 schools each year for each of the previous four years). During that inspection, the teachers, their lessons, the facilities, and the overall orderliness and culture of the school will have been examined. The tradition of English inspection has developed over a long and rich history whereby peer evaluation helps to support improvements in the operation of schools. In recent years, OFSTED has been criticized as being punitive. Whether or not that is true, the point holds that the inspection system further establishes the centrally-controlled nature of education policy under its current design. When a school is scheduled for inspection, an elaborate preparation begins on the part of the teaching staff and governors. Head teachers refer to the process as being ‘Ofsteded’. Documents are prepared, lessons are polished, and the school facility is made to sparkle, to the extent possible. There have been well documented cases of stress-induced medical leaves as a result of the preparation for an inspection by OFSTED.

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This chapter is not the place to consider the opportunity costs of the OFSTED process, although many educators raise this issue often and visibly. But what OFSTED has done in a relatively short time is to have become a watchdog agency with what some have described as a ‘hit-squad’ mentality. OFSTED identifies ‘failing schools’ in need of special measures, outstanding schools, and adequate schools, with a relatively subjective ranking method and a set of criteria used by inspectors with various amounts of training. In contrast to the earlier HMI, it is not the purpose of OFSTED to engage in elaborate aftercare to see changes develop in each of the schools it inspects. The findings of the inspection are prepared and delivered to the governing body and the head teacher. The governing body then responds to the findings with an accompanying action plan for the future. In 1997, the Chief Inspector and Director of OFSTED, Christopher Woodhead, came to be regarded in the popular media as a tyrant of sorts. His rhetoric, widely publicized in the newspapers, told of failing schools, failing teachers, failing head teachers, and poor lesson plans. Educators reacted strongly, claiming that the rhetoric served to demoralize teachers who are already under enormous pressure to raise standards in an environment of increasingly limited resources and larger class sizes. In April 1997, weeks before the general election, the largest teachers’ union in the country, the National Union of Teachers, called for Woodhead to be fired and threatened strikes if the current operations of OFSTED continued. The notable point is that OFSTED, and the mechanisms by which the agency reports its findings, are intended to expose the best and the worst of education to the public at large. For all the faults of the presentation of the agency, the mission is to identify and publicize the conditions under which schooling takes place. The inspectorate, in theory, allows the public to know the quality of schooling, school by school, and that information is intended to help parents in their own decision-making for their children. A related point arises in regard to the OFSTED data base. In the process of inspecting schools, OFSTED accumulates a wealth of information on the performance of pupils, teachers, and schools as a whole. The argument has been made, largely by academics, that the condition of the data is poor, and that accessibility to the data base by researchers has been limited in recent years. If the data is, in fact, poor, than the basis upon which OFSTED has made its conclusions could be challenged, and the politics of this point are

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critical. Access to the data by researchers also would seem to be essential if the objective is to validate findings in a rigorous manner with help from the research community. Local Management of Schools (LMS) The fourth major policy change was the implementation of LMS, which affected schools in three ways: school management; school site fiscal policy; and the connection of teaching and learning with fiscal decision-making. It is with this mechanism that the tension between central and local control becomes most explicit. At the same time, centralized policy structures set a clear course for teachers to follow and head teachers are given leeway to operate a school as they believe is appropriate. The two doctrines are necessarily incompatible, and a dominant feature of education policy structures in many countries, including the United States. From a practical standpoint on a day-to-day basis, LMS does devolve management responsibility to the school site. Head teachers view themselves as being ultimately responsible for what happens in an enormous range of activities, and they are held accountable by parents and local government as a result. This includes all the activities related to running the school on an operational basis as well as the fundamental task of providing educational enrichment. In addition, under LMS, it is required by law that a board of governors be responsible for the conduct of the school: for seeing that the National Curriculum is implemented; for seeing that the legal requirements of religious education are met; for deciding the timing of the school day; for taking up complaints from the community; and for the hiring and firing of staff. Governors are also ultimately responsible for the fiscal control of the school and all the decisions regarding the prudent spending of delegated funds. This is yet another mechanism by which accountability for the performance of a school is made explicit in the 1988 Act. Though criticized for being far from a system of representative democracy around the idea of community schooling, the system does involve some members of the community in scrutinizing each school in England (see Kogan, 1986, for example). The introduction of LMS has certainly improved the transparency of issues around the funding of schools. During a period of real decline in spending in secondary schools, and only modest increases in primary schools, LMS forced explicit reporting of school revenue and spending patterns. Prior to the implementation of LMS, school

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finance mechanisms were widely agreed to be a black box, held within local government. The policy structure forced the devolution of funding from the LEAs to the schools, and at the same time demanded that a rationale be developed and exposed. The implications of this development will be expanded further later in the chapter. Finally, if there is an opportunity for schools to compete with each other in England for pupil enrolment, LMS is the policy structure that enables the competition to flourish. It is with this mechanism that a school can try to promote a particular identity, and innovate within the constraints of central policy structures. With regard to accountability at the community level, LMS is the connecting policy between central government and the families that line a street. The head teacher of a school is the person who is visible and vulnerable in each community, and not the civil servants at the Department for Education and Employment. Central government control and the restrictions to innovation The paradox of a central policy structure juxtaposed against the framework of market-based competition in schools is that the system may in fact restrict education and innovation in dramatic ways. In essence, central government has already crafted ‘the school’ with a curriculum, an assessment framework, and an inspection agency, and imposed serious sanctions for those who fail to meet the criteria. Even under the new Labour government, the tendency to centralize control is pervasive. Deem et al. (1995) has made the point explicitly that schools have been given enormous incentives to remain the same. The manner in which they are governed, and the constraints imposed upon them, converge to promote schools that are offering similar services and vision. If there are choices, the choices are based on socio-economic indicators and have little to do with the mechanics and offerings of a school pedagogically. Further evidence on the notable lack of innovation in the grant maintained schools sector has suggested that the mechanisms to encourage differences have largely been overshadowed by the centralized nature of education policy (see Fitz et al., 1997). As noted earlier, as dramatic as the changes have been at the level of central government, the responsibilities of the local education authorities (LEAs) have changed dramatically. In the next section,

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these changes are reviewed, with particular attention being paid to the changes in accountability at the local government level.

The changing role of the local education authority It is important to realize that both the local authority, and the head teachers of schools do retain pieces of the control on educational decision-making. Perhaps the one segment of school governance that has changed most dramatically since the late 1980s is the local education authority (LEA). This is the local governing layer that sits between central government and the schools. The LEA historically has had a great amount of leverage in local policy matters. In fact, it is the level of power that some LEAs had prior to the 1988 Act that led the Conservatives to desire to restrict LEA power as it was difficult to contend with, politically, in Labourcontrolled local authorities. The Conservatives argued two main points. First, the role of local government, in a market-based model, could be justified only if it provided services at costs that were competitive with other providers. As local government provided staff training, maintenance, catering services, transport, and financial support as a monopolist, it was argued that the LEAs represented the worst of the bloated bureaucracies that symbolized the Labour Party of the 1970s. Second, it was argued that local government put a distance between the people and central government, which added inefficiency to the democracy: ministers should be directly accountable to voters, without government policy being mediated and interpreted at the local level. While the merits of these two arguments could be debated for some time, the reality is that the LEAs have had to re-craft themselves under enormous fiscal and ideological pressure. For every LEA that was bloated in 1987, there is one starving for resources and just getting by in 1997. In fact, the pressure to recast the LEAs as competitive producers of services was taken seriously and now most services that schools receive from local government are ‘bought back’ by the schools at their discretion. In some places the LEA has managed to sell a full complement of services to 100 per cent of the schools it serves. In other places, the number is far fewer, as schools have opted to purchase services from private providers and newly-formed consulting groups. LEAs now wrestle with maintaining a critical mass of advisors who are able to offer services to schools; quality counts and organizations are under considerable pressure to deliver services with increased efficiency.

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The critical point is that the balance of power changed in local government as a result of the 1988 Act. Stuart Maclure, former editor of The Times Educational Supplement, has described the 1988 Act as ‘altering the basic power structure of the education system. It restored to the central government powers over the curriculum . . . and set up formal machinery for exercising and enforcing these powers and responsibilities . . . it introduced important limitations on the functions of the local education authorities, who were forced to give greater autonomy to schools and governing bodies’ (Maclure, 1992). Whereas, prior to the law, schools were held under check by local government, now the balance has clearly changed to schools (head teachers) deciding to what extent they want or need the services that the LEA provides. The best way to describe the role of an LEA is that it ‘enables’ schools to do things they would like. This may take the form of staff training, or fiscal advice, or consultation on personnel policies, but these are hardly the roles of a superior authority. Rather, the LEAs act as service providers. With the strengthening of central government control in education, the LEA has also been required to deliver guidelines that are generated by the Department for Education and Employment (DfEE). A real and necessary tension existed for some time whereby policies developed at the LEA level would converge with those developed centrally. During the 1990s, less and less policy developed at the local level has been able to hold up against the requirements imposed by central government. Data collection and analysis is an obvious example. Existing research and analysis being done by an LEA must, for all practical purposes, be consistent with the efforts of the DfEE in the future. The connection to accountability is that the LEAs, prior to 1988, insured the performance of schools. Without question, if a parent was concerned about the school their child attended, they understood that the chain of command was first to the head teacher, and then to the LEA. The LEA further was responsible for school placements, and in particular the placement of children with special needs. In a sense, the LEA acted to mediate the needs of the ‘community’. It had the capacity to redistribute some funding, and it looked to an overall quality of provision across its jurisdiction. The LEA had oversight for the capacity of schools, and ensured placement for all children. This is in contrast with the model currently in place, whereby schools compete for students to enroll.

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As it turns out, the allocation of pupils appears to be highly inefficient at the time of writing. Stearns (1996) reports that selection has been as much about schools selecting pupils as about pupils selecting schools. This has arisen out of the over-subscription to schools in wealthy areas and the resulting choices that head teachers have made about who is admitted. Because schools have tended to be relatively inflexible and slow to change, one result is that only about half of the schools in England are fully occupied – that is, having a student population of 85–105 per cent of capacity (Audit Commission, 1996b). Approximately 11 per cent of school places are unfilled in English schools – space for nearly 900 000 pupils. The irony is that in the late 1990s the LEA still holds on to some of its obligation to be accountable – both to parents and to central government. But the authority to make changes and impose sanctions has been greatly reduced. In late 1996, The Ridings School in Halifax found itself on the front page of the newspapers as it wrestled with failure – educational failure from the perspective of pedagogy, discipline, and general purposefulness. In all the discussion of the failure of The Ridings School, the focal point became the LEA. In the 1980s, this would have been appropriate and accurate. In current law, however, it is more difficult to know where to apportion blame. School leadership, local government monitoring, and central government policy designs are all likely to have contributed to a school, in a particular area, that was unable to offer adequate educational services. It is not correct to categorize the LEAs as being wholly ineffective in their new role. On the contrary, there are remarkable professional relationships that have benefited from the ‘enabling’ role of local government. There is no benefit to anyone if a school fails, and most head teachers and governors work quite well with their LEA to ensure that their schools are performing well, both educationally and financially. Nevertheless, the power of the LEA has been greatly reduced. Though the variation is significant from authority to authority, LEAs generally have less power than they did before 1988, and yet are still held accountable for the local provision of education.

Decision-making and accountability at the school site There is an extensive academic literature in both the USA and the UK discussing the principle that organizations improve their efficiency

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when people are allowed to make decisions related to their work (see Lawler, 1986; Levacˇ ic´ 1995; and Odden and Conley, 1992). In the private sector, the language is largely about high-performance organizations and the improved productivity associated with flatter organizational structures. This set of ideas has been embraced in the public sector as well; however, there is little evidence of improved productivity. The de facto justification is that morale is improved by these arrangements, and who could disagree with improving morale? Schools are no exception. In both the USA and the UK, it has become a kind of credo that ‘schools are improved’ when head teachers are given the authority to make decisions about the educational program and the expenditure of resources. What makes England different from so many other countries that have experimented with site-based management is that England has taken the credo and implemented it as formal policy. In fact, more than in any other country in the world, English head teachers are given the power to control what happens on their school site during any given day. The decisions are about staffing, programs, finances, and strategy. Each of these areas will be reviewed, but it is critical to remember that as much as there is flexibility, the greater context within which schools operate is bound by central government doctrine. Discretion and judgment at the school site level Head teachers in recent years have become much like the chief executives of schools. Some teach, but many do not. If something goes right, or something goes wrong, the head teacher is directly accountable to parents. Accountability in this sense really means that the parent can decide whether to keep their child enrolled. In the landscape that promotes choice, the final measure is the enrolment of the school. As a result, the job of the head teacher includes developing a strategic vision for what a school ought to be, and the management capabilities to put that vision into practice. In some instances, the job might require accounting for the prudent expenditure of £1 million. The financial end of the work cannot be underestimated. The mechanism by which schools draw revenues is by drawing pupils. If a school is unable to attract and maintain students sufficient to cover its expense base, the inevitable hard decisions about budget cuts and redundancies are required.

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Perhaps it should be the students who should demand accountability, but it is more likely to be the parents, if at all. On this point the variation is great, and depends more on socio-economic issues than on the schools. The point is that some parents are heavily involved with what their children are doing at school, and others are not. As one head teacher said, ‘I’ve recently worked in a school in a socio-economically deprived area where there was no cachet for a parent to be involved.’ The difficult issue is that when decisions are made to attract pupils, they may or may not have to do with sound educational practices or with the needs of the children. It has been reported that the top five factors that influence parental choice in England are the child’s happiness, the child’s needs, the atmosphere in the school, its discipline policy, and the child’s personal preference (Centre for Educational Research, 1996). None of these factors is exactly about the educational program in the school, or about the quality of the pedagogy, although these ideas may be embedded in the broad response categories. None of these factors is directly about league table scores either. When it comes to accountability and decision-making, the relationship between teachers, parents, and students is remarkably clouded. Teachers do what they feel is right, using their professional judgment and professional discretion. On the other hand, within the existing system, the stakes are high for maintaining enrolment and conforming to government standards. As a result, individual head teachers do spend time marketing themselves and their school’s facilities as a way of demonstrating the strengths of the school that they lead. They also advertise the latest test score results their students have achieved, for better or worse. It is fair to conclude that the accountability mechanism only works if parents are involved. For the families who follow their child’s schooling – what they learn, how they progress, their social development – there can evolve some set of criteria that indicate satisfaction. For the parents who are not involved, and even for those who are, central government policy helps to decide if performance is up to par. How are test scores, how is progress, what is the culture of the school, is the line on moral education being held? All these are evaluated in some fashion by the accountability framework of government: progress against the National Curriculum, assessment of pupils, and inspection of schools and teaching. The ironies are worth emphasizing. One arm of government

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policy – that which encourages student selection and market-based competition – places the parent in a position to judge how a school performs. There is evidence to suggest that this policy has not worked, particularly for millions of working class families (Gewirtz et al., 1995). A second set of policies – those that impose assessment and inspection from central government – place the government in a position to judge how a school performs. Both policies are designed to raise accountability for student performance at the level of the school site. And both policy systems have put enormous pressure on the head teacher, and teachers in general. In the end, however, it is not clear that the citizenry finds either of these mechanisms particularly helpful when trying to select a school for a child.

Conclusion The policy structures that have been discussed illustrate that, for all the discussion of choice and flexibility within the education system, it is a highly proscribed policy area. But in some ways it is not a policy area that is poorly disclosed. There is plenty of information about the schools, and about schooling, that is readily available to the public. Central government has gone to great efforts to make some information available, particularly information about the performance of pupils. Local government has similarly been forced to disclose enormous amounts of information about fiscal issues, disclosing to the pound the placement of school revenues and the underlying rationale. Whether the information that is available coincides with what parents believe is useful in making decisions is less clear. In a sense, central government has set up a system of accountability that has a watchdog strategy. The implicit connection is that the public at large looks to the mechanisms that have been established as the basis for making fairly personal decisions about the education of their children. Central government appears to go out of its way to report on the progress of schooling, and on its shortcomings. Enrollment data, test results, college attainment levels, and international comparative data are readily available. Similarly, OFSTED reports on the schools that are excelling, and on those that have failed. It reports on the number of teachers who are ‘good’ and on the number who are ‘bad’. And, as noted earlier, central government has interpreted the idea of setting high standards as being consistent with reporting

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test scores by schools as a way of catalyzing competition and thus bringing about improvement. Importantly, the Audit Commission produces an enormous amount of information about how schools are progressing, particularly within the concept of value for money. As an independent arm of the government, the Audit Commission has maintained an impartial view and has reported on the progress and limitations of policy changes since 1988. The work is not generally used by individuals, although the reputation of the agency is that of high quality and impartiality. Perhaps the best information that is reported is that which begins or ends with the governing bodies of individual schools. From the perspective of a parent, the information from central government is far less important than what is occurring at a local school site. Indeed, parents, and the public at large, have access to the workings of the governing body, and a series of documents are public, by law. For example, following an inspection by OFSTED, a school must make the findings public, and produce a public document that outlines what kinds of corrective measures will be taken. And, as well as the documents being public, the process is public. Meetings are open, and parental views are encouraged, at least in a pro forma way. More than that, for the parent who is interested in the workings of a local school, positions are available to him or her to act as a school governor. In fact, while 350 000 adults across England are governors, at the time of writing there is a shortage of people willing to commit the time and effort that is required for this work. Ultimately, the diagnostics that are available to decide whether a job has been well done in education are extremely crude. This is true in England, in the USA, and everywhere else. The researchers who work on quantifying the effectiveness of a school generally argue that less than 10 per cent of the learning outcomes of a student are related to formal schooling (Creemers 1994). Learning happens in countless other ways, and in countless other places than in school. More than that, the relevant decisions that are made on behalf of a student are embedded within the professional judgment of a teacher a thousand times a day. As much as we assess students for their progress, and critique teachers for their judgment, we know relatively little on an objective scale as to whether decisions are being made in the best way they can. There is a disjuncture, therefore, between the policy structures that constrain teachers and the

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premise that they bolster standards. It seems appropriate that the accountability for outcomes ought to have to rest on the teachers’ shoulders. But the 1988 Act shows relatively little support for teachers as professionals with a hard job to do. In contrast, it has tried to proscribe their jobs without acknowledging the need for extraordinary professional judgments. Central government policy has sought to regulate education closely, in part because the variance in education quality appears to be significant across the country. It has not taken a particularly aggressive strategy towards improving the effectiveness of teachers. Instead, it has monitored closely only what they teach. As one LEA official said, ‘We’re getting close to the point where at 11:00 on a Thursday, all Year 4s across England will be working off page 23 of the Maths curriculum.’ With all of the changes since 1988, it must be concluded that education in England is rampant with mechanisms for accountability. In many ways this is true, and in spite of analytic evidence that is largely inconclusive, many head teachers would say that explicit changes in standards, and the subsequent enforcement of those standards, have helped to raise outcomes. Nevertheless, there still appears to be a significant gap in accountability from the perspective of the public: the average parent still largely guesses what to do when it is time to place his or her child in a school. Central government policy has created an enforcement mechanism that is led by central government. This is quite different from accountability being driven by an external body, or by organized public interest groups. As a result, if one believes that government policies towards improved accountability have been well directed, and that outcome measurements have integrity, the information is useful. Alternatively, those who have questioned central government policies might have found the reporting of progress, and particularly failure in recent years, not very useful towards meeting a long-term goal of educational improvement for students. Note 1 Another major policy change was the implementation of the grant maintained schools. At the time of writing, about 1020 schools (of 25 000) operate with direct funding from central government and are outside local government jurisdiction. The grant maintained schools ostensibly operate as independent schools, and parents choose them on their own merits. While this policy innovation may look like a market-based model in education, it represents less than 5 per cent of students in England and still operates under strict regulatory structures. The low subscrip-

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Neal D. Finkelstein 51 tion rate into the grant maintained sector remained something of an embarrassment for the Conservative government, and Labour plans to bring these schools back into a form of ‘distant’ LEA maintenance as foundation schools.

References Audit Commission (1996a) Adding Up the Sums 4: Comparative Information for Schools – 1995/96 (London: HMSO). Audit Commission (1996b) Trading Places: The Supply and Allocation of School Places (London: HMSO). Campbell, R. J. (1996) Standards of Literacy and Numeracy in English Primary Schools: A Real or Manufactured Crisis? (University of Warwick, Centre for Research in Elementary and Primary Education). Centre for Educational Research (1996) Parental Choice, Involvement and Expectations of Achievement in School (Swindon: Economic and Social Research Council). Creemers B. P. (1994) The Effective Classroom (London: Cassell). Deem, R., K. Brehony and S. Heath (1995) Active Citizenship and the Governing of Schools (Buckingham: Open University Press). Department for Education and Employment (DfEE) (1997) Excellence in Schools (London: HMSO), July. Finkelstein, N. D. (1997) The Coherence and Alignment of Educational Policy in England (University of Warwick, Centre for Research in Elementary and Primary Education). Finkelstein, N. D. and W. N. Grubb, Making Sense of Education and Training Markets: Lessons from England. Paper presented at the Annual Meeting of the American Educational Research Association, San Diego, CA, April 1998. Fitz, J., D. Halpin and S. Power (1997) ‘Between a Rock and a Hard Place: Diversity, Institutional Identity and Grant-Maintained Schools’, Oxford Review of Education, vol. 23, p. 1 (March). Gewirtz, S., S. J. Ball and R. Bowe (1995) Markets, Choice, and Equity in Education, (Buckingham: Open University Press). Kogan, M. (1986) Governing Bodies: The Future Role and Organisation of Local Government, Working Paper No. 2, (Brunel University, Department of Government), p. 11. Lawler, E. E. (1986) High Involvement Management: Participative Strategies for Improving Organizational Performance (San Francisco: Josey-Bass). Levacˇ ic´, R. (1995) Local Management of Schools: Analysis and Practice (Buckingham: Open University Press). Maclure, S. (1992) Education Re-Formed (London: Hodder & Stoughton). Odden, A. and S. Conley (1992) ‘Restructuring Teacher Compensation Systems’, in A. R. Odden (ed.), Rethinking School Finance: An Agenda for the 1990’s (San Francisco: Josey-Bass). Radnor, H. A. and S. Ball (1996) Local Education Authorities: Accountability and Control (Stoke-on-Trent: Trentham Books). School Curriculum and Assessment Authority (SCAA) (1997) Inform Newsletter (London: SCAA) ( July). Stearns, K. (1996) School Reform: Lessons From England (Princeton, NJ: The Carnegie Foundation for the Advancement of Teaching).

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Decision-making in Environmental Policy

4 Decision-making Processes in Environmental Policy and Regulation Robin L. Juni

By its fundamentally collective nature, environmental policy tends to implicate a multiplicity of actors. From microbial threats in Chesapeake Bay and the construction of the Newbury bypass to global warming and ozone depletion, a variety of viewpoints vie for attention when an environmental issue enters the policy arena. Perhaps more than any other factor, this phenomenon has forced questions of transparency to the fore in environmental decisionmaking, while other policy areas remain relatively opaque. Thus, to some degree, issues that have arisen in the implementation of environmental decisions may serve as a harbinger for other policy areas. This section compares institutional and legal structures that affect the transparency of environmental policy decisions – particularly under the pollution control regimes – in the USA and Great Britain, identifies cultural values and experiences that underlie these structures, and concludes with a broader discussion suggesting that management of pluralism and demands for transparency will not soon fade from the policy agenda.

Institutional and legal structures Both the USA and Great Britain allow ‘the public’ – or representatives thereof – a voice in some environmental planning and regulatory decisions. Because a process must be devised for that involvement, issues of transparency and accountability are addressed, at least for those in the process (and arguably for society as a whole), since the putative goal is to involve those members of the public who 52

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have a stake in the decision. Not all such public involvement processes are successful, of course, and some participants may pay only lip service to the discussions, but institutions in both nations have begun to grapple with the issues surrounding improved public participation in environmental decisions. Comparative analysis will be divided on two axes: the type of decision and the level of information provided. First, differences in public involvement can be seen between planning and regulatory determinations. Second, three distinct tiers of public information can be identified: access (ability to know what is happening); consultation (ability to express an opinion, but government retains the decision-making authority); and full participation (ability to vote, or otherwise exercise control in the decision). In general, both countries do a far better job of involving the public in forward-looking decisions, such as planning, and national differences are less apparent in the planning arena than under more retrospective regulatory regimes. Accordingly, while planning decisions will be discussed briefly, this section principally will seek to clarify and explain differences between the pollution control systems of the USA and Great Britain. Public participation in planning decisions Under the British Planning and Compensation Act, specific institutional ‘consultees’ – including organisations such as English Nature – must be involved in most planning decisions, usually at a secondtier ‘consultation’ level.1 If the government knows a particular proposal will be controversial, more groups and organisations may be brought in, to answer concerns that statutory consultees are too much a part of the system to be truly representative of the public. Despite such efforts, the British planning process, like many institutional decisions, 2 still suffers from perceptions that this consultation is a mere formality, and that critical issues have been decided before the public process begins. While improvements undoubtedly could be made, one commentator contends that planning is ‘in many respects a model of what an open democratic system of public administration should be’, finding that ‘there is no more open system of public regulation in existence in the UK’.3 Part of this openness is attributed to the availability of judicial review; McAuslan (1991) suggests that because some British judges have backgrounds as planning lawyers, they are more willing to ‘look behind’ agency planning decisions, and so have opened that field to greater public involvement

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and decision transparency.4 This theme returns in the analysis of pollution control systems. In the United States, similar planning processes occur under a myriad of state and local statutes. For major private projects requiring federal permits or other federal actions, National Environmental Policy Act (NEPA) strictures must be followed. However, NEPA requires only that federal agencies with legal jurisdiction or ‘special expertise’ be consulted in the assessment of environmental impact from a particular decision.5 Comments from private citizens or environmental groups typically are accepted only after a draft decision has been reached, and there exists no statutory mandate that particular groups be involved in a decision. Rather, the NEPA process focuses on ensuring that a rigorous ‘scoping’ of issues occurs, and that feasible alternatives are studied before any project entailing a significant environmental impact may be undertaken. However, some state and local planning laws go beyond typical consultation, to provide a level of information closer to true participation in a decision. For example, the Massachusetts Hazardous Waste Facility Siting Act sets out a facilitated process for public involvement, rather than a more pro forma talking heads meeting, at which officials listen to comments from the floor, but are not typically interested in engaging in dialogue.6 While the Massachusetts process has been criticized as providing little more input than ordinary consultation – the same iron fist covered by a more luxurious velvet glove – such forms of participation can provide more meaningful public involvement than a traditional planning process, if that potential is properly utilized and decision-making authorities are willing to participate.7 As in the British planning system, however, the threat of litigation strongly influences incentives for US agencies and other actors to share decision-making power. In sum, both the British and American planning systems provide principally for public consultation, although the potential for increased involvement via litigation is a somewhat more realistic threat in the United States. With planning in mind as a backdrop, we now turn to the starker differences in pollution-control systems. Public participation in pollution control decisions Legal and institutional structures in the United Kingdom Regulatory agencies in the United Kingdom historically have utilized a discretionary, consensus-based approach to pollution-control decisions, relying on bargaining between an industrial discharger

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and an agency to achieve compliance with broadly-articulated goals.8 In this system, public participation has not generally been considered to be important; moreover, prosecution is seen as a last resort, a step to be taken only with respect to the most extreme and recalcitrant polluter. However, it is critical to remember that – unlike American laws – British environmental statutes do not contain a civil enforcement component. With limited exceptions, only criminal prosecutions can be brought under environmental statutes, and the role of civil law has been reserved for more conventional frameworks, such as nuisance, negligence, and trespass. Thus, any decision to prosecute is a decision to prosecute criminally, with attendant increases in governmental burdens of proof and stigma associated with conviction. It is not surprising that, compared with the United States, many fewer prosecutions occur in this context. Since the mid-1990s, however, the consensus-based British approach has begun to erode. Several interrelated factors have contributed to the trend. First, and perhaps most fundamentally, public attitudes in Britain have shifted to accord more appreciation for the environment: The concept of the environment having rights of its own is increasing in importance, and generally the desire to protect the environment has begun to undermine previous assumptions made as to the benefits of industrial activities which cause pollution. 9 Ball and Bell (1995) further discuss historic British perceptions of the need for environmental regulation, especially as contrasted with continental Europe: ‘With its rainy climate, fast-running streams, ample coastline and relative remoteness . . . the same discharge is supposed to cause less pollution in Britain than in other [European Union] countries, because of its lesser effect on the environment’. 10 However, attitudes may be becoming more comparable: a 1997 survey of numerous countries’ attitudes toward environmental issues suggested that, while Americans were somewhat more willing to fund directly environmental improvements, 69 per cent of both American and British survey participants said that protecting the environment should take priority over economic growth.11 Second, administrative changes are important. Consolidation of all pollution control functions into the Environment Agency – which until April 1996 were divided among the National Rivers Authority, Her Majesty’s Inspectorate of Pollution, and local Waste Regulation

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Authorities – has increased public access to pollution control decisions and enhanced transparency, simply because the organizational responsibilities are now more clear, and ‘one-stop shopping’ for environmental information can occur. Third, that information is much more accessible and more specific. The need to comply with directives and other legislation passed at European Union (EU) level has resulted in increased access to information for the British public, particularly those involved in organized environmental groups. EU directives have similarly encouraged the development of more explicit pollution control standards – emission standards that set permissible maximum concentrations of substances, or define quality objectives for air or water – that are more easily monitored, which may further provide pressure points for litigation, and which may thus encourage concomitantly more transparency in decision-making by environmental officials. Adoption and enforcement of EU legislation is a complex process. Many environmental provisions are passed by the EU Council of Ministers12 as ‘directives’ that are binding on EU members as to the result to be achieved, but do not specify the manner in which national law must accomplish the objective. Because directives are often substantively quite detailed, ‘the level of discretion afforded to member states in implementation is practically quite limited’.13 Procedural and institutional mandates can be equally daunting: Member States have thus, first of all, to transpose and incorporate the Community environmental legislation [including directives] into their national legal system and then to ensure that the environmental provisions are effectively applied in practice. However, their obligations do not end here. They have also to create the necessary local, regional and national administrative, technical and scientific infrastructure to be able to effectively preserve, protect and improve the quality of their environment; to create bodies that are capable of systematically analysing and monitoring emissions, discharges and other environmental impairment; to create, improve and maintain environmental awareness with the public; to make the polluter pay and prevent environmental damage.14 The European Commission (EC) can sue member states in the European Court of Justice (ECJ) for failure to implement directives, and there exists some evidence that exercise of this option is

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increasing15. One commentator has argued that because the EU lacks staff and resources to undertake alternative regulatory measures, such as market-based approaches, ‘the only effective way to influence and to “bite” is by legislation’16 and subsequent proceedings to enforce that legislation.17 Moreover, even if the EC chooses not to litigate, a private person or organization can sue member states for failure to implement directives, and – if the impact on the individual is sufficiently direct – can recover damages resulting from that failure.18 Thus, significant pressures encourage member states to comply with EU legislation, creating what some observers describe as a ‘quasi-federal system of government in which the Member States retain a foreign relations capacity’.19 The focus on legislation as a means to influence members’ environmental policies arguably shifted with the EU’s Fifth Action Program: Up to present, environmental protection in the Community has mainly been based on a legislative approach (‘top down’). The new strategy advanced in this programme implies the involvement of all economic and social partners (‘bottom-up’). The complementarity and effectiveness of the two approaches together will depend, in great measure, on the level and quality of dialogue which will take place in pursuance of partnership. 20 Consistent with the ‘bottom-up’ approach, European environmental ministers have directly expressed support for public involvement in decision-making. 21 Moreover, the role of EU legislation in providing tools – such as more readily available information and specific standards – for that involvement should not be underestimated. Largely in response to EU directives, British statutes and regulations significantly increased public access to environmental information in 1990 and 1992,22 and the ‘move toward openness broadened with the introduction of the Environment Act 1995’. 23 In particular, the British Environmental Information Regulations – adopted to implement the EU Directive on Freedom to Environmental Information (90/313) – provide that any public body, whether local or national, ‘with responsibility for the environment must make environmental information available to any person who requests it’.24 While certain exceptions to the disclosure requirement exist, and the ability of the public usefully to assess the information provided has been questioned,25 ‘the historic ability of the government

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to demand “socialization” as the price for political participation’26 has lessened substantially. In addition to information access, the EC has recognized that citizens’ suits can provide important leverage for environmental groups, and encourages further study of that approach.27 Indeed, both environmental groups and government agencies are using increasingly specific statutes to bring more prosecutions in the UK, particularly at Crown Court – as opposed to magistrates’ court – level. In Crown Court, fines that may be imposed for pollution offenses are unlimited, and imprisonment can be sought. In magistrates’ courts, fines are limited to approximately $35 000. 28 Finally, the role of the EU in encouraging statutory specificity is critical. With respect to water pollution control in Britain: ‘A formal system of water quality classifications and objectives, statutory regulations on drinking water quality, the introduction of specific standards for dangerous substances, and a dramatic shift in relation to the discharge of sewage effluent to the sea can all be traced to EC initiatives . . . Perhaps the greatest impact, however, has been the great publicity that has been engendered by having specific standards set at EC level against which Government action can be measured.’29 While this argument has substantial force, it is important to remember that specificity does not necessarily imply stringency. For example, under similar EU air regulations, violations are averaged over the course of a year, and thus effectively ignore one-time pollution incidents. Moreover, replacing commonsense approaches such as prohibition of ‘dark smoke’ with more quantifiable measures – lead in parts per million or particulate diameter in microns – may be technically easier to monitor, but more difficult for average members of the public to understand. Environmental groups have been cautious in reaction to calls for increased public involvement, at least when that involvement is not supported by specific, binding mandates such as those provided under the water pollution control directives. For example, the European Environment Bureau (EEB), a consortium of environmental organizations based in Brussels, has expressed disappointment with outcomes of the Fifth Action Program and has warned that voluntary agreements encouraged under the Program ‘cannot replace legal requirements’; ‘legislation should be maintained as a baseline and economic and voluntary instruments be used to give incentives for implementation and enforcement’.30

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Legal and institutional structures in the United States The pollution control experiences of the United States illustrate the approach that the EEB may have in mind: specific standards, backed by litigative tools, provide incentives for negotiated outcomes and greater public involvement than exists in Britain. However, the US experience vividly illustrates that transparency and public involvement generally imply significant transaction costs, not least as a result of litigation. Moreover, it is not clear that individual citizens – as opposed to organized environmental groups – in the United States generally have a substantial voice in environmental policy. As discussed below, the US environmental statutes developed under the influence of the civil rights movement, and generally provide particularized standards against which conduct of the government and industry can be measured. Moreover, that information can be used at many more points of access in pollution control regimes. First, a well-developed system of information, both under environmental legislation and under the Freedom of Information Act (FOIA),31 is available to illuminate government decisions. Although the ‘deliberative process’ of the agency is protected under FOIA, along with several other categories of information, many relevant documents can be obtained through well-worded FOIA requests. Second, in making regulatory decisions, the US Environmental Protection Agency (EPA) is generally required to accept and substantively respond to public comment on draft decisions. 32 Third, if any party is not satisfied with that response, the agency decision can be challenged in court as an arbitrary and capricious administrative action. The decision will be vacated if the agency cannot provide an administrative record that sets out a reasonable explanation for its choice.33 In addition, outside the regulatory context, litigation provides powerful incentives for government and industry to involve the affected public in decision-making. For example, under the US Clean Water Act, citizens can gather publicly-available information with regard to a company’s discharge limits, quickly demonstrate numerous violations via a strict liability scheme, then use citizens’ suit provisions to seek penalties and attorneys’ fees from the company. Although any penalties awarded generally must be paid to the federal treasury, Supplemental Environmental Projects may offset a significant amount of penalty and may include payments to fund environmental group projects. 34

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To utilize these points of access optimally, however, expertise is essential. Lawyers must often assist in drafting FOIA requests and filing complaints, and scientists must interpret data to challenge a proposed agency regulation. Thus, although the policy-making role of organized environmental groups who employ such experts is relatively robust, individual members of the public are not involved as often: ‘To involve nonexpert participants meaningfully, efforts must be made to educate them technically or to find individuals who understand the technical issues and can represent the parties’ knowledge, perspectives, and concerns in a way that satisfies those parties.’35 While the challenge is easily articulated, the logistics of participation – education of affected citizens, payment of experts, location and schedule of meetings – are far more difficult to address. Some environmental statutes provide for the award of technical assistance grants to interested citizens’ groups, but funds are limited, administrative processes to secure a grant can be frustrating, and, not insignificantly, unless a crisis looms, most people simply will not have the time to participate.36 Thus, although any member of ‘the public’ has a right to become involved in environmental decision-making, it is important to remember, in practice, that those interests are often represented by local or national environmental groups. In sum, even if through institutional players, the US public generally can achieve access and consultation in environmental decisionmaking, and – mainly through settlement of litigation – can often get a share of participation in particular decisions. This ‘hyperpluralism’ in decision-making is exacerbated by the multiplicity of institutions in government, particularly Congress versus the executive branch. Senators and Representatives can easily vote to give constituents ‘a voice in government’, when executive branch agencies, not Congress, will have to cope with the plethora of public comments.

Cultural values and experiences The contrasting limited involvement in British regulatory decisions has its roots in several cultural and historical factors. Chief among these is the development of the British state as a parliamentary democracy. Because Parliament holds the reigns of both legislative and executive power, there exists limited institutional incentive to permit outsiders access to government decision-making, or to

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develop rules that would limit flexibility to be exercised by the government of the day. In particular, the fact that the government owned many major industries until the mid-1980s may have contributed to a diminished incentive to develop stringent and specific environmental standards. More generally, after examining numerous examples from the United States and Europe, one commentator argues that ‘the main factor which determines the degree to which government information is available to the public is the type of authority elected representatives have over officials and, in particular, by whether officials are directly subordinate to a unified political authority’. 37 In other words, a unified parliamentary structure encourages secrecy, because there exists no incentive to provide ‘oversight’ – in the sense often used by the American Congress – of agencies that are controlled by the legislature. 38 Moreover, for many years, the presence of the welfare state encouraged a more quiescent population that did not, in many circumstances, feel a need to assert their rights. Using Sweden as an example, Steven Kelman (1981) argues that the generally deferential cultural values in Europe – which may encourage the development of a parliamentary government – have their genesis in monarchy.39 James Q. Wilson (1989) draws a relevant distinction between the United States and France. Both countries fought a revolution, but the French were essentially driven by a desire for popular government, with the unfettered discretion once enjoyed by the monarch passing to the people. In contrast, United States citizens wanted, at bottom, a limited government: ‘Americans distrusted everyone who wielded power and sought to prevent the abuse of power by surrounding its holders with constitutional checks and subjecting its exercise to the rule of law.’ 40 Thus, the United States developed a system of governance that constrained the state, and encouraged individual citizens to question government decisionmaking. Opportunities for greater public involvement and increased constraints on agency action in the United States multiplied in the mid-twentieth century, for two major reasons. First, key figures in ‘New Deal’ agencies and policies felt that access to the government had been unduly restricted in the past, and that agencies were in danger of being ‘captured’ by privileged groups, particularly business interests. Second, from the 1950s to the 1970s, the judiciary gradually broadened citizens’ rights in court, both by increasing

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the number of citizens with standing to bring a challenge, and by altering the nature of that challenge to include matters that had previously been considered policy decisions beyond the scope of judicial review.41 Nascent environmental pressure groups capitalized on these trends. In particular, Mary Douglas and Aaron Wildavsky (1982) identify three major reasons why the environmental movement largely began in the United States. First, the absence of a hereditary elite and a decentralized governmental structure meant that sectarian attacks on the establishment ‘center’ were encouraged or, at the very least, tolerated. Second, after the Second World War, the United States economy had a head start on the rest of the world, such that, by the 1960s a high percentage of the population attended college, and on graduation obtained jobs in expanding service industries catering to a richer populace. Accordingly, ‘the economic boom and the educational boom together produced a cohort of articulate, critical people with no commitment to commerce and industry’,42 most of whom had observed or participated in the civil rights and anti-Vietnam War movements and thus could base their campaigns on those models. Third, the development of direct-mail techniques permitted a small group of leaders to gain the support of a far larger membership, the vast majority of whom send money, but do not further participate in the organization.43 These trends accelerated in the 1960s and 1970s, when most of the US environmental laws were drafted and began to be implemented. Environmental activists who had cut their teeth on the civil rights movement were particularly influential: The antipollution movements benefited from . . . imitating the tactics of the civil rights movement . . . [which] earned an honorific place in American life because it sought to redress wrongs in the name of a central value of American individualism – equality before the law. It was good against evil, a modern morality play in which a minority carried the creed. Everything connected with the civil rights movement, therefore, became ennobled, including its tactics – nonviolent protest, nonnegotiable demands, and due process of law. Increased political participation, use of government to achieve group gains, use of lawsuits to claim rights, insistence that rules and regulations be followed precisely as a means of obtaining compliance – these procedural reforms achieved almost a hallowed status by association.44

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Indeed, the moral tone of much United States environmental legislation passed in the 1970s – ‘setting standards that could not be met, using legal orders to enforce them, refusing to consider costs’ – was profoundly influenced by the civil rights movement. 45 Related influence from civil rights disputes can be seen in the courts. Backed by a strong tradition of judicial activism in desegregating schools, for example, the tone of many US courts – even when upholding EPA decisions as non-arbitrary and capricious – is one of reluctance: ‘This is a troubling statutory scheme and a questionable agency decision, but neither is so egregious that the court can step in to remedy the situation.’46 Similarly, US judges are more inclined than their UK counterparts to examine carefully the substance of an agency decision, as well as the procedure followed. 47 Douglas and Wildavsky (1982) argue that environmental groups are inclined to capitalize on this judicial skepticism, viewing litigation as an attractive means to affect environmental policy because courts ‘epitomized their ideal of public authority without public bureaucracy’.48 The availability of attorneys’ fees for citizens’ suits under US environmental laws further reinforces the outlook; indeed, fees from one successful lawsuit, in which a defendant will probably pay environmental group lawyers the prevailing market price for professional services – typically around $150 per hour for an attorney a few years out of law school – while the lawyers are drawing a much lower salary from the group, can finance less remunerative activities. Thus, particularly in a field such as environmental policy, in which multiple stakeholders are keenly interested: The fragmentation of political authority leaves U.S. administrators in a peculiarly vulnerable position. They are confronted with conflicting statutory mandates . . . [that] must often be implemented under the critical eye of other government institutions, and in full view of warring private interests . . . Unable to strike deals in private, American regulatory agencies are forced to seek refuge in ‘objectivity’, adopting formal methodologies for rationalizing their every action. 49 In sum, oversight from Congress, citizens and the courts have resulted in a proliferation of rules that curtail agency discretion to formulate and implement environmental policy in the United States. While this is not necessarily a bad outcome, constraints on government

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are not without cost. First, agency efficiency is impeded: the more time and effort is spent complying with rules, the less can be spent implementing agency programs.50 Second, rules imposed to ensure fairness – to treat like cases alike – can prevent responsiveness: that is, to take special circumstances into account when an agency decision is made.51 Third, to the extent litigation is used as a policy tool, transaction costs and delay will probably increase. In contrast, the ‘regulatory bargaining’ process – as between the government and an industrial discharger – in the United Kingdom historically has done a far better job of dealing with individual circumstances and has substantially avoided litigation. Moreover, even when litigation is utilized, British judges provide more discretion to agencies,52 even though similar standards of review allow both US and UK judges to overturn agency decisions that are not supported in law and fact.53 Thus, the British system has generally achieved responsiveness and efficiency, at some cost of well-articulated, consistently-applied rules and decision-making involvement by a broad constituency of interests. In addition to EU legislative pressures, calls for the citizens’ suit, civil penalty and judicial review strictures so important to environmental pressure groups in the United States are beginning to emerge in Britain. Recent proposals for judicial reform may similarly provide procedural bases for increased court involvement.54 As this chapter has sought to demonstrate, such procedures may make decision-making more accessible and transparent, but are not without significant cost. Moreover, the legal and technical processes utilized can influence significantly the manner in which environmental policy questions are framed, and the answers that are generated.

Conclusion There is no indication that struggles over environmental issues and public participation will go away: globalization of problems and near-instantaneous communication will see to that. It is relatively easy to trust institutions dealing with purely local problems, particularly when no information is available on the processes or solutions identified by others grappling with similar issues. But that is no longer the world in which we live. Sooner or later transparency and participation issues in most policy fields will be forced forward, possibly in response to disaster. Even without a crisis,

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governments and companies who wish to have a voice in decisions made by other governments with respect to rainforest degradation or anti-competition standards will have some difficulty in contending that involvement of others in their decisions is not a legitimate pursuit. Accordingly, before the issue is forced onto the table in a particular context, careful analysis should inform the mechanisms by which decision-making power may be shared and institutions altered to more closely approximate participatory democracy. Such participation comes with a price, but that cost may be less than if protesters chain themselves to the gates of a factory or bury themselves underground to resist a new road. This chapter has sought to highlight some of the institutional and legal structures that affect public participation in environmental decisions, and to suggest cultural factors that may explain and influence these structures. Implementation of measures to alter these structures, to make decisions more transparent, and to share power effectively with the public may be one of the greatest challenges facing the modern regulatory state. Notes 1 Ball and Bell (1995), p. 229. 2 See National Research Council (1996), p. 78 (discussing ‘decide, announce, defend’ approach of US risk characterization decisions). 3 McAuslan (1991), pp. 195, 200. 4 Ibid. 5 National Environmental Policy Act § 102, 42 U.S.C. § 4332. 6 Wheeler (1994), pp. 241, 255–58. 7 Wheeler (1994), pp. 273–80; National Research Council (1996), pp. 122–3. 8 Hawkins (1989), pp. 663, 666–68. 9 Ball and Bell (1995), p. 134. 10 Ball and Bell (1995) pp. 100–101. 11 Washington Post ‘Green, Greener, Greenest’, 22 November 1997 (reporting results of survey conducted by Environics International, Toronto, Ontario). 12 Voting procedures in the Council are critical to the passage of many measures: some matters require unanimity of the fifteen member states; others can be passed over the objections of one or more members via a ‘qualified majority’ voting system, in which each member state is allocated between two and ten votes, depending on size, and a simple majority of favorable votes passes a measure (see Ball and Bell (1995), pp. 57–8). Under this system, Luxembourg has two votes; Ireland, Denmark and Finland each have three votes; Austria and Sweden each have four votes; Belgium, Greece, the Netherlands and Portugal each have five votes; Spain has eight votes; and the United Kingdom, France,

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Decision-making in Environmental Policy Germany and Italy each have ten votes. Serving the European Union: A Citizen’s Guide to the Institutions of the European Union (1996), p. 10. Most environmental measures can be passed by qualified majority (see Ball and Bell (1995), pp. 73–4). Macrory and Hession (1996), p. 127. Macrory and Hession describe other forms of binding EU measures: (i) regulations, which are directly applicable to members and require no national implementation; (ii) decisions of the European Court of Justice or another EU institution, which are binding on the parties to whom the decision is addressed; and (iii) in some circumstances, international agreements to which members have acceded (ibid., pp. 126–7). Kramer (1995), p. 131. Mackenzie (1994), p. 81; but see Kunzlik (1997), pp. 321, 338 (discussing evidence that bureaucracy and lack of trust in EU institutions may have reduced the number of environmental complaints brought to the European Commission and subsequently referred to the European Court). Weber (1986), p. 66. Ludwig Kramer provides a caveat: ‘[L]egislation is sometimes drafted in an inconsistent, even contradictory way . . . which hide[s] subsistent [sic] differences among Member States . . . Directives thus quite often give an added value to the environmental protection where a national administration is willing to provide for such an added protection. Where, however, national, regional or local administration is less convinced of the need to protect the environment, the loose and general drafting of the Community legislation considerably reduces this added value’, Kramer (1995), p. 158. Like most litigation, these matters often are settled before an ECJ decision is rendered; accordingly, a ‘repeat player’ like the Commission can ‘convert litigation into a resource for structured bargaining’ by carefully evaluating the precedential impact of those cases pursued in court. Snyder (1993), pp. 19, 28–31. See Francovich and Bonifaci v. Italy (Case C6–90) [1993], 2 CMLR 66. Macrory and Hession (1996), p. 106. Commission of the European Communities (1993), p. 43. United Nations Economic Commission for Europe (1996) (guidelines endorsed by the Third Ministerial Conference on ‘Environment for Europe’, 23–25 October 1995). See Macrory (1991), pp. 17–19; Ogus (1994), p. 206 (discussing the shift towards formalism in British environmental regulations ‘as the control systems have had to meet the challenges of new threats to the environment, the increasing role of EC law, and the demand for more accountability and a greater decree of public participation in standardsetting processes’). Ball and Bell (1995), p. 150. Ball and Bell (1995), p. 161. ‘Environmental information’ is broadly defined, including ‘information on the quality and state of air, water, soil, flora, fauna, natural sites and other land’, as well as ‘activities which adversely affect these areas and the measures which are used to protect them’ (ibid.). Ibid., pp. 162–6.

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26 Vogel (1986), p. 288. 27 Commission of the European Communities (1996), p. 11. 28 Ball and Bell (1995), pp. 134–5. However, although there are a few exceptions, most UK fines would be considered quite small in the US context. See National Rivers Authority v. Shell (UK) [1990] Water Law 40 (imposing fine of approximately $1.7 million); International Environment Reporter ‘Agency Seeks High-Level Meeting With ICI on Frequent Chemical Spills in Past Months’, 14 May 1997, p. 493 (noting ‘tough stance’ of Environment Agency in rapid investigation, prosecution and award of approximately $25 000 fine). 29 Ibid., p. 423. 30 Van Ermen (1996), pp. 5, 48. 31 5 U.S.C. § 552 (setting forth presumption in favor of disclosure, unless government information fits into a specific statutory exemption). 32 Administrative Procedure Act, 5 U.S.C. §§ 553 and 706. 33 See Citizens to Preserve Overton Park, Inc. v. Volpe, 401 U.S. 402 (1971). 34 Macfarlane and Terry (1997), pp. 20, 21. 35 National Research Council (1996), p. 135. 36 See, for example, 42 U.S.C. § 4368 (NEPA grants to citizens’ groups, so long as such groups are not ‘single-issue oriented’); 42 U.S.C. § 9617(e) (grants under Comprehensive Environmental Response, Compensation, and Liability Act for citizens ‘affected by a release or threatened release’ from serious hazardous waste sites). 37 Robertson (1982), p. 2. 38 However, some evidence suggests that this tendency can be overcome. For example, two British researchers studying climate change issues have observed that, while the influence of ‘back-benchers’ on civil servants remains modest, ‘[p]arliamentary surveillance is becoming more pointed, well researched, well documented, and successfully critical of policy assumptions and policy biases’ O’Riordan and Rowbotham (1996), p. 231. 39 Kelman (1981), pp. 114–15. 40 Wilson (1989), p. 335. 41 Ibid., pp. 85–6, 280–1. 42 Douglas and Wildavsky (1982), p. 159. 43 Ibid., p. 173. 44 Ibid. p. 163. 45 Ibid. 46 See, for example, Montrose Chemical Corp. of California v. EPA, 132 F.3d 90, 94 (D.C. Cir. 1998) (finding that ‘the inconsistency of the agency’s approach has caused understandable concern among interested parties’). 47 Gellhorn and Boyer (1981), p. 273 (‘The trend in recent years seems to be away from judicial deference toward a much closer and more skeptical probing of the basis for administrative rules’). 48 Douglas and Wildavsky (1982), p. 166. 49 Brickman et al. (1985), p. 304. 50 This is precisely the result some observers would wish. In agencies seeking to address areas such as the environment, occupational safety, and consumer protection, ‘[o]pposing groups are dedicated to crippling the bureaucracy and gaining control over its decisions, and they will

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Decision-making in Environmental Policy pressure for fragmented authority, labrythine procedures, mechanisms of political intervention, and other structures that subvert the bureaucracy’s performance and open it up to attack’, Wilson (1989), pp. 242–3 (citing Moe (1989)). However, assuming that society wants agencies to be doing something in exchange for the salaries accepted by its employees, efficiency is a positive goal. Wilson (1989), pp. 326–7. See Cambridge Water Co. Ltd v. Eastern Counties Leather plc [1994], 1 All E.R. 53 (finding that ‘well-informed and carefully structured legislation’ counsels against judicial activism in expanding the theories of environmental liability). Compare Associated Provincial Picture House Limited v. Wednesbury Corporation [1948], 1 K.B. 223 (holding that court must overturn ‘unreasonable’ exercise of agency discretion) with Administrative Procedure Act § 706 (court must overturn ‘arbitrary and capricious’ agency decision). Rt Hon. Lord Woolf (1996), pp. 5–7 (litigation funding for parties with limited resources); pp. 62–4 (case management processes); pp. 124–7 (early accessibility of information).

References Ball, S. and S. Bell (1995) Environmental Law: The Law and Policy Relating to the Environment, 3rd edn. (London: Blackstone). Brickman, R., S. Jasanoff and T. Ilgen (1985) Controlling Chemicals: The Politics of Regulation in Europe and the United States (Ithaca, NY: Cornell University Press). Commission of the European Communities (1993) Towards Sustainability: A European Community Programme of Policy and Action in Relation to the Environment and Sustainable Development (Brussels: Commission of the European Communities). Commission of the European Communities (1996) Implementing Community Environment Law (Brussels: Commission of the European Communities). Douglas, M. and A. Wildavsky (1982) Risk and Culture (Los Angeles, Calif.: University of California Press). Gellhorn, E. and B. Boyer (1981) Administrative Law and Process (2nd edn.) (St Paul, Minn.: West Publishing Company). Washington Post, ‘Green, Greener, Greenest’, 22 November 1997. Hawkins, K. H. (1989) ‘Rule and Discretion in Comparative Perspective: The Case of Social Regulation’, Ohio State Law Journal, vol. 50. International Environment Reporter, ‘Agency Seeks High-Level Meeting With ICI on Frequent Chemical Spills in Past Months’, 14 May 1997. Kelman, S. (1981) Regulating America, Regulating Sweden: A Comparative Study of Occupational Safety and Health Policy (Cambridge, Mass.: MIT Press). Kramer, L. (1995) E.C. Treaty and Environmental Law (London: Sweet & Maxwell). Kunzlik, P. (1997) ‘Access to the Commission’s Documents in Environmental Cases – Confidentiality and Public Confidence’, Journal of Environmental Law, vol. 9. Macfarlane, R. and L. Terry (1997) ‘Citizen Suits: Impacts on Permitting and Agency Enforcement’, Natural Resources & Environment, vol. 12 (Spring).

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Mackenzie, M. B. (1994) ‘European Community Law and the Environment’, in Alan E. Boyle (ed.), Environmental Regulation and Economic Growth (Oxford: Clarendon Press). Macrory, R. (1991) ‘Environmental Law: Shifting Discretions and the New Formalism’, in Owen Lomas (ed.), Frontiers of Environmental Law (London: Chancery Law Publishing). Macrory, R. and M. Hession (1996) ‘The European Community and Climate Change: The Role of Law and Legal Competence’, in O’Riordan, T. and Jager, J. (eds.), Politics of Climate Change: A European Perspective (London: Routledge). McAuslan, P. (1991) ‘The Role of Courts and Other Judicial Type Bodies in Environmental Management’, Journal of Environmental Law, vol. 3. Moe, T. M. (1989) ‘The Politics of Bureaucratic Structure’, in John E. Chubb and Paul E. Peterson (eds.), Can the Government Govern? (Washington DC: Brookings Institution). National Research Council (1996) Understanding Risk: Informing Decisions in a Democratic Society (Washington DC: National Academy Press). Ogus, A. (1994) Regulation: Legal Form and Economic Theory (Oxford: Clarendon Press). O’Riordan, T. and E. F. Rowbotham (1996) ‘Struggling for Credibility: The United Kingdom’s Response’, in O’Riordan, T. and Jager, J. (eds), Politics of Climate Change: A European Perspective (London: Routledge). Robertson, K. G. (1982) Public Secrets: A Study in the Development of Government Secrecy (London: Macmillan). Rt Hon. Lord Woolf, Master of the Rolls (1996) Access to Justice ( July). Serving the European Union: A Citizen’s Guide to the Institutions of the European Union (1996) (Luxembourg: Office for Official Publications of the European Communities). Snyder, F. (1993) ‘The Effectiveness of European Community Law: Institutions, Processes, Tools and Techniques’, The Modern Law Review, vol. 56 ( January). United Nations Economic Commission for Europe (1996) Guidelines on Access to Environmental Information and Public Participation in Environmental Decision-Making (Geneva: UNECE). Van Ermen, R. (1996) Review of the Vth Action Programme (Brussels: European Environment Bureau). Vogel, D. (1986) National Styles of Regulation: Environmental Policy in Great Britain and the United States (Ithaca, NY: Cornell University Press). Weber, B. (1986) ‘Industry and the Environment – the European Standpoint’, in Environmentalism Today – The Challenge for Business (Conference proceedings, 16 April) (London: UK Centre for Economic and Environmental Development). Wheeler, M. (1994) ‘Negotiating NIMBYs: Learning from the Failure of the Massachusetts Siting Law’, Yale Journal on Regulation, vol. 11. Wilson, J. Q. (1989) Bureaucracy: What Government Agencies Do and Why They Do It (New York: Basic Books).

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70 Rationing Human Organs for Transplant

5 Rationing Human Organs for Transplant Jeffrey Prottas

Transplantation as a model for rationing Rationing is a ubiquitous element in health care allocation. The demand for health care is effectively infinite because the aspirations of modern medicine are utopian. Everyone must die, but doctors insist that any specifiable cause of death can be resisted and ultimately conquered. Demand is infinite but the supply of healers and the time for healing is limited, and so rationing must occur. However, rationing is a painful and unpleasant activity, and policymakers have a strong impulse to hide it if they cannot avoid it. Various methods are used. In the USA, health care is largely left to the market system, where public officials can pretend rationing does not occur or, if it does, it is not their responsibility. In other parts of the world, including Great Britain, public officials endeavor to ‘delegate’ rationing responsibility as far down the service delivery chain as possible – often to individual clinicians. In this way, decisions are made less visible, and the responsibility placed on professional caregivers. These and other techniques avoid the need to develop and defend explicit criteria for deciding who will receive care and, more importantly, who will not. Ambiguity, invisibility and complexity are characteristics of health care rationing and serve the important functions of diluting conflict and protecting policymakers from responsibility. Whether this state of affairs can be maintained indefinitely is not clear, but its perceived desirability must be, in part, a function of the characteristics of the realistic alternatives available. The allocation of transplantable human organs provides a model of one alternative. The fact that the rationing of transplants is often done differently 70

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from most other health care reflects a series of particular historical circumstances and a universal human tradition of treating human cadavers as a special class of objects. So there is much that is atypical about transplantation rationing that may limit its utility as an alternative rationing model. But there is also much that is archetypal and that may elucidate particular aspects of health rationing in a way difficult to perceive in other segments of the health care system. The twin goals of this chapter are (i) to consider what can be learned from organ allocation that could contribute to the health care rationing debate more broadly; and (ii) to understand how and why US and British responses to the need to ration organs differ.

Character of rationing in transplantation The starting point for the process of organ allocation in both nations is the public nature of the decisions to be made. Human organs are public resources to be used in response to public goals. In Great Britain this is not unusual, but it is in the USA. In the USA, health care generally is treated as a commodity to be bought and sold. Buying or selling of human organs, however, is explicitly against the law (as it is in most other nations). Organs are not private goods, and access to them must be regulated by rules enacted by institutions responsible to the public. Second, the rules used to ration organs must operate in a particularly rigid environment and one that therefore makes the issues of rationing particularly stark. Rationing of human organs is unambiguously a zero-sum game. The supply of organs is, in the short run, fixed. The demand for organs exceeds supply on a permanent basis. Every decision to allocate a transplant to one person is a decision to refuse others. If hearts or livers are being distributed, the decision is, in effect, to let someone die, the rationing element is reduced to its most simple and painful form. It is not possible to invest more in transplantation to increase the ‘pie’ – although there may be long-term steps that could marginally increase organ supply. There are no meaningful alternative treatments to transplantation for non-renal organ failure and those awaiting a renal transplant who have already rejected the dialysis alternative. It is therefore necessary to face the reality that one’s rationing rules determine who will not receive treatment: a fact easily lost in the broader health care arena. Third, the allocation rules used necessarily combine highly technical

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information about medical efficacy with public views about justice and equity. Transplantation is one of the most complex of medical procedures. This is not primarily a function of the surgery itself but of the management of the body’s rejection of the implanted organ. A great many factors influence the probability that a given graft will function in a host body over time, including immunological factors, the recipient’s other medical conditions, and the age and condition of the donated organ. The relative impact of different factors remain a matter of dispute among experts, are subject to changes and, at best, are statements relating to statistical probabilities – that is, they describe the impact of a factor on a large population in terms of a central tendency. Such statements can be applied to specific individuals only with great caution. Graft failure often leads to death and always leads to a wasted organ and so the probability of success is a central rationing criteria. Specification of factors influencing that probability requires expertise. But graft survival is not the only criterion used in organ allocation. It cannot be because, in the first instance, it cannot discriminate among a number of equally appropriate candidates. Scores, even hundreds, of potential recipients may be equally likely to benefit from a given heart based on scientific knowledge about graft survival. Moreover, as organs are a public resource obtained by donation, issues of social equity cannot be wholly ignored. For reasons not completely understood, African-Americans have a lower rate of renal graft survival than white Americans, but excluding them as recipients on that basis is not a morally or politically acceptable rationing decision. Graft outcome data contains a degree of uncertainty both in that many ill-understood factors influence outcomes and small intergroup differences are difficult to translate into meaningful data about individuals. For example, suppose a person with a good HLA match (human leukocyte antigens – an immunological make-up similar to that of a given donor) has a statistical probability of a five-year graft survival 8 per cent better than another person with a poorer match. Can this probability be reasonably applied to two specific patients with many other potentially relevant clinical characteristics? Should it matter that the individual with the poorer match has been waiting three years for a transplant and the other person only six months? What role should the likelihood of finding another suitable organ play – some people are highly sensitized to foreign antigens and may encounter a usable organ only once in several

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years. Others, not so sensitized, may have scores of chances each year. This need to merge imprecise and complex technical information with social values relating to ‘fair’ access is unavoidable in transplantation. Finally, acting on this need in a socially acceptable way is essential to the continued existence of organ transplantation. Organs are donated and so the good reputation of the transplant system is a precondition for the continuation of the supply of organs. The primary expressed concern of the public is that organ allocation be fair and open to all, and that the rights and interests of organ donors be protected. In both Great Britain and the USA the media is quick to produce stories that call into question the fairness of organ allocation. Moreover, organ procurement depends on the cooperation of doctors and nurses treating potential donors, and these professionals feel strong obligations toward the families of organ donors. They, with organ procurement coordinators, are aware of the heroic kindness these families exhibit and understand that the transplant system has an obligation to use their gifts in an effective and fair way. Allocating organs for transplantation reflects, in many ways and in a simplified form, the issues of rationing health care generally. In both, the supply exceeds demand on a permanent basis, and complex issues of technical efficacy and social equity are intertwined. In transplantation, supply is effectively fixed and all decisions are distributional. This is not strictly true of health care, as the decision of how much in the form of resources can go into health, versus other social sectors, can be altered. However, in so far as there is a political consensus that the health sector’s share of resources is already high enough, or too high, the same issues regarding how to distribute a fixed supply of care to an unmeetable demand emerges. In both Great Britain and the USA there appears to be such a political consensus. To some degree, therefore, organ allocation provides a model of how both societies deal with health-care rationing in circumstances where that rationing is unavoidable. Organ allocation has another, even less agreeable, characteristic in common with broader health rationing systems. Scientific and clinical information is essential to make any sensible rationing decision, and the medical profession holds a monopoly on this information. In transplantation, this privileged position is acknowledged via the direct involvement of transplant surgeons in the development and application of organ allocation schemes. However,

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the allocation of an organ directly affects the interests of the transplant surgeons and transplant centers involved. While the ultimate beneficiary of the transplant is a patient, the immediate recipient of that organ is the transplant hospital where the procedure will be done. The professional status of the medical team, the reputation of the hospital and, in America, the income of both, are sensitive to the number and quality of the organs they transplant. In a real sense then, the medical community both sets the rationing rules and benefits from them. In transplantation, this is transparent and measurable, and its effects on rules can readily be identified. Any public rationing will encounter similar problems as the need to include medical providers’ expertise in any decision-making inevitably imports their self-interest at the same time. The phenomena are not surprising but are cautionary for those thinking about lessons for a wider stage.

The US system: public and procedural The United States has one of the most differentiated, complex and, surprisingly, public organ rationing systems in the world. One of the central concerns of this chapter is to understand the difference between the US and British systems, and to try to understand the implications for transplantation as a learning model in public health rationing. Institutional structures The US system operates at two, possibly three, institutional levels. At the national level there is a quasi-governmental body officially known as the Organ Procurement and Transplantation Network (OPTN). The OPTN is an organization with which the federal government contracts to operate and oversee organ transplantation in the USA. (The contracted organization is the United Network for Organ Sharing (UNOS). UNOS pre-existed the OPTN and was, in effect, a provider association. UNOS and OPTN are terms used interchangeably.) By federal law, UNOS is the legally predominant element in the US transplantation system. It has the authority to set all organ allocation rules, organ procurement practices and to certify transplant centers. UNOS is funded by public money and membership dues, but membership is required of all organ procurement organizations (OPOs) and hospitals with a transplant program. UNOS’s power over

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transplantation – subject to final oversight by the Secretary of Health – is almost absolute. The decision-making structure of UNOS is, in broad outline, defined by federal statute. The make-up of its board of directors is legally defined and corporate in nature. Representation of all key players in the transplantation system is required, so a proportion of the board must consist of transplant surgeons, representatives of transplant hospitals, organ procurement agencies, tissue-typing laboratories, and members of the public unaffiliated with transplantation providers. At the board level, transplant surgeons and hospitals do not represent a majority, but are the largest single group, and when combined with other providers of care, do predominate. Below the mandated board level UNOS makes its decisions after the fashion of most professional associations. There is an extensive committee structure, ranging from ethics committees to patient affairs committees to three organ-specific committees – kidney, heart, and liver. The organ-specific committees have the responsibility for setting organ allocation rules. These committees are dominated by transplant surgeons specializing in their respective organs. Organ allocation rules are of two general sorts. The nation is divided into about sixty-five service areas, each served by an organ procurement organization (OPO). The allocation of kidneys within these OPOs is controlled by general criteria indicating what factors may and may not be used in formulating allocation rules. The weighting and structuring of these factors are a matter of local discretion. In addition, UNOS promulgates rules defining the sharing of organs among OPOs. Organs must be sent from one OPO to another under limited and specific circumstances, and the rationing rules for inter-agency sharing are explicit. OPOs may also share organs that they do not want to transplant, and that sharing is also controlled by specific UNOS rules. Non-renal organs are dealt with in analogous ways, expect that the sharing of organs is regional. Legally all UNOS rules are subject to oversight by the Secretary of Health. In general, this oversight has been largely pro forma and procedural, as the Secretary has not wished to be involved in complex medical or ethical controversies. In 1997, after a series of hearings, the Secretary did intervene to change the rules under which liver allocations were made. This followed a long-standing controversy within the transplant community on this issue. The outcome of that intervention remains unclear, as the political fears of prior administrations proved to be well founded. The Secretary’s decision

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is being fought on several legal and political fronts. However, the formal right of intervention has been established clearly. In the final analysis, the Secretary of Health can decide the rules for the rationing of organ transplantation, and so bears final responsibility for those rules, whatever they are. This might be thought of as a third institutional level of decision-making. Local institutions The sixty-five officially designed organ procurement organizations (OPOs) in the United States each have a geographically defined service area. In principle, these areas do not overlap and include the whole country. The size and distribution of OPOs is largely a historical accident and hence is strikingly irrational: catchment areas vary in size from under one million to in excess of 16 million people. OPOs are authorized by the federal government to procure organs and are the only organizations that may do so. Legally, the federal government can close any OPO on a number of grounds and transfer its service area to another entity. The make-up of the board of directors of OPOs is, like the make-up of the UNOS board, set in federal law. All renal-related procurement costs – the majority of OPO costs – are paid for by the End-Stage Renal Disease Program. In principle, therefore, OPOs are highly regulated and controlled by the federal government. In practice, interference (aside from financial audit) is virtually unknown. OPOs are free to allocate organs procured within their service area, and used within that area, according to their own rules. UNOS defines which criteria are acceptable, and which may not be used, but the weighting of acceptable criteria is a local prerogative. In general, patient characteristics may be used as desired, but all patients within the area must be treated equally. When there are several transplant hospitals in a single OPO this means that the hospital in which a patient is listed may not influence his or her place in the queue. Some patient characteristics are also excluded, so, for example, race may not be used as a criteria. But each OPO can decide to allocate organs using tissue matching criteria, or to ignore the immunological match between donor and recipient. It can also decide to give consideration, or not, to waiting times. There are substantial variations across OPOs. In general, the national system controls the use of organs that move between OPOs and defines a limited number of circumstances in which such ‘sharing’ is required. Organ allocation within OPOs

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is much less constrained. However, local allocation rules must be written and available. UNOS routinely compares the actual allocation of local organs to the local OPO’s rules and can demand an explanation for any deviation from those local rules. In effect, the national system requires procedural justice of the local system – which allocates the vast majority of organs. Substantive justice is left, within broad guidelines, to local determination. The overall political structure and operation of American organ allocation therefore has four central characteristics: (i) There is legal dominance by the national-level decision-making institutions. UNOS operates under delegated federal governmental authority, and can set all rules and exclude any other institution from transplantation. Ultimate authority, and so ultimate responsibilities, lies within the federal government. (ii) Federal law has imposed a representative model on the leadership of all institutions involved in the allocation of organs. The directors of UNOS and each OPO must represent certain specified ‘stakeholders’ in organ allocation. The main changes imposed by this federal intervention in the mid-1980s were to require the inclusion of patients and the general public in decision-making. Previously transplant surgeons were the only members of OPO boards, but now they cannot be a majority on those boards. In addition, the public nature of allocation rules has been enforced. OPO rules must be available to UNOS and to any interested party. In addition, UNOS rules are treated as the regulations of a public agency and must be published in the Federal Register for comment prior to promulgation. (iii) These formal changes have mitigated but by no means ended the practical dominance of the transplant surgeon and hospital in allocation decisions. UNOS’s committee structure replicates the decision-making patterns of professional associations and gives professionals most directly involved in transplant control over the allocation rules of their own organs. Physician expertise and the intensity of their interest in allocation rules insures their domination of the central leadership of UNOS. More voices are heard in UNOS decision-making, but the old voices predominate. (iv) At the local level, much the same point can be made about OPO boards. Expert knowledge, intense interest and large numbers usually insure that surgeon interests direct OPO policy.

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In fact, surgeon control is stronger at the local level, where public visibility is lower and where it is more difficult to recruit knowledgeable outsiders to be actively involved in decision-making. This fact is combined with a strong unwillingness on the part of UNOS to intervene in local autonomy. This unwillingness reflects the medical profession’s traditional unwillingness to second-guess colleagues, and the fact that the UNOS leadership is selected from local leaders who have a vested interest in ensuring local autonomy. Overall, the US allocation system has moved very far towards formal public control, but has only in a limited way achieved practical public control. Indeed, the major thrust of system change has been on procedural rather than substantive issues. Allocation decisions are now public and ‘transparent’. These decisions are made in the presence of outsiders and are generally debated using terms of public discourse. Extra-legal factors, such as expertise and willingness to invest time and energy, however, have ensured that those most affected by allocation decision – the transplant programs – continue to dominate the content of decisions.

The UK system of organ allocation: deference and devolution The organ allocation system in Great Britain consists of two unequal parts. There is a national level embodied in the United Kingdom Transplant Support Service Authority (UKTSSA) – a Special Health Authority of the National Health Service (NHS) – and a local level consisting of the transplant centers in the nation’s fifty-four transplant units. UKTSSA provides the administration for a series of professional advisory groups (one for each solid organ and one for corneas), who are responsible for determining the national protocols for organ matching and allocation. The advisory groups comprise representatives from the transplant community, surgeons, physicians and transplant coordinators, as well as representatives from the medical Royal Colleges. At the local level, clinical decisions are made about who will be transplanted, depending on the available donor organs. National process and structures Membership of the Special Health Authority comprises seven members, appointed by the UK Department of Health. At the time of

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writing, non-executive membership includes one surgeon, one physician (chairman), one immunologist, and two representatives from commerce and public sector service. Additionally, the chief executive and a staff representative are board members. This board oversees the operation of the UKTSSA as a Special Health Authority of the NHS, and devises and directs strategy and operational priorities for its own activity. However, as in UNOS, it is the organ-specific committees where rules and practices originate. The Liver, Cardiothoracic and Kidney Advisory Groups make the key decisions regarding catchment areas and organ-sharing rules. The advisory groups are made up of the transplant surgeons directly involved. Because there are only eight heart transplant and seven liver transplant units, the director of each unit is a member of the relevant UKTSSA advisory group. The greater number of renal programs precludes this, and so the Kidney Advisory Group consists of representatives of those programs – chosen by the transplant units themselves. The decision-making advisory group meetings are administered formally by UKTSSA, and members of the Authority’s staff attend the meetings. For the Liver and Cardiothoracic Advisory Groups, meetings are usually held on the same day as the Royal College of Surgeons’ meeting, to allow feedback from the earlier meeting at which the surgeons will usually discuss the salient issues among themselves prior to the advisory group meeting, and come to agreement. In effect the formal meetings that follow are largely pro forma. There is nothing in the least sub rosa about these procedures. The decision-making structures with regard to organ allocation issues are designed specifically to allow the directors of the transplant units and the other representatives to discuss allocation matters and to reach a consensus on what the policies should be that UKTSSA is given the task of carrying out. Criteria and content Two kinds of decisions made at the national level are important for the way organs are allocated to patients in need. One has to do with the catchment areas from which transplant centers draw donors, and the other is the terms under which transplant centers will transfer donated organs among themselves. Organ procurement catchment areas are important to a transplant program because they define the number of organs that program will be able to transplant. Organ supply determines transplant

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numbers and, all things being equal, a larger population base means more donors – or at least more potential donors. For this reason, transplant programs are very concerned about how catchment areas are defined.1 As in the USA, catchment areas in Great Britain appear to have been defined essentially on historical grounds. However, the collegial nature of decision-making on these matters seems to have introduced some flexibility, and the boundaries of some areas have been changed by mutual agreement or by amalgamation among transplant centers. (This is in stark contrast to the USA, where catchment areas are defended with a disconcerting ferocity.) However, the catchment areas of renal programs, liver programs and heart programs are not coterminus. This greatly facilitated the alterations mentioned but is poor policy with regard to effective organ procurement. Nor should the flexibility of procurement regions be exaggerated: at least one renal program has no catchment area at all and so must depend solely on the sharing of another catchment’s kidneys! Nevertheless, catchment areas are defined via nationwide mechanisms. The Royal College of Surgeons determined a protocol in 1993 which links each transplant unit’s contracted activity with the population pro rata. UKTSSA facilitates organ-sharing rules. Organ-sharing rules deal with the conditions under which a transplant center is obliged to export an organ it has procured to another transplant center. These rules are organ-specific and, in Britain, are determined by agreement through the advisory groups and implemented via the UKTSSA duty office. The rules for sharing a kidney are, in both Great Britain and the USA, the most extensive, as tissue matching is only an issue with regard to kidney allocation. UK rules require that one of each pair of kidneys retrieved be donated to the national pool but, from 1 July 1997, both are to be given up to the pool when identical matches exist. A computer-matching program on the National Transplant Database is run for all patients to select those most closely matched to the donated kidney. The computer program identifies the patients for whom an identical match exists, and the kidney is offered to the unit for a named patient. Where there is more than one patient selected, other criteria are called into play, such as sensitization status and age matching between donor and recipient (an exactly analogous rule operates in the USA). The operational definition of a ‘beneficial’ match has recently been changed. The procedure was illuminating. The rationale for sharing organs based

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on a ‘beneficial’ match lies in the data indicating that a similarity between an organ’s immunological characteristics and the recipient’s immunological characteristics result in better transplant outcomes. This is a widely accepted fact, although there are disagreements as to how much similarity leads to how much better an outcome. In principle this is a scientific dispute regarding data and its interpretation. In 1997 the UKTSSA, under the leadership of an eminent surgeon, examined its outcome data and reported that a somewhat broader definition of ‘favorable’ match correlated to better outcomes. These data were presented to the Kidney Advisory Group who agreed to a change in the national allocation system to alter the definition from a beneficial to a favorable match – thereby increasing the number of kidneys to be shared outside their own institution. The agreement was won based on the scientific data. The obligation to share based on match is accepted for identical matches, but continued to apply to only one of the two kidneys procured from a donor for a less good match! While the scientific evidence was persuasive to the transplant community it did not – and was not expected to – lead to a decision to share all reasonably matched organs, but only half of them. In July 1998 a new three-tier national kidney allocation scheme was introduced, based on the following points: Tier 1 000 mismatches allocated nationally regardless of location but retained for any local 000 mismatches, where local refers to the retrieving unit. (000 mismatch means that no HLA mismatch has been detected between the donor and recipient.) Tier 2 Favorable matches allocated nationally, but one of a pair of donated kidneys allocated locally. Tier 3 All other kidneys retrieved locally for use by retrieving unit, or by local joint waiting list alliance on the basis of locally agreed sharing protocols. The decision regarding this national matching scheme was taken by representatives of the entire renal transplant community of the UK and the Republic of Ireland at a meeting held early in 1998. Of course, all things being equal, such sharing should have no long-term effect on the organ supply in any particular location. That is, one is as likely to import an organ based on a good match as to export one. In practice, differences in program size and procurement success can lead to permanent imbalances, so the rules include a variety of mechanisms to ensure that the ‘balance of exchange’ among hospitals does not remain too out of balance over

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time. The result of these favorable match rules is that, in 1997, 44 per cent of all kidneys were allocated to favorably matched recipients. This is a rather large number, reflecting the transplant community’s broad agreement on the importance of tissue matching. Rules for sharing non-renal organs are much simpler. No hospital has to share organs at all – with the partial exception of an emergency category for liver sharing. In effect, any hearts or livers procured by a transplant hospital are its to allocate to its own patients using local rules. In fact, most of the allocation activities for all organs occur at the local level. Any that cannot be used are shipped to another unit on a rota agreed by the profession Doctor-directed rationing In the UK, only half the available kidneys are allocated to a named patient on the national transplant waiting list. For the remainder, and for livers and cardiothoracic organs, doctors make decisions about who should receive them. Each transplant surgeon is free to develop whatever allocation approaches seem to be the most appropriate. Each transplant hospital, indeed each transplant surgeon, has his or her own criteria for allocation and his/her own methods of applying these criteria. In general, neither the criteria nor the way they will be applied are documented. A review of decisions taken is impossible, as is an anticipation of decisions to be taken. Renal allocation is somewhat more likely to be routinized than non-renal because of the importance of HLA matching. However, most hospitals simply dichotomize HLA matches into the local equivalent of favorable or not favorable. Giving priority to the former is virtually universal – although exact definitions may vary. However, the size of local waiting lists and the simple dichotomization by HLA match means that choices must still be made among a number of patients. The standard factors are always mentioned: clinical status, waiting time, location, and sensitivity. Increasingly, renal transplant centers have come together to form local alliances which do have written and agreed local criteria for matching and allocation. The UKTSSA duty office usually provides the means through which local patient selection is made, using the locally-agreed criteria. Non-renal allocation is even more subjective, as the tissue match criterion does not apply. In one interview, a heart surgeon was asked to allocate an organ from a hypothetical donor to a patient on his waiting list. After considerable resistance and an insistence that clinical factors rarely

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left much room for choice, he undertook the exercise. His list consisted of just under a dozen patients, and three or four could be eliminated based on donor size. He had detailed social knowledge as well as clinical information about each patient, and discussed how they and their family were dealing with the waiting and fear, their living conditions and how quickly they could be contacted. In short, he used his detailed knowledge in a compassionate and complex way to select whom was next in the queue. In so far as there were any consistent rules they were implicit, internalized and non-replicable. He readily admitted that a colleague who made this decision on alternate days might have decided differently. He thought that most surgeons at other hospitals used essentially the same approach, although they might consider somewhat different factors. He did not, in fact, know exactly how others allocated hearts. He, like all interviewees, characterized the process of allocation as ‘club rules’ – shared but not explicit or systematic. And, like all such rules, they admitted of exceptions. The non-renal system in particular is small enough so that ad hoc accommodations are easy. Requests for emergency status are evaluated individually by each surgeon. In general, they are approved, but too-frequent requests from a colleague will generate adverse comment. At the same time, if a colleague requests an organ for, say, the sister of a senior operating room nurse on ‘compassionate’ grounds, no one sees this as out of bounds. In Great Britain there are few rules, criteria or procedures designed to ensure consistency across the nation. About 25 per cent of kidneys are allocated based on HLA match directly to patients regardless of where they live or where the kidney was procured, but beyond that there is no national level policy regarding access to renal transplant. Non-renal organs are either a purely local matter or are shared by ad hoc agreement among surgeons. There is no systematic attention to consistency in local allocation practice at all. Virtually all non-renal organs and 56 per cent of kidneys are allocated by local decision-makers. There is no expectation that these doctors will behave in a consistent way across hospitals, there is no general requirement that surgeons in the same unit adhere to the same rules, and there is no method to ensure that a single doctor employs similar criteria over time. (Nor, it must be emphasized, is there any evidence that these consistencies do not exist.) The point is that there is no evidence of any kind, and no expectation that there ought to be.

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To what degree do social class, gender, race or perceived social worth affect allocation decisions? There is little or no evidence either way. The occasional scandal arises, as when a young woman was refused a liver transplant after she presented in an emergency ward with a drug overdose. Her parents understood that she was excluded because she had used drugs. Later, the hospital insisted that clinical factors had excluded her. In fact, the two are difficult to disentangle – drug abuse is both a social and clinical fact. As the hospital had no written guidelines at all it was impossible to examine the decision, even post hoc, to determine original intent. In fact, as the surgeon involved was in the USA at the time the story broke, the hospital could make no definitive statement until she was contacted – it had no way to know what criteria were used. None of this demonstrates that poor decisions are being made. In terms of simple outcomes, British outcomes are perfectly in line with the best world standards. Nor is there any evidence of insensitive and arbitrary decision-making and, at least among the score or so of surgeons interviewed, it was clear that thoughtful and compassionate decisions were made. What is also clear is that these decisions are treated as if they were the private provinces of the doctors involved. It is literally impossible to examine organ rationing in Great Britain against agreed-upon criteria to test its acceptability. First, because no such criteria exist; and second, because the only data available are the final decisions and certain minimal demographics. (It was possible to examine HLA matching and outcomes, and so change that piece of renal allocation policy.) But even this required a separate, non-routine data collection effort.

Explaining the differences The British and US system differences are very striking in the way they have chosen to ration transplantable organs. Moreover, these differences are quite counter-intuitive. Great Britain’s health care system is national, accessible to all and paid for publicly. The US system is essentially private, with great access differences and with an absurdly complex system of payment. One might well expect that rationing of transplantation in Great Britain would be public and built around equity considerations. In the USA one would expect vast local differences and the institutionalized inequalities that characterize the health system as a whole. In fact, the differences do not follow this pattern at all.

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Organizationally the central difference between US and British organ rationing are: (i) National-level decision-making has a much larger role in the USA. (ii) Non-doctors are systematically involved in rationing decisions in the USA. Only surgeons play a role in allocation in Great Britain. (iii) Written guidelines and written records of decision are required in the USA, and public review is routine. Decisions at the local level in Great Britain are informal. This, in turn, reflects emphasis on different issues. In the USA, two concerns have led the system to take on its institutional character. The first is a concern for inter-group equity in access. This takes the form of disputes over the acceptability of differences among regions and localities, and of concern for differences across racial and class lines. Second, there has been a preoccupation with merging non-medical with medical criteria. This reflects, in general, disbelief that medically defined criteria are purely scientific and socially neutral. The two concerns clearly contain similarities. However, as substantive agreement on the proper resolution is very hard, these concerns have been translated into requirements for decisionmaking transparency and procedural justice. (Part of this emphasis may also reflect the impossibility of addressing directly substantive equity in non-renal transplantation were access to private insurance a practical pre-condition for even getting on a waiting list.) In Great Britain there has been almost no discussion of intergroup equity. Data on differences in waiting times is not grouped by hospital or region. Racial and class differences in access are presumed to be non-existent. The fact that organ transplantation operates within the universal care model of the National Health Service makes issues of accessibility for categories of persons seem irrelevant. Therefore allocation issues at the national level have been essentially professional in nature, revolving around the scientific definition of beneficial match and using graft survival as the sole decision criteria. Social equity being assumed, only effectiveness need be considered. However even a cursory investigation quickly reveals that there are substantial differences across hospitals in average waiting times for a transplant. This reflects the epidemiological reality that need for transplantation is not evenly distributed across populations, and the organizational reality that not all organ procurement efforts are equally successful. Therefore, in areas of relatively low demand

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and of good procurement outcomes, waits are short – often much shorter than when other conditions apply. In transplantation, the defining shortage is that of organs. The NHS’s elimination of financial inequalities does not address all the causes of unequal access in transplantation. In Great Britain we do not encounter the distrust of professional decision-making that is so common in the USA. In the USA it would be assumed that a white, male professional in unfettered control over a valuable resource would allocate it in a prejudicial manner. The assumption might not be that this is intentional but that ingrained social perspectives would play a role. No prolonged interview with an American doctor would end without a denial (or admission) of this kind of social prejudice on racial, class or life-style grounds. (Although, of course, Americans never actually use the term ‘class’.) No equivalent defensiveness was encountered among British surgeons. Even when they were asserting the use of ‘compassionate’ allocation as a professional courtesy they considered that their transparent commitment to the patients’ good insulates them from any charge of unfair practice. They could all point to a limited number of other surgeons who had, in the past, stepped over the line in their allocation practices. There was, in fact, often agreement, both on the individuals and the instances. The ‘line’ was not formally defined nor, in an outsider’s view, logically obvious, but was quite clearly widely shared. In organ rationing, the US system is formal, public and ruleorientated: in Great Britain, it is informal and professionally dominated. Which requires explanation, and at what level ought one to look for explanation? The correct answer is ‘both’ and ‘at all levels’, but neither my space nor knowledge allows that. What they do allow is three tentative levels of explanation without an attempt to attribute relative weights definitively. Health system differences In the United States transplantation is different. The US health care system is largely private, fragmented and market-driven. Transplantation is treated sui generis. Its history is embedded in the End Stage Renal Disease Program, itself a unique departure from ordinary US practice. Under the ESRD program, all persons suffering from renal failure are eligible for Medicare. Within the Medicare program, transplants are also treated differently, as all costs associated with organ procurement are covered by the federal government – not the usual

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80 per cent. Transplantation has been further singled out by federal and state statute in a variety of ways; in particular, human organs may not be bought or sold, may only be obtained by certified non-profit organizations, and are considered a public good merely held in trust by hospitals. While the NHS does treat transplantation as being different from other services in a number of important ways, these are seen as merely technical responses to the problems of scarcity and the demands of organ procurement. Transplants are not considered qualitatively different from other medical treatments. The NHS starts with the perspective of health care as a public good, and so transplants are only technically, not philosophically, different. The NHS rations, of course, but prefers to do so by devolving as much decision-making as far down the system as possible. The efficiency arguments for this are numerous and contentious. The political arguments are irrefutable. During 1996 the NHS, in fact, attempted to devolve more control over transplantation financing to the local level to avoid having to make explicit financial rationing decisions centrally. Those in the transplantation community and health policy-makers do understand that applying routine NHS practices to organ transplantation raises difficulties. At its core, the problem reflects the odd fact that money is not the most scarce element in transplantation. NHS rationing is essentially driven by how resources are allocated; within a given pot of money, choices among services must be made, and every effort is made to see that those decisions are taken locally. However, central policy is that no human organ will go untransplanted for lack of money, so the only issue is who will get it. Standard NHS methods that might assure reasonable equity in access for other services may not work for transplantation. In the USA, this difference is easily accommodated. There, organs are rationed in a public and explicit manner, and conflicts among group interests routinely emerge, as do conflicts over competing definitions of fairness. The process is public and often painful. But it is also seen as being qualitatively different from issues arising in the health care system as a whole. The ‘danger’ of contagion, of insisting that the open, explicit model be applied elsewhere is negligible. Americans can learn the lessons of a public rationing system in transplantation, safe in the knowledge than no one expects them to apply those lessons more widely. No such comfortable safety exists in Great Britain. All health care

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is public, and if national policy required public debate, public criteria, public review and public involvement in organ allocation, why shouldn’t the same level of transparency be applied universally? For a functioning system with wide public support like the NHS to take such a risk would be, at the very least, rash. One level of explanation therefore suggests that Great Britain has not constructed a public system for rationing organs because if it did so, it is probable that it would have to be used for other purposes as well. No nation has been willing to face such a challenge. Transplant system differences System-level considerations help to explain why policy-makers are more or less willing to formalize and ‘socialize’ organ rationing. But we also see additional differences between Great Britain’s and the USA’s transplant communities that explain their preferences regarding such a change. The transplant communities in the USA and Great Britain are tightly bound in professional and personal terms. The leaders of these communities know each other, may have trained together, often work together, and routinely share clinical information. In professional terms they form almost a single community. Structurally, however, the two systems are very different. A core element in the difference is size itself. Not only is the USA five times the size of Great Britain but it has substantially more transplant programs per capita. In addition, Great Britain’s transplant system is, professionally, more formally structured and hierarchical. The Royal College is a selective, elite organization, and whenever transplant issues arise, the government turns to it for advice. The American Association of Transplant Surgeons is open to all transplant surgeons. Even at that it must share (or dispute) the role of spokesman for the transplant profession with the American Association of Transplant Physicians. (Not to mention associations of transplant nurses, associations of organ procurement specialists, and others.) The result is that decision-makers in Great Britain’s transplant system are well known to each other, and the system, as a whole, is very cohesive. There are, of course, disputes, but resolution on a personal level is preferred, sought and achievable. The larger number of transplant hospitals in the USA, and the greater ease of starting new programs and re-starting moribund ones also means that there is a lot more movement among US surgeons. This, combined with a lack of formal hierarchy, means that many more

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professionals feel entitled to speak for ‘transplantation’ and dispute the views of senior practitioners. The greater number of voices in the USA also have a greater diversity and a greater degree of conflicting interests. The social diversity of the United States is barely mirrored in the transplant community, but urban–rural differences, regional differences and, to a small degree, racial differences, all contribute to disagreements within a far-flung transplant community. However, the most salient tension within the professional community in the USA has to do with competition over organs. The size of a transplant program is of great importance in the USA. A larger program confers many benefits on the transplant surgeons involved: more status and power within the hospital, professional recognition, and students. For the hospital, the size of the program also has financial implications, although these are secondary. Transplantation is a very small activity from a financial point of view, although no hospital administration wants to lose money doing it. But, for the hospital, a good transplant program allows it to attract doctors and obtain referrals. None of these considerations is wholly absent in Great Britain but each pertains less strongly. Transplant programs are more rarely at serious risk of being closed. The more orderly and predictable way hospitals are funded and organized isolate transplant programs from at least the short-term impact of organ allocation patterns. Even more important, the community’s leadership can decide among itself, almost on a one-to-one basis, how to tweak the system so that no program is badly hurt. There may be mavericks, but they are largely powerless, and there may be programs doing badly, but they are rarely desperate. The stability and hierarchical nature of the transplant community puts a premium on, and makes possible, the accommodation of each surgeon’s need to maintain his or her program at a reasonable level. There is little opportunity or motivation to grow at the expense of other programs. These differences have been reflected in the role of the transplant communities in ‘socializing’ rationing decisions. It is not necessary to go into detail regarding that history in the USA. Suffice it to say that various segments of the transplant community have frequently approached the government to intervene in the organ allocation process when it could not prevail within the professional community itself. So proponents of HLA matching as a rationing tool were instrumental in getting the federal government to set up the OPTN and to pass the first transplantation Acts. Non-

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renal transplanters urged government involvement in certifying heart and liver transplant programs; those unhappy with the use of urgency as an allocation tool for livers have sought government regulations forbidding it. In short, conflicts within the transplant community in the USA are often violent and public, and the losers have repeatedly gone outside the community to overturn decisions. Thus ‘socialization’ of decision-making in the USA has been, in part, the result of pressure from segments of the transplant community itself. (Although it is likely that the implications of each individual action were not understood and (by some) this is now regretted.) British transplanters have been much more able to present the public with a united front and mutually acceptable solutions to any differences. Size and hierarchy have been key. Social forces and interest groups Mistrust of all institutions is endemic in the United States, and since the late 1980s this mistrust has been extended to include the medical profession. At the same time, the American tradition of voluntary association around everything from changing stop signs to saving the snowy owl to protecting the automobile industry from the Japanese, exists in the transplant world. Dialysis provider groups, histocompatability laboratories, and patients’ groups all exist and demand a role in allocation decisions. As already mentioned, the universal American assumption is that unfettered discretion by a doctor will result in more or less socially prejudiced decisions. The result is a complex phenomenon that is ill understood, but it provides the social context for the public support for mandating forms of public control of organ allocation. I do not pretend to know the degree to which the British public is moving in a similar direction but, within the transplantation world, any such trend is not noticeable. There are no visible national or local groups clamoring for access to organ allocation decisionmaking. For example, for a variety of non-prejudicial reasons, the transplant rate among Asians in Great Britain is very low compared to that among whites. Yet even in areas with large and organized Asian communities, allocation decisions are never questioned. Indeed, no surgeon interviewed reported being questioned on even an individual basis regarding choices s/he made. Explanation at this level of generality is highly speculative, but it may be that the stereotype of British social culture retains a degree of validity. At least compared to the USA, the British public seems to have a high

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degree of social trust in many of its institutions. The NHS and the medical profession overall seem to be regarded with respect and even deference. Whether this reflects the more hierarchical nature of British social relationships or the insulation of the medical profession from the market-driven excesses of its American counterpart, or some mix of these and other factors, the phenomenon remains. The British public appears to trust doctors to make allocation decisions in a fair way, while Americans do not.

Conclusion Nothing in this research can address the question of the appropriate level of social trust in organ rationing. Despite the efforts of medical professionals on both sides of the Atlantic to insist otherwise, organ allocation is not primarily a technical issue. Outcomes, the Holy Grail of modern health services research, are not terribly sensitive to variations in the medical content of allocation rules. In part this reflects significant agreement on medical factors and practices and, in part, it reflects the huge pool of waiting recipients. When there are ten recipients for each organ, a variety of approaches will select a suitable one. The real issues in allocation are therefore ethical and social. Within the pool of medically acceptable recipients, selection must still occur and only social and ethical criteria can be used. Social diversity in the United States and the political expressions of that diversity require a relatively transparent decision-making process. The organ supply requires public trust, and transparency is the only way to obtain it. Conflict over values is familiar to Americans, and acceptable. They are used to evaluating decisions by procedural criteria. Public trust, equally, is the necessary foundation for organ transplantation in Great Britain. The fact that this trust can be maintained by a system of professional autonomy is neither better nor worse – merely different. Whether either system proves itself robust enough to maintain the public’s trust over the long term while engaging in the kind of rationing required in organ allocation remains to be seen.

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Note 1 Two factors are important for organ supply. The first is the number and character of the people living in the catchment area. The relationship between the size of the population and the number of potential donors is self-evident. However, not all social groups donate, or can donate, at the same level. In the USA and, anecdotally in Britain, the white middle class are the most likely to donate. Areas with large concentrations of elderly people are, for clinical reasons, a poorer source of donors. Beyond these demographic foundations the quality of the organ procurement effort is a major factor influencing the number of organ donors. In the USA and Great Britain there are very wide differences among organ procurement programs’ rates of success. Much research has gone into methods of structuring the organ procurement system to obtain the best results. While this study did not systematically examine British organ procurement, inevitably the issue was raised. My overall impression was that dedicated and hardworking organ procurement staff were working in a poorly structured and poorly organized system. In general, neither the financing nor authority lines in the organ procurement system reflect modern research on this matter. Great Britain’s organ procurement success rates provide some support for this admittedly tentative conclusion.

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6 Opaque Markets and Firearm Regulation Jim Leitzel

The ‘policy production process’ can be characterized as a system that employs various pieces of information as inputs, and in some way processes the available information into public policies; the policies then have effects, which in turn can inform further policy changes, and so on. Transparency, or openness in the policy process, is generally thought to be desirable for promoting good policies and for limiting corruption.1 Effective democratic governance, in particular, would seem to require a high degree of transparency, prying open the black box that translates information into final policies. In terms of developing good public policies, however, the quality of the information that goes into the process is often just as important as the working of the system itself: garbage in, garbage out, as information technologists might remind us, irrespective of the power of the computer or the subtlety of the software. Transparency, of course, also can play a role in making available relevant information. A transparent (and democratic) process will most probably encourage interested parties to bring their knowledge, preferences, and opinions forward, to where they can be aggregated and evaluated. But even in transparent environments, limited or incorrect information will hinder greatly the design of appropriate public policies. There are some realms of society, however, in which poor information is inherent. Illegal activity, in particular, tends to be conducted surreptitiously, for obvious reasons. Within the economic sphere, illegal or informal exchange is typically described by terms that, as it were, highlight its opaque nature: the underground economy, black markets, the shadow economy, the hidden economy, and so on. The formation of policies whose effectiveness depends on either 93

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the current state of the black market, or the black market response to a regulatory change, therefore, would seem to be especially perilous. The purpose of this chapter is to examine one policy area – firearm regulation – in which both black markets and violent crime are of fundamental importance, and to explore the quality of information available in formulating gun controls in the United States and Great Britain. Comparisons between these two nations are frequently made in discussions of firearms policy, because of their many shared traditions, in combination with their divergent experiences with gun controls and crime. This chapter will attempt to compare the different information bases on which US and British firearm policies have been predicated. The central role that black markets play in determining the effectiveness of gun control derives largely from what might be termed the ‘futility syllogism’: gun controls apply (by definition) to legal exchanges; criminals acquire guns illegally via black markets; therefore, gun controls cannot reduce the availability of guns to criminals. The logic is dubious: formal market controls can exert an influence over the informal market, particularly when combined with purposeful efforts to police illegal firearm transfers.2 The futility syllogism nevertheless rightly focuses policy analysis on the response of the black market to formal market controls on firearms. The remainder of this chapter is organized as follows. The second section presents a survey of what is known and what remains unknown with respect to firearms behavior in the USA and Britain. The third section examines information pertaining more specifically to the acquisition of firearms, particularly acquisition outside official channels by criminals or youths. The fourth section considers how firearm regulation and the firearm policy debate in Britain and the USA are influenced by the availability of information as summarized in the previous sections; and the fifth section provides a brief conclusion.

Information on firearm misuse The United States Guns are neither good nor bad in themselves; it is the misuse of guns that generates a public issue.3 In the United States, such misuse is depressingly common: there were 38 505 firearm-related deaths in 1994. Gun suicides were slightly more frequent than gun homicides, while accidents accounted for less than 4 per cent of total gun

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deaths.4 Firearms are involved in about 60 per cent of suicides and 70 per cent of homicides. 5 Information about non-fatal shootings is much less complete. For every gun homicide, there are several non-fatal gunshot wounds. One study of hospital emergency rooms concluded that there were 2.6 non-fatal cases treated for every fatal case; the Centers for Disease Control estimate 3.3 non-fatal crimerelated firearm injuries per homicide.6 The total costs of firearm injuries and death in the USA in 1992 have been estimated to be $63.4 billion.7 Injuries are not the only source of costs of firearm misuse; indeed, most gun crimes do not result in the firing of a gun. In 1993, about 582 000 murders, rapes, robberies, and aggravated assaults involving a firearm were reported to the police; about 41 per cent of robberies in 1995 were committed using firearms.8 The National Crime Victimization Survey (NCVS), which provides a means of identifying unreported as well as reported crimes, estimated that 23 per cent (1.3 million) of the victims of serious violent crimes faced assailants bearing firearms in 1993. 9 Further, firearm crime has increased significantly since the 1970s. Between 1974 and 1993, the number of violent offenses committed with a firearm increased by 78 per cent. 10 The mere presence of firearms may raise (or reduce) fear for some people. One survey indicated that 71 per cent of Americans feel less safe when others in the community acquire firearms. 11 Firearms come in many different varieties, and it may be important for policy development to have more detailed information about the types of firearms whose misuse generates the highest social costs. Handguns are differentially used in crime: while only around a third of the existing US stock of guns consists of handguns, handguns are responsible for approximately 80 per cent of firearm murders, and an even higher percentage of other serious firearm crimes. 12 There is some evidence that criminals prefer well-made, powerful handguns, though relatively inexpensive, low and medium-caliber pistols also figure disproportionally in crime.13 In recent years, there has been a trend among criminals away from revolvers and towards semi-automatic pistols, and an accompanying trend towards multiple gunshot wounds in individual victims.14 There is thus substantial information available on the extent of firearm misuse in the United States, although the costs of that misuse are much less precisely known, and there may be many other dimensions of concern that are not well understood.15 (As an example,

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fear of gun misuse may dissuade people from public areas at night, contributing to urban neglect and decay.) One currently contentious issue in the USA pertains to the benefits of firearms for defensive purposes. There is wide disagreement over the extent to which guns are used to defend against crime. The NCVS suggests 82 000 or fewer defensive uses annually, while other surveys indicate much higher figures.16 Kleck and Gertz (1995) report the results of a survey that indicates some two million defensive gun uses annually, and they suggest (p. 180) that defensive gun use in the USA ‘probably is substantially more common than criminal gun use’. This issue will undoubtedly continue to be debated. False positive responses, even if fairly infrequent, could account for much of the differential in the estimates, and the actual circumstances of a ‘defensive gun use’ may be far from an innocent victim using a gun to ward off an unprovoked attack by a violent criminal. 17 Even unambiguous cases of defensive gun use should be compared with evidence suggesting that gun ownership is a significant ‘risk factor’ in homicide and suicide in the home.18 Great Britain In Britain, there is significantly less gun crime than in the USA. In 1994, there were 14 755 offenses recorded in Great Britain that involved firearms, about 0.3 per cent of all recorded infractions. There were seventy-five firearm homicides (thirty-eight shot-gun and twentyeight pistol homicides), comprising approximately 10 per cent of all homicides;19 recently, in typical years, there have been about 150 firearm suicides (less than 5 per cent of suicides), and fifteen fatal gun accidents.20 As in the USA, recent years have witnessed a growth in firearm crimes. In England and Wales, the 12 977 notifiable offenses involving firearms recorded in 1994 represented an increase of more than a third over the 1989 figure.21 Roughly half of these offenses were perpetrated with air weapons, and most of these cases consist of relatively minor property damage.22 Notifiable offenses involving pistols have grown particularly quickly: in England and Wales, from 1232 in 1984 to 2981 in 1994, an increase of 142 per cent.23 Pistols accounted for 23 per cent of firearms offenses in 1994, shotguns for approximately 9 per cent, and rifles less than 1 per cent.24 Robberies with firearms are also much less common in Britain than in the USA, with only 4104 recorded in 1994.25 (In 1994, guns were used in only 6.8 per cent of robberies, though in the earlier years of the 1990s, robberies with guns

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comprised more than 10 per cent of all robberies.) 26 Pistols are the most frequently used weapon in firearms robberies (used in nearly 60 per cemt of gun robberies in 1994), and are the most prevalent type of gun used in other serious crimes involving firearms, including murder. 27 While information on firearm homicides and woundings is fairly complete and reliable, more detailed information or statistics on less-serious crimes tend to be less available. The specific type of firearm that is used in a crime is often unknown. Many robberies, for example, that are thought to have been conducted with a controlled or banned firearm may in fact involve either a low-powered air weapon or an imitation firearm. In one recent survey of robbers who employed firearms, only 41 per cent claimed to have used a real gun; nevertheless, less than four per cent of firearm crimes in 1994 were known to have involved an imitation.28

The acquisition of firearms The United States There are about 200 million privately-owned firearms in the USA, about a third of them handguns. Handguns also account for approximately half of the 4.5 million guns added to the firearm stock each year. 29 Except for categories of weapons that are virtually prohibited, such as fully-automatic firearms or sawn-off shotguns, there is not a clear division of weapons into those that are legally owned and those that are illegally owned. (This is in contrast to the British case – see below.) However, certain categories of people, including felons and (for handguns) youths – are unable to possess firearms legally. The legal market for new guns consists of recorded sales to legitimate buyers from dealers who hold a Federal Firearm License (FFLs). Almost all new gun sales to legitimate buyers enter the firearm pool in this fashion; exceptions include illegal imports, guns stolen prior to a retail transaction, and home-produced weapons. FFLs also legally transfer used guns. Further, private individuals can legally transfer firearms, with little regulation except a prohibition against transfer to someone (a felon or youth, say) known to be ineligible for firearm possession. About half of annual firearm transactions involve used guns; similarly, approximately half of firearm transactions do not involve an FFL. 30 How are guns that are used in crime acquired?31 Information relevant to this question is fairly sparse. First, many people who misuse

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guns are adults without a previous felony conviction – including about half of those who murder – and so they can acquire a firearm legally.32 Numerous individuals with a felony conviction also try their hand at acquiring a gun through an FFL, though. Background checks required by the 1994 ‘Brady Bill’ have resulted in some 6600 rejections of prospective firearm purchasers per month, with a felony conviction or indictment serving as the basis for some 70 per cent of rejections.33 There are also a host of ways for high-risk individuals to acquire guns illegally, primarily through an initial diversion from the legal stock. One important channel is theft: some 500 000 firearms are stolen in the USA each year, most of them handguns, and some surveys of criminals indicate that stolen guns are often acquired informally, and later used in crimes.34 A second channel for diversion from the legal stream is through illegitimate (or only nominally legitimate) sales by FFLs. (An example of a transaction that is only nominally legitimate is when a legal buyer is fairly clearly acting as a ‘straw man’, making purchases on behalf of prohibited individuals.) Some FFLs seem to specialize in supplying guns to high-risk individuals: a very small percentage of FFLs are the original source for most guns traced by the Bureau of Alcohol, Tobacco, and Firearms.35 High-control areas such as New York City and Massachusetts appear to spawn some small-scale gun-runners, who purchase multiple guns in southern states with less stringent controls, and drive them north for informal resale. One study found that a Virginia law limiting an individual’s handgun purchases to one per month led to a halving of the percentage of firearms recovered during criminal investigations in the north-east USA that originated in Virginia.36 People involved in the illegal drug trade are another proximate source for guns to criminals. With a significant demand for guns to conduct their drug business, and with experience in dealing in illegal markets, it is not surprising that drug dealers also can behave as illegal firearm brokers. Cook and Moore (1995, p. 289), sum up the informal market as follows: [T]he illicit gun market consists of a relatively large number of relatively unspecialized enterprises. It is filled with burglars who happen to find some guns next to the silver, some small entrepreneurs who brought a small stock of guns back from the South, or armed robbers or gangs who have accumulated an arsenal for their own purposes, and are sometimes willing to trade or sell a gun to a colleague.

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To characterize a market, economists typically gather information on prices and quantities transacted. In the case of the US black market for guns, however, this information is rarely available. There are indications that handgun prices on the informal market are higher than prices in the legal market in strict-control areas such as New York City. In other areas, the illegal gun market appears to parallel the market for stolen goods, in that prices are discounted relative to the formal market.37 Quantity information is almost nonexistent, though the importance of the legal stock of firearms as a source of supply for the black market suggests that the black market tends to be more active in areas with a higher concentration of legally-owned guns.38 Even serious adult criminals appear to acquire handguns at a fairly low rate, however – perhaps as infrequently as one gun per year. 39 With little hard data, researchers fall back on qualitative descriptions, such as claims that guns are ‘readily available’. While such characterizations lack precision, and as a result may not be useful guides for policy, they nevertheless appear to be accurate, at least for many urban areas in the USA. Ash et al. (1996), from interviews with juvenile offenders in metropolitan Atlanta, found that the majority had come across their first gun in a passive manner, without planning to do so. Nevertheless, this ready availability does not seem to apply across the board. In one survey of individuals who had been arrested for crimes in urban areas, only slightly more than half said that guns could easily be obtained illegally, and a much lower percentage (37 per cent) indicated that they could acquire a gun within a week. 40 Great Britain One consequence of the certification system in Britain is that there is good information on the numbers and types of firearms that are legally owned. At the end of 1995, there were approximately 174 000 firearms certificates outstanding in Great Britain, and 723 000 shotgun certificates. Estimates for the number of guns covered by these certificates in England, Scotland, and Wales were 502 000 firearms and 1 435 000 shot-guns. In early 1996, about 200 000 handguns were legally owned, based on certificates held by 57 510 individuals, though handguns were subsequently banned.41 It should be noted that the certification system does not extend to most airguns, though they apparently are widely held, particularly in rural areas. The certification also does not extend, of course, to toy guns or other imitation firearms.

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The extent to which legally-owned weapons are used in gun crimes (or accidents or suicides) is unknown. No statistics are maintained concerning crime committed by firearms certificate holders.42 There is some evidence suggesting that the vast majority of gun crimes are undertaken with firearms that were never legally held.43 The firearm mass murders in Dunblane in 1996, and in Hungerford in 1987, however, both involved legally-owned weapons, as do some domestic homicides. An examination of homicides in England and Wales between 1992–4 indicated that in 14 per cent of the cases, the firearm employed was legally held by the suspect.44 The Cullen Report, prepared after the Dunblane massacre, suggests that the use of illegal firearms has grown since 1969, though the increase cannot be quantified; and that also unknown is the extent to which what appear to be firearms used in crimes are, in fact, imitations.45 The limited evidence seems perfectly consistent with the conclusion drawn by Lord Cullen:46 while most gun crime involves illegal firearms, a relatively small but significant number of crimes are committed with legally-owned weapons. There is no reliable figure covering the number of illegally-owned guns in Great Britain: estimates range from 200 000 to multiple millions of weapons. One source of illegally-held guns is diversion from the legal stock. In 1994, there were approximately 3000 thefts that involved one or more firearms, though many of these concerned weapons that are not under certificate control: airguns were the principal weapon stolen in just over half of the cases.47 Smuggled weapons are another potential source of illegal ownership. Customs seizures of illegally-imported handguns average around 200–300 per year, while seized shotguns and rifles generally comprise a smaller figure.48 There has been significant concern that eased border controls within the European Union (EU), combined with the transitions in Eastern Europe during which many military weapons have apparently entered the illicit trade, would lead to a flood of smuggled arms into Great Britain. So far, however, confiscations have not revealed a major new influx. Another possible source of illegal guns is home-manufactured firearms, but again, there is no information concerning what, nevertheless, must be a relatively small category. (It is also likely that home-produced firearms are less lethal than most formally-produced guns.) Military or police weapons also find their way through informal channels into illegal private ownership. There have been periodic amnesties in Britain, in which gun owners

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could turn over illegally-possessed guns (that had not been used to commit crimes) without fear of prosecution for violation of the certification system. A 1988 amnesty (following legislation prohibiting many types of semi-automatic rifles) collected 48 000 weapons, and a 1996 amnesty netted a further 22 939 guns.49 Also, some 600 000 guns have been surrendered outside of amnesties since the Second World War.50 One common scenario, for example, involves the death of the owner of an unregistered gun; survivors find the firearm tucked away in an attic, and then turn it into the police. The police are instructed to be generous with respect to surrendered arms: ‘No obstacle should be placed in the way of a person who wants to surrender firearms or ammunition.’ 51 The return of illegally-held arms could result in discreet questioning by the police, but little pressure, unless circumstances exist to give particular concern, and firearms dealers are often encouraged by the police to take in unregistered guns.52 Surrendered arms, if they are not useful for museums or for inspection by the police, are destroyed. 53 In a memorandum prepared for the House of Commons 1996 inquiry into the possession of handguns, Michael Yardley differentiates between the ‘grey pool’, consisting of unlicensed guns held by people who have no ill-intent, and the black market, which are illegal weapons that can be accessed by criminals.54 He surmises that the grey pool is shrinking, in part because of amnesties, and that the black market is increasing. Yardley suggests one estimate of four million unlicensed guns in the grey market, far more than the number of legally-owned weapons. The black market is considerably smaller. The Cullen Report (Cullen, 1996, p. 107) cites a figure of 2000–4000 illegal guns available to criminals, and Lord Cullen notes: The wide range of these estimates [of the number of illegal guns] demonstrates that there is no certainty as to the size of the total number of firearms which are illegally held. The number of firearms which are used in practice by professional criminals may well be relatively small. How easy is it to illegally acquire a firearm in Britain? Here, the information is almost completely anecdotal. There is almost no price or quantity information, aside from occasional claims along the lines of ‘a gun can be had in Manchester pubs for £150’. Once again, rough characterizations, such as assertions that a ready supply

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of guns is available to criminals, substitute for the hard data that currently are unavailable. That guns can be had is clear, but the infrequency of their use in crime suggests that they cannot be had very easily.55 As with other illicit commodities, the key to acquiring an illegal firearm is to establish a connection to a source of supply. For many – indeed, probably most – British people, this is not a simple task. Because guns are durable goods, the possibilities for repeat purchases do not lubricate the market to nearly the same extent as they do with many illegal drugs – and the advantaged position of drug dealers in the illicit firearm trade has already been mentioned. For those outside the illicit drug trade (or perhaps – and only perhaps – the shooting community), access to an illicit firearm is likely to require prolonged search. Even the relatively large and well-financed Irish Republican Army (IRA), which apparently has amassed a sizeable arsenal of firearms and explosives and has had an interest in repeat and multiple acquisitions, appears to be quite limited in its ability to acquire the most powerful guns. In April 1997, British security forces confiscated a Barrett Light 50, a particularly forceful semi-automatic gun, thought to have been used for nine fatal sniper attacks since 1992. It was reported that the IRA could have two such guns at its disposal.56

Information and policy There is substantial (if incomplete) information on the extent of the problem of firearm violence; and the information indicates that the problem is vastly greater in the USA than in Great Britain, though it has increased markedly in both nations in recent decades. The earlier section describing the acquisition of firearms, alternatively, suggests a negative conclusion: there is very little information available about the acquisition of firearms by criminals, particularly in Great Britain. Policy analysis begins with a characterization of the current state of affairs. It then goes on to analyze how that state would be changed through policy reform. In practice, this step is often guided by the results of previous reforms. Poor information about the current state of affairs thus makes it doubly hard to design desirable policies, by reducing the accuracy of assessments of the current initial conditions, and of the results of previous policies. This situation is exacerbated within the social sciences, where controlled experiments generally are unavailable. With respect to firearms policy, there remain deep

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divides about the effects of various policies, even where the basic data are known and uncontroversial. A current example relates to the impact of liberalized concealed-carry laws in some US states. 57 The first question in firearm policy analysis often concerns whether or not a given measure can raise a barrier to gun acquisition (use, carrying, and so on) by high-risk groups. 58 The black market is fundamental for addressing this question. If the black market is functioning well, and cannot be influenced by different gun policies, then the futility syllogism noted in the introduction indicates that gun controls will have no effect, or perhaps – by differentially disarming law-abiding citizens – a perverse impact on crime. But as discussed in the previous section, there is very little information concerning the real availability of guns on the black market (particularly in Britain), and even less information on how the black market is affected by new policies. Theoretical thinking is helpful – formal markets and informal markets are linked (as the market for new and used cars is linked), and so there is a potential to influence the black market through formal market controls59 – but in the absence of empirical evidence, almost any claim concerning the outcome of a policy change is defensible. This is the price exacted by the lack of information about the black market for guns. Despite (or perhaps because of) the dearth of relevant information, many commentators seem to implicitly or explicitly accept that the black market for firearms is characterized by large quantities and low prices, that this situation cannot be changed, and therefore, that gun control is futile. Consider these excerpts from a memorandum made available to the 1996 House of Commons inquiry into the possession of handguns: The precise number of unlicensed firearms in existence . . . is clearly very large and may well be greater than the number of legal guns. It is certainly sufficiently large that violent criminals appear to have no severe problems in acquiring illegal weapons . . . Criminals, meanwhile, have no difficulty in obtaining semiautomatic and even automatic weapons. Reduced frontier controls in Europe have certainly made it easier than ever before to illegally import guns . . . there is a bigger demand for guns than ever before. 60 Polsby (1995, p. 220) provides a similar example of this style of reasoning, applied to the USA:

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Of course, gun runners will seek the least cost and most convenient source of supply, whatever it may be, legal markets, if available, but if they cannot deliver what is demanded, the turn to illegal markets, of smuggled guns or guns manufactured in cottage industry, is a simple operation. Further assertions about the responsiveness (or lack thereof) of highrisk groups to changes in the effective price of buying a firearm often accompany black market claims: ‘Thus the bad guys are highly motivated gun consumers who will not be easily dissuaded from possessing, carrying, and using guns.’61 The lack of information about the black market not only tends to provoke the sorts of assertions listed above, but also occasionally generates some seemingly faulty logic, along the lines of ‘because gun controls will not be perfectly effective, they are useless’. Here is an example of this argument, from the Home Affairs Committee report on the Possession of Handguns62 (emphasis as in the original, footnote omitted): But, more significantly, a wholesale ban [on all guns] would also be ineffective. As long as it is possible to obtain guns on the black market or through illegal importation, the possibility of their use, whether for armed robbery, or violence to an individual, or even multiple killings by an unbalanced individual, would remain. If there is to be a ban on the possession of all guns, meaning guns which would otherwise be lawfully in someone’s possession, the improvement in public safety would be minimal. Besides, the repercussions of a total ban would be farreaching for all occupational users; large numbers of exemptions might have to be made. We believe that a ban upon all guns would not prevent unstable individuals from gaining access to guns illegally, and we therefore reject this option. No bans, of course, are leak-proof. The point of most prohibitions, however, is only to raise a significant barrier to acquisition of the banned commodity: eradication is generally not a feasible option. Those who have connections to sources of illicit supplies will still be able to acquire firearms, but it can be made difficult to establish such connections, and it can be made risky for would-be suppliers to deal with any but close acquaintances. The fact that an underworld exists in which guns are available to certain individuals

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is not necessarily a reflection of the failure of controls, if that underworld is not too large. Some of the dexterous speed with which claims of hopelessness with respect to gun controls are made can perhaps be attributed to the seeming failure of other prohibitions, and in particular, the ban on some drugs, in the face of black-market circumvention. Guns are not drugs, however, and they differ in some ways that suggest that it is easier to disrupt a large-scale black market for guns. Most obviously, as stated earlier, there is much less room for repeat purchases in the informal gun market, and thus it is more difficult to establish reputations and therefore trust between would-be buyers and sellers. Guns are bulky relative to drugs, so large-scale gun sellers should be easier to detect. Further, the production side of almost all guns takes place in legal, and hence regulated, firms, providing an anchor for controls at later stages. Finally, even the ban on drugs has been successful in the (limited) sense of greatly increasing street prices over what they would be in an uncontrolled market. While the current limits to knowledge render it very difficult to predict confidently the effects of a given gun control measure, there are some points that can reasonably be gleaned from a comparison of the USA and Great Britain. First, there are about a hundred times as many guns in the USA as in Britain. The existing inventory of legally-owned guns is a major source of black-market weapons. All else being equal, then, the susceptibility of the black market to policing would seem currently to be greater in Britain than in the USA. Note, however, that this is not to say that the adjustment of the black market to counteract the impact of a restriction on the legal market will occur more easily in the USA than in Britain: the size of the market, in itself, says little about its responsiveness to changed conditions. Second, the social costs of gun violence are immensely higher in the USA than in Great Britain, and the current benefits of firearm ownership for personal protection are also higher in the USA.63 These profound differences suggest that the optimal regulatory regime might also vary considerably between the USA and Britain, and indeed, might even vary within each country: handgun violence in US urban areas, for instance, might call for a different approach than high suicide levels in some rural areas. As an example, consider the ban on ownership of handguns, the implementation of which was completed by Britain at the end of February 1998. Within the British context, this ban imposed direct costs on a relatively small

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and identifiable number of individuals, primarily those who legally owned such guns for target-shooting, and these people were partially compensated for their previously-legal firearms. Further, the relatively infrequent use of guns for criminal purposes implies that the ban has little scope to lead to increased predation by criminals on law-abiding citizens. In the USA, such a ban would impose costs on many millions who own handguns for personal protection, while the relative saturation of guns would not provide much assurance to these people that criminals would be less able to procure a firearm. This comparison with the USA indicates that to maintain Britain’s relatively low gun violence situation, it is important that British people believe that, by and large, others will not be armed with guns. The stricter controls that have appeared in Britain in recent years have helped to maintain that belief, as does the limited firearm carrying by police. Alternatively, in the high gun violence USA, stricter controls will, in many instances, be unable to provide much assurance that others are unarmed, while at the same time imposing costs on many more law-abiding people. (In some circumstances, it should be noted, substantial assurance that others are unarmed can be achieved, even in the USA: metal detectors at airports provide a case in point.) The paradoxical logic of arms races, in which behavior is to a large degree determined by perceptions of the behavior of an adversary, therefore suggests that strict controls can be more beneficial in relatively safe Britain than in the USA.

Conclusion There is very little information available concerning the black market for firearms, despite the fundamental role that the black market plays in determining the effects of policies. As a result, the conclusions of firearm policy analysis often rely on assertions, implicit or explicit, about the functioning of the black market. This is natural, and even desirable, as long as it is clear where the evidence ends and speculation begins. The dearth of information on the functioning of the black market could be a counsel of despair, if there were no hope of improved information in the future. Nevertheless, while it is frequently difficult to obtain reliable information about illegal dealings, existing studies indicate that it is not impossible. Black markets may never become completely transparent, but neither must they remain so opaque. Interviews with criminals, the back-tracing of guns used in

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crime, and even undercover operations, could all be used to glean relevant information. 64 The standard ending to a chapter such as this –, a call for further research – is called for here, with some confidence that better information about the workings of the black market for guns could lead to improved firearms policies, and lower social costs from firearms violence. Notes 1 For one argument against transparency, however, see Dixit (1996), p. 106. 2 Cook and Leitzel (1996). 3 See Wright (1995), p. 67. The potential desirability of subsidizing some gun availability (for police officers, most commonly) may also generate a public interest in firearms, as may fears induced by gun availability even in the absence of misuse. Gun misuse is most commonly associated with violent crime, though accidents and gun suicide also warrant public attention. 4 National Summary of Injury Mortality Data, 1988–1994. 5 For the homicide figure, see Zawitz (1995); on suicide, see the National Center for Injury Prevention and Control (1998). 6 The Annest et al. (1995) study based on hospital emergency departments covered the period 1 June 1992 to 31 May 1993. The CDC estimate is quoted in Zawitz (1996). 7 Miller and Cohen (1995). 8 Zawitz (1995) and US Department of Justice (1996). The 1995 crime rate in the USA was the lowest since 1985. 9 Zawitz (1995). The serious violent crimes were rape and sexual assault, robbery, and aggravated assault. 10 Greenfield and Zawitz (1995). 11 Hemenway et al. (1995). 12 Zawitz (1995). Of all murders in 1993, 57 per cent were committed with handguns, out of a total of 70 per cent that were committed with firearms, so about 81 per cent of all firearm murders were committed with handguns. The 1993 NCVS indicated that 25 per cent of rapes and sexual assaults, robberies, and aggravated assaults involved a firearm, and of those, 86 per cent involved a handgun. 13 On the preference for well-made, high-calibre weapons, see Wright, et al. (1983), and Sheley and Wright (1993); on the frequency of cheap pistols in crime, see Wintemute (1996). In a study of Milwaukee firearm deaths, 1990–4, Hargarten et al. (1996) note the predominance of inexpensive pistols in both homicides and suicides. 14 Wintemute (1996). The decline in revolvers relative to pistols is also evident in production data: in 1973, pistols formed 28 per cent of US handgun production, rising to 80 per cent in 1993. Zawitz (1995). 15 MacCoun et al. (1996), p. 338, in a study on drug policy, note that ‘Assessment of costs under a given [regulatory] regime usually requires at least three distinct steps: identifying all the relevant dimensions of consequences; estimating their magnitudes; and then assessing the costs of those consequences.’

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16 See Kleck and Gertz (1995), pp. 157–60, for a discussion of surveys touching on defensive gun use. 17 Cook and Ludwig (1996), pp. 68–76 provide some potential explanations for the wide discrepancies in estimates of defensive gun uses. 18 Kellermann et al. (1992, 1993). 19 Possession of Handguns, vol. II (1996), p. 58, hereafter cited as ‘POH2’. Shooting is the fourth most common form of homicide in Great Britain, behind attacks with sharp objects, kicking and beating, and strangulation. (See the reference to the Boyd report in the memorandum of Tony Geraghty to the House of Commons possession of handguns inquiry (POH2, p. 105).) 20 In 1989, for example, there were sixteen accidental firearm deaths, and 152 suicides (POH2, p. 114). 21 POH2 (p. 3, footnote 1). 22 POH2 (p. 58). The air weapons data in this source are for England, Wales, and Scotland. 23 Possession of Handguns, Vol. 1 (1996, p. x), hereafter cited as ‘POH1.’ 24 POH2 (p. 58). 25 Greenwood memorandum, POH2 (p. 115). The 1994 figure represented a fall of some 30 per cent from the 1993 total. 26 Greenwood memorandum, POH2 (p. 115). 27 Greenwood memorandum, POH2 (pp. 116–17). 28 Firearms Consultative Committee (1996), pp. 14–15. 29 On the US firearms market, see Cook et al. (1995), Cook and Moore (1995), and Cook and Ludwig (1996), pp. 14, 26. Data from manufacturers and importers of firearms indicates substantially higher additions to the stock each year; see Cook and Ludwig (1996), p. 26. 30 Cook et al. (1995). A 1994 survey indicates that 60–70 per cent of transactions involve an FFL, though this estimate could be too high if people are less likely to reveal informal transfers than they are to reveal formal transfers. See Cook and Ludwig (1996), pp. 26–7. 31 I have found almost no information on the source of firearms used in suicide. 32 Kleck (1986) notes that the high frequency of criminal records that are free of felony convictions, even among those who have repeatedly engaged in violent activity, implies that ‘guns could be denied, under selective gun control measures such as permissive licensing laws, to about half of the people who will commit homicides in the near future’. 33 Manson and Lauver (1997). 34 See Cook et al. (1995), Zawitz (1995), and Sheley and Wright (1993). 35 See Koper and Reuter (1996). 36 Weil and Knox (1996). 37 Cook et al. (1995). 38 Cook and Moore (1995), p. 277. 39 Koper and Reuter (1996). With respect to youths in Washington DC, these authors suggest that a generous estimate is that 2200 purchases of illegal guns are made annually, a frequency some three orders of magnitude less than that for illegal drugs. 40 Decker et al. (1997).

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41 The figure of 200 000 handguns in private hands, which included 160 000 high-calibre weapons, turned out to be a significant over-estimate, as the actual number of high-calibre pistols turned in after the ban was 116 000. The discrepancy could in part be traced to the mistaken inclusion by some police forces of rifles or shot-guns as handguns, and by the unreported disposal of some weapons. See Home Office Press Notice, 3 November 1997, at www.coi.gov.uk/coi/depts/GHO/coi4117d.ok. 42 Firearms Consultative Committee (1996), p. 54. 43 See the discussion in The Cullen Report (1996), pp. 106–8. (This is the common, though unofficial, name for the published inquiry by Lord Cullen; see the references for the complete bibliographic information.) 44 Home Office Research and Statistics Directorate (1996), p. 323. 45 Cullen (1996), p. 107. 46 Cullen (1996), p. 108. 47 POH2 (p. 59). 48 POH2 (p. 148). There is significant year-to-year fluctuation in the seizure of firearms. CS gas canisters, which are prohibited in Britain but not in other European countries, are the most commonly-seized illegal weapon. 49 POH1 (p. xi, footnote 62). 50 POH1 (p. xi). 51 Firearms Law: Guidance to the Police (1989), p. 158. 52 Stevenson (1996), p. 130. 53 Firearms Law: Guidance to the Police (1989), p. 158. 54 See POH2 (pp. 143–7). 55 British journalists occasionally investigate the black market for guns by attempting to procure an illegal gun, and in general, they find that it requires substantial effort. See, for example, Paul Mungo ‘A Power in the Land’, Guardian Weekend, 1 June 1996, pp. 20–5. 56 David Sharrock, ‘IRA Sniper’s Rifle Blamed for Nine Killings Seized’, Guardian, 12 April 1997, p. 1. 57 See, for example, McDowall et al. (1995a, 1995b), Polsby (1995), and Lott (1998). 58 If a gun control does raise a barrier to gun acquisition by high-risk groups, there remain the questions of whether it does so at acceptable cost (including enforcement cost and the inconveniencing of low-risk users), and whether the result will be a reduction in the costs of violence (or possibly suicide and accident), given that it may also disarm low-risk groups, or lead to strategic changes (such as weapon substitution) that could increase the levels of violence. 59 Cook and Leitzel (forthcoming). 60 Yardley memorandum, in POH2 (pp. 144–5). For similar assertions, see also the Kendrick memorandum, POH2 (p. 135), and the Greenwood memorandum, POH2 (p. 129). 61 Wright (1995), p. 66. For a further example, see Polsby (1995), p. 220. 62 POH1 (p. xviii). For a US example, see Wright (1995). 63 The discussion in this paragraph and the next draws on Cook and Leitzel (forthcoming). See also Leitzel (forthcoming). 64 A pilot program in the USA recently attempted to trace all crime guns recovered by police in seventeen cities. One of the conclusions of the

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Opaque Markets and Firearm Regulation program was that such tracing efforts can help to identify illegal traffickers in firearms. See the information on the Youth Crime Gun Interdiction Initiative provided by the Bureau of Alcohol, Tobacco and Firearms at www.atf.treas.gov/core/firearms/ycgii/ycgii.htm.

References Annest, J. L., J. A. Mercy, D. R. Gibson and G. W. Ryan (1995) ‘National Estimates of Nonfatal Firearm-Related Injuries,’ Journal of the American Medical Association, vol. 273, no. 22, pp. 1749–54. Ash, P., A. L. Kellermann, D. Fuqua-Whitley and A. Johnson (1996) ‘Gun Acquisition and Use by Juvenile Offenders’, Journal of the American Medical Association, vol. 275, pp. 1754–8. Cook, P. J. and J. A. Leitzel (1996) ‘Perversity, Futility, Jeopardy: An Economic Analysis of the Attack on Gun Control’, Law and Contemporary Problems, vol. 59, pp. 91–118. Cook, P. J. and J. A. Leitzel (forthcoming) ‘Gun Control’, The New Palgrave Dictionary of Economics and the Law. Cook, P. J. and J. Ludwig (1996) Guns in America. Results of a Comprehensive National Survey on Firearm Ownership and Use. Summary Report (Washington, DC: Police Foundation). Cook, P. J. and M. H. Moore (1995) ‘Gun Control’, in J. Q. Wilson and J. Petersilia (eds.), Crime (San Francisco: ICS Press). Cook, P. J., S. Molliconi and T. B. Cole (1995) ‘Regulating Gun Markets’, Journal of Criminal Law and Criminology, vol. 86, pp. 59–92. Cullen, The Hon. Lord (1996) The Public Inquiry into the Shootings at Dunblane Primary School on 13 March 1996 (The Cullen Report) (London: HMSO). Decker, S. H., S. Pennell and A. Caldwell (1997) Illegal Firearms: Access and Use by Arrestees, Research in Brief, US Department of Justice, Office of Justice Programs, National Institute of Justice ( January). Dixit, A. K. (1996) The Making of Economic Policy: A Transaction-Cost Politics Perspective (Cambridge, Mass.: MIT Press). Greenfield, L. A. and M. W. Zawitz (1995) Weapon Offenses and Offenders: Firearms, Crime, and Criminal Justice. Selected Findings, NCJ-155284, US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics (November 1995). Firearms Consultative Committee (1996) Seventh Annual Report (London: HMSO). Firearms Law: Guidance to the Police (1989) (London: HMSO). Hargarten, S. W., T. A. Karlson, M. O’Brien, J. Hancock and E. Quebbeman (1996) ‘Characteristics of Firearms Involved in Fatalities’, Journal of the American Medical Association, vol. 275, pp. 42–5. Hemenway, D., S. J. Solnick and D. R. Azrael (1995) ‘Firearms and Community Feelings of Safety’, Journal of Criminal Law & Criminology, vol. 86, no. 1, pp. 121–9. Home Office Research and Statistics Directorate, The Use of Licensed Firearms in Homicide – England and Wales, republished in Munday and Stevenson (1996), pp. 321–5. Kellermann A. L., F. P. Rivara, G. Somes, D. T. Reay, J. Francisco, J. G. Banton, J. Prodzinski, C. Fligner and B. B. Hackman (1992) ‘Suicide in

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the Home in Relation to Gun Ownership’, New England Journal of Medicine, vol. 327, pp. 467–72. Kellermann, A. L., F. P. Rivara, N. B. Rushforth, J. G. Banton, D. T. Reay, J. T. Francisco, A. B. Locci, J. Prodzinski, B. B. Hackman and G. Somes (1993) ‘Gun Ownership as a Risk Factor for Homicide in the Home’, New England Journal of Medicine, vol. 329, pp. 1084–91. Kleck, G. (1986) ‘Policy Lessons From Recent Gun Control Research’, Law and Contemporary Problems, vol. 49, no. 1, pp. 35–62. Kleck, G. and M. Gertz (1995) ‘Armed Resistance to Crime: The Prevalence and Nature of Self-Defense with a Gun’, Journal of Criminal Law & Criminology, vol. 86, no. 1, pp. 150–81. Koper, C. S. and P. Reuter (1996) ‘Suppressing Illegal Gun Markets: Lessons From Drug Enforcement’, Law and Contemporary Problems, vol. 59, pp. 119–46. Leitzel, J. A. (forthcoming) ‘Evasion and Public Policy: British and US Firearm Regulation’, Policy Studies. Lott, J. R., Jr (1998) More Guns, Less Crime: Understanding Crime and Gun Control Laws (Chicago: University of Chicago Press). MacCoun, R., P. Reuter and T. Schelling (1996) ‘Assessing Alternative Drug Control Regimes’, Journal of Policy Analysis and Management, vol. 15, no. 3, pp. 330–52. Manson, D. and G. Lauver (1997) ‘Presale Firearm Checks’, NCJ-162787, US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics (January). McDowall, D., C. Loftin and B. Wiersema (1995a) ‘Easing Concealed Firearm Laws: Effect on Homicide in Three States’, Journal of Criminal Law and Criminology, vol. 86, no. 1, pp. 193–206. McDowall, D., C. Loftin and B. Wiersema (1995b) ‘Additional Discussion About Easing Concealed Firearm Laws’, Journal of Criminal Law and Criminology, vol. 86, no. 1, pp. 221–6. Miller, T. R. and M. A. Cohen (1995) ‘Costs of Penetrating Injury’, in R. Ivatury and C. G. Cayten (eds.) Textbook of Penetrating Trauma (Philadelphia: Lee and Civigia). Munday, R. and J. A. Stevenson (eds.) (1996) Guns & Violence. The Debate Before Lord Cullen (Brightlingsea, Essex: Piedmont Publishing). National Center for Injury Prevention and Control (1998) Suicide in the United States, Division of Violence Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia at www.cdc.gov/ncipc/dvp/suifacts.htm. National Summary of Injury Mortality Data, 1988–1994 (1996) (Atlanta, Ga: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control). Polsby, D. D. (1995) ‘Firearms Costs, Firearms Benefits and the Limits of Knowledge’, Journal of Criminal Law and Criminology, vol. 86, no. 1, pp. 207–20. Possession of Handguns, volumes I and II (1996) House of Commons, Home Affairs Committee (London: HMSO). Sheley, J. F. and J. D. Wright (1993) Gun Acquisition and Possession in Selected Juvenile Samples, Research in Brief, NCJ 145326, US Department of Justice, National Institute of Justice, Office of Juvenile Justice and Delinquency Prevention (December).

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Stevenson, J. A. Lord Cullen’s Inquiry. Evidence, reprinted in Munday and Stevenson (1996), pp. 71–178. US Department of Justice, Federal Bureau of Investigation, FBI National Press Office Release, 13 October 1996. Weil, D. S. and R. C. Knox (1996) ‘Effects of Limiting Handgun Purchases on Interstate Transfer of Firearms’, Journal of the American Medical Association, vol. 275, pp. 1759–61. Wintemute, G. J. (1996) ‘The Relationship Between Firearm Design and Firearm Violence’, Journal of the American Medical Association, vol. 275 (June). Wright, J. D. (1995) ‘Ten Essential Observations on Guns in America’, Society, pp. 63–8 (March/April). Wright, J. D., P. H. Rossi and K. Daly (1983) Under the Gun: Weapons, Crime, and Violence in America (New York: Adline de Gruyter). Zawitz, M. W. (1995) Guns Used in Crime: Firearms, Crime, and Criminal Justice. Selected Findings, NCJ-148201, US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics (July). Zawitz, M. W. (1996) Firearm Injury from Crime: Firearms, Crime, and Criminal Justice. Selected Findings, NCJ-160093, US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics (April).

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7 Emerging Issues in Emergency Medical Rescue Thomas Judge

This chapter describes the demand for unscheduled services within the pre-hospital emergency care system of the National Health Service (NHS). As pre-hospital care in Britain and the USA have developed from common antecedents, lessons learned (or yet to be learned) are essential to future policy decisions in the allocation of resources in both countries. Dilemmas in pre-hospital emergency care illustrate the intended and non-intended effects of policy design and system development, including issues of accountability and transparency. A variety of factors, including changing demographics, technology advances, consumer knowledge and expectations, and world economic competition, will continue to force a reappraisal of social contracts across all areas of public expenditure, especially health care. While there has been near constant debate as to whether or not the NHS has been funded appropriately throughout its fiftyyear history, expectations and demand have grown at a much faster pace than resources in recent years. This has, in turn, given rise to increasing public concern about the ability to deliver care, and to new questions about the rationing and prioritization of services. As shown in Figure 7.1, in the tightly constrained NHS, spending on health care is less than the other G7 countries, and about half of what the USA spends. One of the most visible components of health care is the provision of emergency medical services. Emergency care is inherently unpredictable by nature. It is also experiencing rapid growth as demand increases. As a result, it is a useful policy area with which to understand larger system problems in health care and the public decisions required to provide adequate services in the future. 113

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13.6

12

10.5

9.8

10

9.2 7.8

8

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UK

6 4 2 0

USA

Germany

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Italy

Source: Analysis based on OECD Health Data 98; National Expenditures on Health: A Comparative Analysis of 29 Countries. Organisation for Economic Cooperation and Development. Paris. Available on the internet at: http://www.oecd.org/els/health/fad_1.htm

Figure 7.1

Total expenditure on health as a percentage of GDP, 1996

Emergency care and the demand dilemma The emergency care system we take for granted in the 1990s is a relatively recent phenomenon. In Britain, as in the rest of the developed world, the three decades since the 1960s have witnessed a complete transformation in emergency care. Generally, it has evolved as a reactive response to clinical problems rather than by efforts of conscious design (Delbridge et al., 1996). The evolution of the system has been incremental and often driven by forces other than the clinical understanding of medical issues. New providers and technology have been deployed widely, with tremendous knock-on effects in other areas of medicine. Theories and research into resuscitation coupled with the ever-increasing portability of advanced technology have led almost overnight to the development of an emergency care system. Historically, the initial encounter and interface between illness or injury and the health care system was with the patient’s general practitioner (GP). GPs served as primary emergency respondents and controlled access to secondary, hospital-level care. Ambulances transported the sick and injured who, by the nature of their medical problems, were beyond the care capabilities of the attending GP and could not be transported by any other means to a hospital. However, emergency medical problems were primarily dealt with at the community level by GPs, with very limited emergency care service in hospitals. Ambulance services arose primarily from

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community-level ‘rescue’-type responses to injuries from, for example, fire, drowning, and road traffic accidents. Additional limited roles developed from war-time experience for managing mass casualty incidents and disasters, primarily through the voluntary efforts of the St John Ambulance Service (St Andrew in Scotland) and the Red Cross. As a result of the National Health Service Act of 1946, local government authorities were required to provide a ‘free’ ambulance service (International Trauma Foundation, 1980, p. 307). Ambulance care attendants were minimally trained, if at all, and considered to be on a par with hospital porters and public transportation workers. Additionally, the transportation system was designed to convey those without adequate private transport for non-acute services. Similarly, acute emergency care at the hospital level was relatively unsophisticated. Hospital services were described as ‘casualty units’ in Britain, reflecting the war years and the need to treat trauma. Units were small; typically a room or several rooms (hence the concept of the emergency room known in the USA), sometimes staffed by a nurse (or, as commonly, attention was gained merely by a bell at the door) with back-up from whatever ‘caretaker’ physician was most available, whether trained in resuscitation or not (Audit Commission, 1996). Emergency medical care was limited. Many health problems we consider ‘solvable’ today such as ‘heart attacks’ (acute myocardial infarctions, or AMIs), and severe trauma were less treatable before the 1970s and were common causes of mortality. Routine resuscitative interventions that are performed in the 1990s by paramedic and technician crews were strictly within the province of physicians, if they were available at all, and most techniques were unavailable. In the late 1990s, the goal of a comprehensive healthcare system and each component within the system is to provide seamless care. In the case of emergency care, the system must be capable of delivering time-sensitive intervention (like resuscitation) to those with sudden and potentially life-threatening illness while at the same time responding to all other requests for unscheduled care. This dichotomy of needs creates a two-track dilemma in designing and implementing an effective system. On the one hand are patients in need of immediate life-saving services, the driving force for developments in emergency medicine. This cohort, who experience an unpredictable accident or sudden illness and need emergency

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attention, is very visible, in large part because of the media. The other side of the picture – caring for ordinary medical conditions or minor injuries – represents the vast majority of the workload. These are a combination of urgent-to-minor problems and include a recurrent ‘crisis’ in emergency hospital admissions during the early winter. This patient cohort is also the foundation of the larger system problem for policy designers. Overall utilization of emergency care is one of the fastest growing and least understood sectors within the NHS, as evidenced by the increasing difficulty of matching resources with demand (Calman et al., 1996, p. 7). Unlike other sectors of health care, however, factors driving the growth in emergency care are not clear. By all accounts, there is no consensus identifying any single or group of factors that are either pushing demand or could be controlled to limit demand (Harrison, 1997, p. 83). The challenge is to design and deliver a system that can respond to both the ‘extraordinary’ and the mundane, with acceptable results and costs in each case. Achieving the system goal of comprehensive care is made more difficult still because of increasing societal expectations at a time of limited resources. At least four major reviews (Audit Commission 1995; NHS Executive, 1996) dealing with the organization and funding of emergency care in the community, the structure and performance of ambulance services, and the organization and best practice in Accident and Emergency Units at hospitals (A&Es) have been developed since the mid-1990s. But up to the time of writing, despite an increasingly sophisticated pre-hospital care system, the design challenge in emergency care remains a moving target. This translates into a two per cent year-on-year increase in A&E attendance in England and Wales since 1981, and emergency hospital admissions have gone up by 40 per cent since 1990 (Audit Commission, 1996). Ambulance transport volume has grown year-on-year, and is now nearly 30 per cent higher than utilization in the late 1980s (National Audit Commission, 1997), with an eight per cent growth rate for the fourth consecutive year in 1995–6 (Department of Health, 1996). This growth in demand seems counter-intuitive in light of other developments in the health service. As an example, Scotland has experienced emergency ambulance transport utilization increases in double digits over recent years, with a rise of 11.3 per cent in 1995–6 (Scottish Ambulance Service, 1996) and A&E admissions increasing at an average rate of 2.8 per cent since 1971. This is happening

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despite reductions of nearly 25 per cent in GP practice list sizes (the numbers of registered patients), little change in overall resident population, only a three per cent increase in the population aged over 65, little change in violence-related epidemiology, and overall decreasing mortality from heart disease (Health Policy and Public Health Directorate, 1994). To date, there is no single explanation for this phenomenon. By and large, causes are described as ‘poorly understood or multi-factorial’ as they ‘cannot be explained solely by epidemiological factors’ (Calman et al., 1996, p. 7). The problem of demand for unscheduled care, however poorly understood or explained, is a real and growing threat to the entire health care infrastructure. Waiting lists for elective surgery have significantly lengthened in late 1990s as the recurrent crisis of wintertime emergency admissions disrupts scheduled care. The admission problems seem to get worse every year, and ambulance utilization more than doubled during the 1996–7 end-of-year holiday season. Further, the dynamics of winter admission problems seem to be changing. A recent working group has warned that the problem is ‘now affecting trusts throughout the year’: Although the pressures in the winter of 1996–97 were the worst ever, there was neither an epidemic nor a lengthy period of very severe weather. So the threat of worse problems hangs over the NHS. (NHS Confederation, 1997) From a policy standpoint several questions arise. Is the growth in demand a result of unmet need, changes in demographics, a response to increasing technology, or provider and organizational changes? Undoubtedly, each of these factors influences demand. As the sources of change in demand are not fully understood, the difficulty in managing them depends still further on understanding the interaction between multiple needs that are inherent in practicing emergency medicine. Three factors are driving the policy dilemmas in the healthcare system. They are provider-induced demand, pathway to care problems, and rising public expectation. All are complicated by changing demographics, and especially by an aging population that requires more healthcare-related support services. The increasing mismatch between demand and available resources suggests, at a minimum, the necessity of a fundamental review of basic design questions in the emergency care system.

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Provider and organization-induced demand In the case of emergency medicine, rapid growth in the system’s infrastructure has paralleled the rapid growth in demand. As with other areas of healthcare, this evolution of emergency medicine into an entirely new specialty has ramifications for public policy. As new therapies for once intractable problems become available, both medical providers and the public demand access to them. This drives changes to the system. Further, the proliferation of new providers, while perhaps increasing availability of services and ease of access, does not in itself translate into improvements in care, nor reductions in cost. Nor does the increase of numbers of providers necessarily balance demand for care. There have been suggestions recently that the opposite is more likely to be the case, with increases in provider supply, based on estimates of perceived need, fueling demand (Pencheon, 1997). Increasing demand and rising costs, together with unclear results and bad publicity, have led to calls for a more organized and comprehensively capable emergency care system. The introduction to the 1994 Scottish Office Policy Review, Emergency Healthcare in Scotland, illustrates this approach: The Report takes as its starting point the needs of patients who require urgent healthcare without having been able to make any prior arrangements. It has therefore had to take account of the complete spectrum of patient’s A&E health care needs. That approach involves recognition of the fact that such patients require the services of a wide range of services and medical specialties, including A&E departments, associated specialties such as orthopedics, anesthetics, and coronary care, ambulance services, and primary care services. The report gives the name ‘A&E Service’ to the totality of these components. It is important that this should not be regarded as synonymous with the specialty of A&E medicine. (Health Policy and Public Health Directorate, 1994) It goes on to detail the how this system should be implemented: Health Boards, as the primary agents of change in the NHS, through the contracting process and as purchasers of services on behalf of their populations, should plan to secure an A&E Service which:

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•

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meets the identified needs of the population, both resident and visiting; takes account of public wishes and expectations; provides the most effective intervention possible within the timescale required; makes optimal use of the resources available; provides the most appropriate form of care in the most cost effective manner, by striking the correct balance of provision between primary, hospital and major trauma care, with appropriate ambulance support; [and] is accessible to the population to a degree commensurate with the right treatment being available at the right time and place.

The envisioned system, however, exists more on paper than in practice. Problems emerge even in the description. The call for a comprehensive service composed of many specialties does not include, at least by name, providers more likely to be considered as part of the ‘social care’ system, despite numbers of patients overwhelming the A&E service on a regular basis with ‘social care’ needs. Further, it defines what ‘A&E medicine’ is not, although coordinating this system and providing links between comprehensive primary, social, and specialist care services is, in fact, the essence of A&E medicine. In response to a widening gap between demand and available resources, a variety of initiatives are being tried. These include: increasing the availability of care points with urgent care centers, minor injury units, and GP surgeries; expanding the scope of services by providers, by utilizing GPs, paramedics, community pharmacists, and newly-defined nurse practitioners; and adding new technology, such as prioritized dispatching systems for ambulances, health advice lines, and an increasing role for public safety, fire, and police services. Most of these have developed at the local level in response to resource issues. Many of these ideas are supported in a call for restructuring emergency care that was issued in 1996 through a Chief Medical Officer’s consultative document entitled Developing Emergency Services in the Community (Calman et al., 1996). Despite centralized control of the overall budget and organizational infrastructure, providers within the NHS represent a diverse group of interests, with devolved budgets and responsibility for care. Further, as noted earlier, the growing number of providers responsible for unscheduled care raises accountability issues. Additionally, the

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diversity of interest has been accentuated by the introduction of the internal market in healthcare. Health Authorities and Regional Administration have always had distinct budgets for community care – GPs and acute care – A&Es and Ambulance Trusts. Community mental health and social care budgets have also been distinct. The Ambulance Trusts illustrate problems in this funding approach. Although assimilated by the NHS in 1974 and reconfigured to Health Authority boundaries, service areas remain tied to historic political divisions, primarily around county or shire lines. Ambulance Trusts also contract for non-urgent transport with Acute Hospital Trusts on an open-market basis, and contracting does not always follow A&E boundaries. Increasing competition between the Ambulance Trusts, because of market testing by Acute Trusts, coupled with ever-tighter resources for capital improvements, complicates the problem. The convoluted geographical boundaries between different NHS Ambulance Trusts often mean that assets of one service may be much closer to a call as time-sensitive as cardiac arrest, but are generally not utilized if crossing the artificial boundary is required. Much of the time this would not be possible, even if desired, because of the lack of integration in the command and control of the respective Trusts. While adjoining Trusts could conceivably share in the capital requirements of developing new control centers, Trusts have generally not grouped together to share infrastructure investment. Investment priorities of the Ambulance Trusts and their funding Health Authorities are also often less than congruent. With changing practice boundaries between the social and medical care systems, the goal of managing people close to their homes is further complicated by perverse incentives to move problems elsewhere. Although the emergency care system is designed for critical illness or trauma, in practice its role has become the management of all types of medical and trauma problems, from minor to lifethreatening. It serves as the public safety net for a myriad of what may be defined as ‘non-medical’ problems incurred by homeless, mentally ill, poor, transient, and immigrant people with language and structural access problems to the NHS and the social services. By default more than design, crisis mental health problems, clinical and social needs, crisis substance abuse (especially the effects of alcohol), and problems with residential support systems, have become the default responsibility of the emergency care system, especially after hours.

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Attributes of event-driven medical problems

Occurrence outside care point 24-hour occurrence Seasonal variations Minor to life-threatening misfortune Some occurrences are time-sensitive Unpredictable Unexpected Both unplanned and scheduled care Expected planned chronic care crisis Health maintenance

Unintended consequences in system design, failures in social policy, and changing demographics have large ‘knock-on’ effects in the healthcare system, and each of these factors relies by default on the emergency care system – with results something akin to squeezing a balloon. Table 7.1 lists the attributes of the more common problems seen by the emergency care system in both the pre-A&E and the A&E settings. While some of these problems require specialized care, many can be solved by a lower level of service and provider. This is especially true of simple health maintenance, follow-up procedures, and social care. Although budgets between social care, mental health care, and medical care are distinct, problems incurred by the affected populations are not. Clearly, the distinctions between social and medical problems can become blurred. An elderly patient suffering poor nutrition while living without adequate heat may develop a range of medical problems as a result. In the absence of shared strategies and responsibility there is the risk of serious gaps in care, and related long-term consequences. The disconnection in budgets and responsibility between medical and social care has been recognized as a key theme in the need for change identified in the newly-released White Paper entitled Developing Emergency Services in the Community: There are unmistakable signs of pressure on our emergency care system. Hospitals across the country came under intense pressure in Winter 1995/96 to cope with surges in demand for emergency admissions. There continues to be an unprecedented demand on acute mental illness beds. There has been a consistent increase in recent years in the number of ‘999’ calls being made and in the number of new A&E attendances. (Calman et al., 1996)

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Emergency care crosses many boundaries and budgets. The only universal constant in many areas is the ambulance service that is purchased from a variety of Trusts, which may or may not have any incentive to cooperate with a ‘system of care’. Who responds, the location of definitive care, and referrals outside the responsible Trust (ECRUs) are decisions influenced as much by provider ease as patient need. It is still far too easy to transfer problems to someone else’s budget, with the A&E admission to the hospital being the final catch-all. Although problems with boundaries are universal, London provides the ultimate example of this problem. The London Ambulance Service (LAS) is the only comprehensive emergency care system among two Regions, fifteen Health Authorities, thirty-four Acute Hospital Trusts, some seventy Community Trusts, and hundreds of GPs. An unintended consequence of the introduction of the internal market and the Patients’ Charter have been ‘league tables’ measuring throughput as a test of responsiveness and quality. This has forced Trusts to provide ever more services in order to justify budgets. This is an unintended but serious consequence for the emergency medical care system, with the circular effect of driving far higher utilization rates, and perhaps more importantly, much higher levels of expectation from the public. The system goal of ‘money following patients’ has never been realized as resources continue to follow established healthcare structures. Moreover, despite the unmanageability of the current system, incentives are aligned against change. Change is difficult, as current incentives revolve around individual Trust performance rather than system-wide performance. Measuring quality via throughput is also problematic, as it may not be in any way related to quality of life measurements. Moreover, despite rapid growth in emergency care and a near-constant crisis surrounding ambulance utilization, A&E attendance, and emergency admissions, every provider must maximize activity in order to demonstrate high levels of performance. In combination, these factors create an ever-expanding spiral of utilization in a system with fixed resources. Clearly, current practice is non-sustainable but it is yet unclear from where the catalysts for change will come. During the course of managing an unscheduled patient-care request, there are numerous opportunities to re-think resource allocation at the micro level. In a recent working paper on managing demand, Pencheon (1997) describes these opportunities as ‘interfaces’:

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These opportunities tend to concentrate where the significant resource dependent decisions are made: i.e. at interfaces. These are between self-care and professional care, primary and secondary care, across boundaries within secondary care, between secondary and tertiary care, and between health care and social care. (Pencheon, 1997) An effective emergency care system must be able to identify and respond to the wide spectrum of healthcare problems, from minor to life threatening, and allocate sufficient resources to manage problems comprehensively in real time on a reliable basis. At the distinct points of access, response, and management, multiple providers and options need to be available and utilized. This depends on sophisticated communications and decision-making technology. But at each of these interfaces the movement of the clinical problem must be evaluated in real time and directed to one of many care pathways. The current strategy and system, however, delivers less than it might, given the resources that have been allocated. The planned or unplanned interactions between the providers, patients, and the community at large do reflect in the ability of the system to translate resources into needed services, but responsibility is diffused across multiple providers and budgets. Central direction of resources is limited to defining standards of response for each provider rather than overall system design and accountability. Further, the center has done nothing to prevent duplication or provide effective coordination of resources. Pathway paradigms: the management dilemma The development of an overall system design, as suggested above, is hampered by traditional patterns in delivering emergency care. While the content and practice of both primary care and specialist care are well defined, emergency and urgent care are not. Emergency care has evolved into the provision of short-term interventions in health crisis with the important distinguishing feature of location – these events occur outside established medical-care delivery points. Table 7.2 illustrates the attributes of problems small to large, simple to complex, and compares these attributes between emergency and urgent care. Table 7.3 details how these attributes interface with the demand for unscheduled services. It is important to recognize the key differences in provider capability, and the locations where care can be delivered. Emergency care for the critically ill or injured

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Table 7.2

Attributes of emergency versus urgent care

Emergency-driven attributes

Urgent care attributes

• • • •

• •

• • • • • • •

Unplanned and unexpected Unpredictable Crisis – extremely time-sensitive First few minutes to first hour are crucial Critical and potentially life-threatening Less than 3–5 per cent of patient volume Some patients will not survive despite interventions Resource- and technologyintensive Sensitive to expertise in handling volume Concentration of resources and specialists necessary Must be managed on specific site through transport

• • • • • • • • • •

Time-sensitive First minutes to hours are crucial Minor to major problems 90–95 per cent of patient volume Limited critical resources and technology Misfortune and chronic-care based After-hours and access to care barriers Demographic and geographic considerations Unplanned palliative crisis Unplanned chronic disease management Social and psychological care problems Manageable in multiple settings

requires constant exposure to a fairly small group of patients at the tertiary level. But the much larger group of patients may be seen in less specialized settings. Whether access is through the 999 system or the GP, generally there are four stages to delivering care: • access to the healthcare system; • alleviation of symptoms, including critical life-support interventions; • stabilization of major problems; and • referral to a secondary source for definitive care. This makes sense for the critically ill or injured patient for whom appropriate care is unavailable from any other source. In addition, the increased use of radiographic imaging and laboratory tests as essential components in the testing process require the use of the ‘central site’. What is less clear is whether or not this makes sense as the predominant pathway for all patients. Initially, the idea of the new paramedic provider was based on the problem of not having a physician immediately available to help every patient with time-sensitive critical problems. While

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Practical and organizational reasons for increased demand Reasons for Increased Demand

• • • • • • • • • • •

Reduced family support networks Poor access to primary care Use of A&E in place of visit to GP Use of home visits to bypass GP appointments system Absence of more appropriate community-based services Failure to register with GP Preference for A&E over GP deputizing service Easier access to emergency services Lack of explicit alternatives to 999 Lack of understanding of what to do (especially for refugees and recent immigrants) Need for urgent access to morning-after contraceptive pill

paramedics have taken on skills previously strictly within the province of specialist physicians, their abilities remain limited for assessment and less urgent care. This makes sense, because even though advanced skills are delegated to non-clinicians for treatment of critical injury or illness, there are limits to technician and paramedic training, and these limits require a conservative approach to medical risk management. These non-clinicians, despite excellent skills in identifying and treating what is ‘wrong’ with a patient, need to assume something is wrong with a patient that caused the original contact with the emergency system. The possibility that a problem is not recognized by ambulance personnel requires a ‘big net’ to bring all problems from the community to a hospital-based clinician. The much greater investment in physician training allows the physician to determine as much what is not wrong with a patient as to determine the course and extent of intervention. As such, no matter how minor the problem, the ambulance component of the emergency-care system requires transporting patients to a hospital to determine what, if anything, is wrong, followed by treatment or discharge. Despite the gradual evolution of skills and equipment in the pre-hospital setting, the defining role of the ambulance service is still one of transport from the community or periphery to the hospital or the center. Virtually the entire range of emergency and urgent problems are handled along a single prescribed pathway: access, assessment, and intervention, followed by transport to the A&E for definitive assessment and management.

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Gathering and delivering all problems to a central location allows specialist providers to work efficiently, but up to an unknown point. Clearly, the recognized dilemmas of cardiac arrest and critical trauma remain the primary challenges for emergency-care systems and take precedence over other functions; these clinical conditions must be reversed within minutes. However, cardiac arrest and lifethreatening trauma are only a small component of emergency care delivered outside either the GPs surgery or A&E facilities. In a financially constrained system, ‘gold standard’ performance for the fraction of patients experiencing life-threatening dilemmas comes at the expense of the vast majority of problems encountered by emergency-care providers. The reverse is also true. Answering the common complaint efficiently and effectively makes it more difficult to respond to the extraordinary. The original focus on transportation after intervention in managing emergencies shapes the second paradigm, the ambulance as a ‘bus’ service. Despite the advent of priority dispatching called for in new performance standards, there is currently no option but to dispatch an ambulance to virtually every 999 request. Despite increasing skills and technology deployed on ambulances, the primary role of the ambulance service remains transport after limited (but sometimes sophisticated) intervention. Ambulance transport is not necessarily dependent on medical necessity, despite a near twentyyear debate over medical necessity and transport utilization (Ambulance UK, 1970–95). Further, there is no universal agreement as to which interventions should be performed outside a hospital, as these interventions delay the inevitable transport of patients to the hospital setting. Assumed throughout the debate is the transport paradigm. There are also problems with identity. The non-emergent, general patient transport services run by the Ambulance Trusts add to both the perception and reality of the transport role. In the absence of a legal description of what constitutes an ‘ambulance’, a wide variety of vehicles are described as ‘ambulances’, with the term used interchangeably to describe the most capable ‘mobile intensive care units’ as well as vehicles comprising not much more than a van with a cot or bench. Personnel descriptions are much the same. Ambulance staff are described in total as ‘ambulance men/ women’ by both the media and clinicians. In the next breath they all become ‘paramedics’, with expectation of the ability to perform life-saving miracles. Further, as with vehicles, absence of regulation means that anyone can describe themselves as a ‘paramedic’, with or without qualifications.

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The location of care points is the next paradigm, the ‘one size’ theorem. Following from the comments above, not only is an ambulance dispatched to every call but, further, by direct or indirect rule, the outcome of virtually any 999 call is transportation of any injured or ill party to a hospital. Although GPs are actively engaged in managing problems where they occur, unless the problem is so small as to preclude the need for diagnostic testing, the problem is gathered to the center. Public access and education to use the 999 system coupled with increasing GP workloads limit the ability of the GP to serve as the possible end-point of care. As with other system interactions, the lack of data regarding changes in non-office GP visits and the utilization of other care points makes it difficult to determine cause and effect. Even more important, practice pathway paradigms create as many problems as they solve. Traditional pathways from incident to A&E all move problems from incident location to the top of the care chain, following the ‘high rise’ paradigm. This occurs whether the patient enters the system from the 999 or the GP route. The goal is to have a specially trained senior physician provide at a central care point definitive assessment and treatment for real, potential, and imagined problems. The cost of delivering this level of assessment at the incident site is impossible to manage. But often the determination is that something is not wrong; put another way, the ambulance provided transportation to see whether someone needed medical care or not. Utilization of GP intervention at the residential level does not necessarily change the equations of the latter two paradigms. Before the widespread deployment of paramedics, GPs were the primary responders at the community level to all emergencies, despite their lack of formal training in resuscitative medicine. In addition to their role as care providers for the critically ill, they played key roles in the treatment of minor emergent problems and as gatekeeper in referring ill or injured people to secondary hospital care. Now, with GP utilization rising, complaints from GPs over the terms and conditions of their work have led to increased reliance on alternative approaches to after-hours care, such as deputizing and co-op services. Increasingly, this results in GPs seeing unfamiliar patients with urgent problems, or just unloading the call to the ambulance service. This inevitably lowers the threshold for transport and admission (Nicholl et al., 1995). Evidence is limited, but most Ambulance Service Trusts are experiencing a leveling of doctors’ urgent calls simultaneously with an increase in emergency calls

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from the general public (Department of Health, 1996). The combination of GP instructions to call the ambulance service directly for some problems such as chest pain, and slower response by GPs than by the ambulance service suggests anecdotally that the public is increasingly accessing the emergency-care system directly, for minor as well as for critical problems. Although GPs still respond to urgent and emergency problems in the community, most are either poorly prepared or equipped to provide advanced resuscitation (West and Penfold, 1997, pp. 37–40). Thus GP-initiated care is increasingly confined to first-level intervention, diagnosis, and a subsequent call to the ambulance service for transport to the hospital. There is also some question as to whether GPs are acting as effective gatekeepers, with anecdotal reports of GPs transferring care to the 999 and A&E system. In the late 1990s structural changes have been introduced into the system to increase the ‘gatekeeping’ role of the GP, with a publicly heralded theme of a ‘primary care led’ NHS. A similar approach has been introduced by managed care in the USA, with the goal of controlling utilization and limiting access to secondary care. In the area of unplanned and unscheduled care, traditional strategies for controlling utilization and growth in demand, and consequently costs, are, however, usually unhelpful. For example, by definition, controlling utilization through scheduling GP appointments is impossible in unpredictable events that require emergency or urgent intervention. Equally difficult is delaying and/or limiting access to secondary care through strategies such as waiting lists for elective procedures. Overall, there is no clear management plan. The recent NHS Confederation report, Tackling Emergency Admissions – Policy into Practice calls for the government to ‘issue national guidelines on referrals’ with ‘clear criteria for GPs, ambulance staff, and hospital doctors on when they should refer or transport patients as emergencies to hospital’ (Health Service Journal, 1997). The problem, however, is deeper than ‘guidelines’ might be able to manage, as responsibility is not always certain. With limited budgets and increasing demand, the problem of shifting responsibility for care is the most pressing issue. The ‘big net’ approach – gathering all problems in order to not miss subtle ones – and subsequently moving the problem to secondary assessment and treatment creates a system that focuses problems at the top of a pyramid. This is the most resource-intensive

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and costly option. Emergency care at the community level and unwarranted A&E attendance are among the most rapidly growing sectors of medicine. All the providers of unscheduled care are seeing increasing demand. Facing continually rising attendance past budgeted levels, GPs, Ambulance Trusts, A&E clinicians, community providers, and Trust managers across the country are now complaining of ‘inappropriate’ attendance. Looking at the system from the user’s standpoint, delivery mechanisms may exacerbate demand by not delivering care at the appropriate point and by the appropriate provider. One has to wonder if, from the patient’s standpoint, when they call 999 whether they ‘want’ to go to hospital in an ambulance? Does the public really ‘want’ to attend A&E and wait for hours to take care of some fairly minor but immediate problem they do not know how to solve? Alternatively, do patients ‘want’ either to wait to see a GP during surgery hours, wait for a scheduled appointment for an immediate health need, or even call out a GP after hours? However, faced with need and a limited number of choices, people will use the systems that have been designed, but perhaps not always as they have been intended. Public expectations and political imperatives The complexity and emotionally laden interactions between the individual and the emergency-care system make rational decisions about resources difficult, as both success and failure receive highprofile public and political attention. The ‘big’ and public problem posed by patients needing resuscitative care has been the primary driver of system design and allocation of resources in emergency care. Despite the implementation of a sophisticated emergency-care system in Britain, the impact of cardiac arrest and critical trauma remain substantial. An estimated 250 000 people per year experience acute myocardial infarctions (Handley, 1995), with estimates of potentially reversible premature cardiac death estimated at 75 000 deaths per year (NHS Executive, 1996, pp. 32–8). The case of lifethreatening trauma is similar, with a report from the Royal College of Surgeons estimating that up to 33 per cent of 514 trauma deaths were avoidable in a 1000-cohort study (Royal College of Surgeons of England, 1988). The broad spectrum of problems, the time-sensitive nature of decision-making in urgent and emergency care, and the high emotive content of the acutely ill person highlight the system design

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dilemmas on a daily basis. This should not be surprising. Given the choice, most people will choose to spend whatever is needed for a loved one who is ill. At the individual case level, the emotional issues around emergency resuscitation cloud our understanding of the problems inherent in delivering medical services. Whether or not the outcome or intervention is judged to be successful, a circular logic takes over: this is a problem where we clearly need more resources, and we cannot and should not make any decisions to ration care. Clearly, the ability to intervene in formerly untreatable conditions with new technology and techniques are potent forces driving growth in public expectations of new services – often prior to any reliable evidence that new interventions work. While the lack of evidence-based practice remains an issue across medicine, it is highly visible in the emergency sector because of the pervasive influence of the media. Almost as soon as new interventions are reported, they become dramatized in both documentary and fictional media, thus creating demand for their use. Currently, it is nearly impossible to find a single report on health care that does not incorporate the sounds and visual images of the ambulance service and/or the hospital A&E department. While ‘emergency’ imagery in stories having nothing to do directly with emergency care seems incongruous, the emergency-care system bridges and ties together all other providers and components of the healthcare system. The dramatic appeal of emergency care has become the visual metaphor of the ‘system’ within the NHS, with corresponding increases in political sensitivity. The high emotive content also attracts media and public attention when mismatches between resources and services result in delivery failures. As pointed out in a recent system evaluation: However, although emergency services may have an important part to play in the health service, they do perhaps receive an inappropriately high profile, especially when named lives are lost or saved. A death can revolutionize public opinion and health care policy, where an ocean of misery may have no effect. Investing in emergency health care should be done as objectively and dispassionately as possible. (Pencheon and Hadridge, 1995, p. 14) The effect of the media is enormous in portraying dramatic rescues and emergency medical service (EMS) personnel as lifes-savers. Tele-

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vision shows such as ‘Rescue 911’ in the USA and ‘999’ in Britain re-enact the drama of rescue and resuscitation events for the public. Another example of this phenomenon is the proliferation of medical helicopters, many of which are supported by the public through donations. Helicopters are dramatic, with high visual appeal for the media. With the exception of the Scottish Ambulance Service, which fully funds an integrated ground and air system to cover island and rural populations, increasing numbers of Ambulance Trusts are developing air medical programs outside of NHS finances. While much is made of the fact that in most cases funding is non-NHS, programs still need to be staffed and supplied. There are opportunity costs as well. These costs require NHS resources. While all these programs are innovatively managed and there is a role for air medical evacuation, clear demonstrable benefit is limited (Nicholl et al., 1995). The question is not as much about the role of medical helicopters, but rather how many, and where should they be deployed? In the geographic setting of England and Wales, using long-established methodology for placement, a case might be made for perhaps three to four helicopters in total rather than the current eleven. Further, this does not take into account already deployed military assets. In the wake of media coverage, politicians have followed the public’s interest and desire for ‘doing everything possible’, with imperatives for equity and access to new interventions. Without any specific evidence as to the efficacy of paramedic-level care, Ambulance Service Trusts now provide a paramedic on every ambulance, primarily to treat cardiac arrest and life-threatening trauma. As with the benefits of helicopters, recent UK studies have questioned the strategy of universal deployment of paramedics, having found no difference in cardiac arrest survival outcomes between treatment by technicians and by paramedics (see, for example, Nguyen Van Tam et al., 1997, pp. 142–9; Mann and Guly, 1997, pp. 149–51, Rainer et al., 1997, pp. 278–83; Mitchell et al., 1997, pp. 274–8). Questions as to the efficacy of paramedic interventions in the field of trauma have also been raised. This has further led to questions about the effectiveness of trauma services in hospitals, and considerations of institutional reorganization (see, for example, Knapp et al., 1997; Nicholl et al., 1998; Nicholl et al., 1996). Further, in 1996 an extensive review of the Ambulance Services was conducted by the Department of Health, with proposed

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improvements to response time requirements by the year 2001. In making a case for benefits of improved standards put forward in the Ambulance Review, the impact on reversing cardiac arrest by improving ambulance response time was referred to (NHS Executive, 1996). Accomplishing improvements in ambulance response times requires significant infrastructure investment. This includes combining redundant and/or unutilized response capability, sophisticated communications, management information, and advanced command/control systems. These are required to allocate resources in real time, and to deploy staff and ambulance resources effectively. But in a cash-limited system, the only alternative is to accept a lower level of acceptable response-time interval (RTI) standards, often part of the mix as well. The 1996 Ambulance Review calls for improving performance to ‘life-threatening’ calls (Category A) through the use of prioritized dispatch systems from the current 50 per cent standard for all calls to 75 per cent reliability in eight minutes or less for ‘life-threatening’ calls by the year 2001. All other calls must meet current response standards of 95 per cent reliability in fourteen minutes for urban areas, and nineteen minutes in rural areas. In addition to cardiac arrest, Category A calls include adult chest pain, unconscious or seizing patients, severe respiratory problems, severe trauma, anaphylactic shock, severe obstetrical hemorrhage, and all calls for children under two years of age. Originally the requirement for Category A ambulance response under eight minutes was for 90 per cent of these calls, but this was dropped back to 75 per cent because of cost considerations. The required improvement in Category A calls from the current 50 per cent reliability in eight minutes will undoubtedly have an impact on premature death. But the compromise 75 per cent threshold standard, as pointed out by one commentator ‘really amounts to planning to arrive too late to make a difference’ (Roberts, 1995). Further, recognizing that many requests for ambulance care and transport are non-urgent, the Ambulance Review called for a new ‘Category C’, without specified response time requirements. Both the creation of a third category and the lowering of standards, long used in the USA, would have aided Trusts in improving performance for Category A and B calls. But the option was withdrawn in the political review over fears that the public would see Category C as a means of rationing access to health care. There are other problems in public perception and system knowledge. While the plus side of the media influence perhaps develops

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public and political support for the emergency-care system, on the negative side, the excitement that sells a television show is often at the expense of reality. Public perceptions are created by projecting a constant set of health crises that do not really exist – at least in such numbers or constancy – such as the flow of patients through dramatic shows like ‘ER’ or ‘Casualty’. Tied to this mythology is the perception of ambulance technicians, paramedics, fire-fighters, A&E physicians and nurses as heroic life-savers despite the reality of their day-to-day jobs. A recent review of US media by the New England Journal of Medicine found a 67 per cent survival rate of patients with cardiac arrest on prime-time television, far in excess of the current 15–30 per cent discharge rate common across the USA (New England Journal of Medicine, 1996 pp. 1605–7). Results are probably similar in Britain. Most of the patients portrayed on these shows are relatively young, under the age of fifty, while the common experience of cardio-respiratory arrest is in patients over seventy-five years of age. Despite increasing expenditure on emergency medical services, the impact of resuscitation is, at best, mixed. While dramatic results in resuscitation have been managed in some systems, success in one setting has not been broadly reproducible despite continuing growth and deployment of resources. The demonstrated gold standard of out-of-hospital 30–40 per cent success rate in survival from cardiac arrest is achieved in only a handful of systems worldwide. Estimated reported survival rates in Britain – no standard reporting format exists – range between 2 and 11 per cent (NHS Executive, 1996, pp. 32–8; Goodacre et al., 1996, pp. 4–8). If there is an eight minute window of opportunity, at maximum, to reverse sudden cardiac arrest it is not the current EMS system that is likely to make the major difference. At a minimum, defibrillation should be available from every public safety response point, such as fire brigades and police services. The evidence is available. The best of systems highlight 30 per cent survival from out-of-hospital cardiac arrest – that means that seven out of ten people do not survive; success rates in Britain are even lower. If the current technology of automatic defibrillators had been available in 1967 rather than 1987, the emergency-care system of today would look far different (Mustalish et al., 1994). There are lessons to be learned, however, from the system designs that have been considered over time. Although delivering widespread resuscitation is clearly possible, success requires a

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sophisticated system, is expensive, and clearly does not benefit each person to whom it is delivered. Moreover, delivery is not measured consistently, and a tremendous amount of mythology surrounds both the process and the results. These issues present a variety of dilemmas for the emergency-care system. The time requirements in which decisions must be made force the need to resuscitate. But determining death traditionally remains solely the province of the physician. Unless the evidence of irreversible death is overwhelming, the limits of technician and paramedic training create a de facto requirement to resuscitate nearly all patients, regardless of the potential benefit. Research has shown that some patients do not benefit from resuscitation. These include patients with prolonged arrest states, submersion greater than one hour, and cardio-respiratory arrest secondary to blunt trauma. Yet routinely, scarce resources are used in futile efforts to reverse these conditions. Moreover, once started there are no current mechanisms to allow resuscitation to terminate without a physician order. Recent recommendations by the Royal Colleges Ambulance Liaison Committee have begun to address the futility issue in the form of guidelines (Baskett and Fisher, 1997, pp. 13–16). These may be accepted by individual Ambulance Trusts, but they are only in the form of guidelines and remain conservative, with very limited options for either not starting, or terminating, resuscitation efforts. Additionally, there is the question of those who do not want resuscitation. Primarily these are patients with terminal disease. General practice is for the patient’s physician to write a ‘Do Not Attempt Resuscitation’ order, but there is no consistent, universally accepted format in place across Britain. This may result in considerable frustration with emergency crews unable to locate orders in the midst of a crisis. Management of cardiac arrest has come to be a narrow proxy for clinical reliability even though it represents the extraordinary rather than the typical patient. Cardiac arrests represent less than one per cent of calls in emergency-care systems, while cardiac complaints represent as many as 27–29 per cent of calls in most systems (Maine Health Information Center, 1996). Since the 1960s, care for acute myocardial infarctions (AMI) has evolved from treating symptoms to the administration of clot-dissolving thrombolytic agents capable of completely eliminating the damage from an AMI. In turn, this has spurred both technology, in the form of interpretative

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twelve-lead echocardiograms, and practice in the form of fasttracking AMI patients, to administration of lysing agents. All these techniques can be administered in a range of settings: pre-hospital, A&E, or the cardiac care unit of a hospital. Technology once very expensive and available only in the coronary care specialty unit is now deployable on ambulances with trained paramedics in attendance. At the end of the day, treating cardiac arrest is palliative care at best, and the chase to improve mortality statistics slows down proven success in reducing morbidity, a far better economic investment. A recent journal article explains the value of better management of acute myocardial infarction (Rawles, 1997, pp. 13–19). The recognized treatment pathway is early recognition, access, immediate intervention with oxygen and nitrites, opiate analgesia, and thrombolysis. Despite years of evidence that maximum benefits of treatment must be achieved ‘in the community at the first opportunity; [as] coronary care initiated in hospital can only have limited impact on mortality’, the benefits of early opiate and thrombolytic administration remain largely unrealized until entry into the hospital. GP involvement in acute cardiac care is limited in most places, and paramedics are not allowed to administer either the opiate or thrombolytic agents. With increased survival rates nearly double the rate of salvage from arrest states, the economics are overwhelming, not only in the immediate term but in reducing long-term disability. While recent efforts by several of the Ambulance Services to ‘fasttrack’ AMI patients have shown good results in reducing ‘door to needle’ time, these efforts are limited even in locales where operational because definitive care still waits until some point after hospital arrival. Meeting the objectives of ‘most effective intervention possible within the timescale required’ with the right treatment being available at the right time and place can be accomplished with a combination of training for both paramedics and GPs. Obviously, the costs of implementing changes would be substantial. But as Rawles (1997) points out in his analysis of costing, ‘by giving any thrombolytic agent half an hour earlier we gain as many lives as we would from giving alteplase (r-tPA) instead of streptokinase – at no additional cost and without the penalty of two additional strokes per thousand’ (Rawles, 1997, pp. 13–19). This half hour improvement translates to nearly £1100 per patient.

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Policy and transparency The examples above illustrate the tensions in system design. In events that are unscheduled, time-sensitive, time-limited, and simultaneously require the efforts of multiple providers, it is difficult to balance public expectations and political imperatives against system resources, organization, and evidence of benefits. The emphasis on the dramatic may come at the expense of the overall role emergency care plays in the community. The goals of designing, implementing, and evaluating any healthcare intervention lie in answering three interconnected questions: • Is the proposed course of action going to be effective – are the intended results or goals achievable? • Can the intervention be delivered efficiently – are the intended results reliably deliverable within the available resource base? • And, last, there is the question of efficacy – are the obtained or hoped-for results worthwhile in both clinical outcomes and as an investment target for limited resources? The failure to answer all these questions is one of the great dilemmas in modern medicine. This is especially true in emergency care and resuscitative medicine, in which the ability to intervene dramatically has become the rule rather than the exception. In the past few years, both the limits of resuscitation and costs have become more visible. Medical providers and the public have started a process towards rational and deliberate decisions about the end of life with such measures as advance directives about limiting care. To date, the debates have been mainly at the margins, divisive and often more driven by media hype than careful and deliberate philosophical and ethical questioning. It is not surprising, given the context, that these efforts have neither brought about widespread change nor increased the public’s understanding of the limits of care. Faced with otherwise impending mortality, medical providers, patients, and the public have, by and large, chosen to do more rather than less, employing whatever means and resources are available. From the individual viewpoint, healthcare is a series of therapeutic decisions between medical provider and patient with extraordinary rights to privacy and resource allocation. Results of these interventions and decision-making as regards access to resources have similarly largely been held between individual patients and the healthcare provider. From each individual patient decision comes the system. This is

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the real test of design across a population if the goal is to deliver care equitably with easy access. While the needs and goals of resuscitation are perhaps clear at the individual level, interventions that may benefit the individual patient must further be measured in the aggregate, not only for access and equity, but also for effect. From this viewpoint, the clarity of the intervention decision, even for the individual, is much more difficult. Faced with new ‘lifesaving’ technology and ability for intervention, the most common system strategy has been to meet demand. This has occurred via continually increasing spending rather than by measuring results in the form of outcomes, on the aggregate scale, or making societal decisions as to the targeting of resources. The above elements are indicative of the problem of universally matching resources and need in the context of the highly visible NHS. While only having an impact on a fraction of patients, resuscitation is complex, time-sensitive, expensive and highly visible. Critical unexpected illness and trauma are the interface of medical miracle and ‘fiscal failure’. High visibility and public expectation complicate the picture. Public mistrust of the Conservative government’s stewardship of the NHS was a significant factor in the Labour landslide victory in 1997. Also, emergency care does not respond easily to the traditional remedies of reducing pressure on the health care system – re-scheduling appointments and elective surgery. This has meant a near-constant crisis – not only in the winter, but also in the summer months – of ‘emergency admissions’. It is not likely that the population morbidity is changing anywhere nearly as rapidly as system behavior, with current incentives for all overstretched providers to shift problems to other budgets. Moreover, improvement in mortality may increase community morbidity, requiring either new or changed priorities for effective system designs in the future. Problems in system design and a lack of understanding as to the effects of design on demand limit the effectiveness of responses to life-threatening problems. At the same time, the volume of work to answer the everyday needs of unscheduled care threatens to overwhelm the entire emergency-care system, with huge effects on other sectors of the NHS. Further, there are at best blurred lines of responsibility between medical and social care. When working on design questions, the process must be robust and incorporate all social and medical providers. Prior to the 1997

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general election, the policy quoted by Department of Health personnel reflecting ministers’ views was ‘our only policy is that we have no policy’ (Personal communication). This cannot be sustained. Guidance will not change provider incentives. Systems need governance. Essential are clear goals and performance standards measured in appropriate ways, sensitive to the required medical intervention. Rather than admissions, if the goal is to manage patients as close to home as possible, all providers in the emergency and social care system need to adhere to clear and shared strategies to prevent unnecessary admissions. Providers at all levels need to work together to achieve the earliest discharge possible to lower-level care, and to manage urgent problems at the lowest level possible. More importantly, despite continuing efforts to build ever more sophisticated emergency-care systems, there is a threshold at which delivery of additional services will not result in added benefits. Managing cardiac arrest is predominantly a question of delivering a defibrillator for adults. This includes, but is not limited to, the questions of ambulance response time and the additional training of paramedics (Guly et al., 1995). Life-threatening trauma is mainly a matter of prevention through engineering and safety programs. When it does occur, recognition, a specific series of limited interventions, and transport to specialist care in the shortest amount of time possible constitute legitimate care (Nicholl et al., 1998).

Minding the gap Resuscitation, an imperative in the face of life-threatening illness or injury, is set against not only the sometimes unclear and everchanging abilities of medicine, but also competing needs and goals of the other sectors in the larger healthcare system. This gives rise to the question of priorities, more commonly seen as the political minefield of ‘rationing’. In 1997, a working group from the King’s Fund looked at the funding and sustainability of the NHS. They eventually discarded an overall economic approach of estimating how much a society should expend on health care, commenting that this criterion is not useful ‘until much more is known about the costs and benefits of current expenditure’ (Dixon et al., 1997). They went on to a more fundamental finding, ‘that the ability to do more good in terms of health benefits does not necessarily imply that more good ought to be done’ – the heart of the resuscitation dilemma. The question is one of demonstrated benefits. Richard

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Lamm, the former governor of Colorado, described this dilemma as the need to recognize that ‘most of our medical miracles are fiscal failures (Lamm, 1994, pp. 45–51). In the long run, the focus must be on how available resources should be spent. Despite the political sensitivity to ‘rationing’, the economics of sustaining the NHS will force the first real shared debates on priorities in the next few years. Indeed, work by the Institute of Public Policy Research on the use of citizen juries, and the recent NHS strategic planning discussion document, Priority Setting in the NHS have initiated the process (Lenaghan, 1996): The Government recognizes these pressures, not least in its commitment (which has been honoured each year) to real term increases in NHS spending. Even so, budgets will always be finite while demand is potentially open ended. There will always be a gap between all we wish to do and all that we can. Setting priorities is a fact of life (NHS Executive, 1997). This will be a difficult but necessary exercise in the coming years. Priorities are not just about what specific services are offered or not offered. They are as much about medical provider behavior, structures of medicine, political goals, and the consideration of what constitutes the public domain. If public resources are ever more limited, what is more important: complex medical therapies with unknown benefits, or better schools? There are difficult choices in every sphere and, as noted earlier, the ability to do more good does not in itself mean that more good should be done. To date, the public has in the main been excluded from both debate and decisions, relying on the political process to represent their purchasing interests and physicians to represent their health interests. This chapter illustrates issues with this exclusion. Will (or even can) politicians give up popular, highly visible services, despite mythology surrounding the value of the services? And, perhaps more important, will or can medical providers do the same? In the future, more public input needs to be included. As the King’s Fund working group concluded: ‘Funding will continue to be an issue in the NHS, as in any healthcare system. Demands inevitably outstrip supply and an uneasy balance has to be struck. Whether this balance will remain acceptable enough to maintain public support is open to question’ (Harrison et al., 1997, pp. 296–8). The working group goes on to suggest that there is no reason to

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believe continued support is not forthcoming. But the issue of transparency remains a potent force for change if the public loses trust in the abilities of the political process and medical providers to make good choices on their behalf. This is witnessed by the massive and rapid changes to medical infrastructure and medical providers in the USA in the late 1990s. Two other steps need to occur in the debate about priorities. First, a reasoned approach to restructuring must include understanding the efficiency gains that have been made by process improvements. Second, and perhaps even more important, the assumptions that are made in providing healthcare must be scrutinized continually. If we do not have the questions right, a rational debate about the future is not possible. References Ambulance UK (1970–95) Various letters and editorials. Audit Commission (1996) By Accident or Design: Improving A&E Services in England and Wales, National Report (London: HMSO). Audit Commission (1998) A Life in the Fast Lane: Value for Money in Emergency Ambulance Services, National Report (London: HMSO). Baskett, P. and J. Fisher (1997) ‘Recognition of Death by Ambulance Personnel’, Ambulance UK, vol. 12, no. 1, pp. 13–16. Calman, K. et. al. (1996) Developing Emergency Services in the Community, vols 1 and 2 (NHS Executive) (November). Calman, K. (1996) Developing Emergency Services in the Community, vol. I, Emerging Conclusions; Vol. II, The Evidence Base, Chief Medical Officer’s Review, NHS Executive, Department of Health, 96CC0020. Delbridge, T. (ed.) (1996) EMS Agenda for the Future, National Highway Traffic Safety Administration, US Department of Transportation, DOT HS 808 441 NTS-42, Washington, DC. Department of Health (1996) ‘Ambulance Services, England: 1995–96’, Statistical Bulletin, vol. 11, no. 7. Dixon, J., A. Harrison and B. New (1997) ‘Is the NHS Underfunded?’ British Medical Journal, vol. 314, no. 4 (January). Goodacre, S., A. Gray and A. McGowan (1996) ‘Collection of Uniform Cardiac Arrest Data by Ambulance Services in the UK’, Ambulance UK, vol. 11, no. 6, pp. 4–8 (December). Guly, Mitchell, Cook, Steedman and Robertson (1995) ‘Paramedics and Technicians are Equally Successful at Managing Cardiac Arrest Outside Hospital’, British Medical Journal, vol. 310 (April). Guly, U. M., Mitchell, R. G., Cook, R., Steedmand, D. J. and Robertson, C. E. (1995) ‘Paramedics and Technicians are Equally Successful at Managing Cardiac Arrest Outside Hospital’, British Medical Journal, vol. 310, pp. 1091–4. Handley, A. J. (1995) ‘Defibrillation and the Chain of Survival’, Ambulance UK, vol. 10, no. 2 (April). Harrison, A. (1997) The London Health Care System (London: King’s Fund).

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Harrison, A., J. Dixon, B. New and K. Judge (1997) ‘Is the NHS Sustainable?’ British Medical Journal, vol. 314, pp. 296–8 (25 January). Health Policy and Public Health Directorate (1994) Emergency Healthcare in Scotland. Future Structure of Accident and Emergency Services. Report of a Policy Review (The Scottish Office). Health Service Journal, ‘Government “Must Issue Guidelines” To Tackle Emergency Admissions’, 4 December 1997. International Trauma Foundation (1980) ‘The Ambulance Service within the Health Service’, Ambulance Journal, p. 307 (November/December). Knapp M., M. Forsythe and B. Wall (1997) Costs and Effectiveness of Paramedic Pre-hospital Management of Major Trauma, Report to NHSE Health (University of Kent/London School of Economics) (May). Lamm, R. D. (1994) ‘Healthcare Heresies’, Healthcare Forum Journal, pp. 45–51 (September/October). Lenaghan, J. (1996) Rationing and Rights in Healthcare (Institute for Public Policy Research). London, UK. Maine Health Information Center (1996) 1996 Statistics Report. Mann, C. F. and H. Guly (1997) ‘Paramedic Interventions Increase the Rate of Return of Spontaneous Circulation in Out of Hospital Cardiac Arrests’, Journal of Accident and Emergency Medicine, vol. 14, no. 3, pp. 149–51 (May). Mitchell, R. G., U. M. Guly, T. H. Rainer and C. E. Robertson (1997) ‘Can the Full Range of Paramedic Skills Improve Survival from Out of Hospital Cardiac Arrests?’ Journal of Accident and Emergency Medicine, vol. 14, no. 5, pp. 274–8 (September). Mustalish, A. C. and Post, C. (1994) ‘History’, pp. 3–23, in S. Kuehl (ed.) Prehospital Systems and Medical Oversight, 2nd edn (St Louis, MO: Mosby Year Book Inc.). New England Journal of Medicine (1996) ‘Cardiopulmonary Resuscitation on Television’, vol. 335, no. 21, November 21, 1996 pp. 1605–7. Nguyen Van Tam, F. S., A. F. Dove, M. P. Bradley, F. C. G. Pearson, P. Durston and R. F. Madeley (1997) ‘Effectiveness of Ambulance Paramedics versus Ambulance Technicians in Managing Out of Hospital Cardiac Arrest’, Journal of Accident and Emergency Medicine, vol. 14, no. 3, pp. 142–9 (May). NHS Confederation (1997) Tackling NHS Emergency Admissions – Policy into Practice, NHS Confederation Birmingham Research, Park Vincent Drive, Birmingham, UK (November). NHS Executive (1997) Priority Setting in the NHS: A Discussion Document, Department of Health (February). NHS Executive (1996) Review of Ambulance Performance Standards, Final Report of Steering Group, Department of Health (July). Nicholl, J., H. Snooks and J. Bazier (1995) The Costs and Effectiveness of Helicopter Emergency Ambulance Services. Information for Purchasers in England and Wales, Medical Care Research Unit, University of Sheffield (March). Nicholl, J., P. Coleman, G. Parry and M. Pickin (1995) The Provision of Emergency Ambulance Services in South Yorkshire. Final Report, Medical Care Research Unit, University of Sheffield (August). Nicholl, J. Turner, J., and Dixon S. (1996) The Cost Effectiveness of the Regional Trauma System in the North West, Medical Care Research Unit, University of Sheffield.

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Nicholl, J., Hughes S., Dixon, S. and Yates D. (1998) The Costs and Benefits of Paramedic Skills in Pre-hospital Trauma Care: Final Report to the Standing Group on Health Technology, Medical Care Research Unit, University of Sheffield. Pencheon D. (1997) On Demand. Cambridge and Huntingdon Health Authority (January). Pencheon, D. and P. Hadridge (1995) ‘NHS Executive Oxford and Anglia’, Emergency Care Handbook, p. 14 (October). Personal communication (1997) NHS Executive (London: Department of Health). Rainer, T. H., R. Marshall and S. Cusack (1997) ‘Paramedic Technicians and Survival from Cardiac Arrest’, Journal of Accident and Emergency Medicine, vol. 14, no. 5, pp. 278–83 (September). Rawles, J. (1997) ‘Pre-hospital Coronary Care’, Pre-Hospital Immediate Care, vol. 1, no. 1, pp. 13–19 (March). Roberts, G. (1995) ‘Improving the Odds’, Ambulance UK (April). Royal College of Surgeons of England (1988) The Management of Patients with Major Injuries (London: Royal College of Surgeons). Scottish Ambulance Service (1996) NHS Trust, Annual Report. West, R. J. and N. Penfold (1997) A Questionnaire Survey of Resuscitation Equipment Carried by General Practitioners and their Initial Management of Ventricular Fibrillation, British Journal of General Practice, vol. 47, pp. 37–40.

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8 Power and Influence in the Making of British Budgets Lynda Edwards

On 1 March 1997, a federal commission on government secrecy issued its findings which, among other things, stated that ‘the government kept too much secret for too long and blamed what it termed “a culture of secrecy” for fostering and perpetuating conspiracy theories’.1 The commission, chaired by Senator Daniel Patrick Moynihan (Democrat – New York) recommended that Congress pass a law that would make it easier for citizens to have full access to government records and proceedings, and called for the creation and financing of a National Declassification Center to oversee the new openness. In the United States, where the machinery of government operates in an environment of procedural formalism, and in one where it is assumed that the public has a right to know about and to judge, aggressively if necessary, the activities of its elected officials, that grave announcement was applauded by citizens of both parties. America prides itself on being a country of laws and not of men, and the view that the federal government’s ‘culture of secrecy . . . will moderate only if there comes about a counterculture’2 of openness, a climate which simply assumes that secrecy is not the starting place, is quickly gaining prominence. In fact, the proposals for new legislation were welcomed by the Democratic White House and at the time of writing were under review by the Senate and House intelligence committees, both of which are controlled by the Republican party. I asked some British citizens to interpret these American developments from a European perspective. The responses were interesting. ‘I think that the British public is much less concerned about conspiracy theories and the withholding of data. British people are 143

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much less paranoid,’ commented one person. Why? ‘I don’t know. There’s something about people accepting things the way they are. There’s a sport about questioning things for the sake of questioning them in the US . . . There’s a permanent civil service here. Even the people who write questions for the prime minister who are there in their jobs all the time – their appointments are not political. So decisions made at the highest levels of government are not as political as they are in the States.’3 Another citizen remarked, ‘It’s true that some people are not concerned about secrecy, but there are some people who are very concerned about it. Journalists, for example. They’ve done studies on it . . . Some people think it’s quite bad here. There has been a move to pass a freedom of information act here as well, which really would not be a bad thing.’4 These views represent extremes on the spectrum of opinion about decision making at the highest reaches of government in the United Kingdom, and about the public’s right to know about the process. For the purposes of this study, I will investigate the process of budgeting in Whitehall (specifically on issues related to prisons) and use the impressions developed by the query as a starting point for a discussion about how decision-making at the national level occurs in Britain. In the British context, it is useful to discuss the budget process not only in terms of politics and process, but also in terms of power and influence wielded by ministers and their closest advisors. This chapter investigates how these variables drive budgetary outcomes in the United Kingdom. Methodologically, it integrates political, economic, sociological and historical approaches to data collection and analysis to test a theory about which legislative rules governing public finance drive budgetary outcomes and about what role politics plays in determining how those budget outcomes develop. It also investigates whether or to what extent the power of British ministers dominates the creation of those budgetary documents or, if instead, the influence of their top civil servants or advisors provides the actual organizing mechanism for that function. Said differently, how exactly do power and influence result in the setting of national priorities in this system? What is the place of politics and process? Who wields actual power during budget negotiations, which can be quite contentious, particularly in the final stages? Do ministers or their advisors have actual influence? Is the arrangement necessarily an ‘either/or’ proposition? Finally, is it process, politics,

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power or influence which drive the creation of British budgets? I link the four concepts and analyse how they inform each other and how they affect budgetary outcomes in Whitehall. Drawing further distinctions between them should clarify how decisionmaking occurs in Whitehall’s closed and secretive corridors. The main focus of this project is on the action of the EDX Committee, 5 the role of ministers, the role of their top assistants or officials who advise the ministers, the role of the party machinery, the executive budget process, the limited role of legislators in the earliest stages of decision-making, and the relationship between ministers versus civil servants in the making of budgets. These are the factors that affect the manner in which national priorities are set. They operate within a culture of discretion and secrecy which frames the activity analyzed below. The system is not a transparent one, so recording how budgets are derived and which variables create them is no small task.

The analytical framework Power is the ability to do or to act. One has power when one possesses the strength, authority, or control to do something. Influence is agency, and to some extent, authority, in the exercise of power. One has influence when one possesses authority to do something. Influence is an aspect of power. It shares in the concept of power. The standard view is that the power of a minister drives the setting of national priorities in the part of the budget that the minister oversees. Of course, in politics, nothing is static. The modern view is that the relationships are non-hierarchical behind closed doors. 6 How precisely does that standard change within a specific budget cycle? In the United States, I have shown that it is useful to discuss the budget process in terms of the politics that affect budgetary outcomes. Four analytical categories were created and highlighted for doing this – process in the large (the separation of powers arrangement); process in the small (the rules of the budget game); politics in the large (partisanism); and politics in the small (constituent demands). These four variables drive budgetary outcomes – that is, they affect the manner in which national priorities are set, how the budget timetable is met, and the success of deficit reduction efforts differentially across budget cycles. The comparative influence of the four analytical categories on budgetary outcomes during a

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decade of budget cycles became the central question for an earlier piece of work.7 Such a comparison showed how the importance of each of the four forces waxed and waned during each cycle, or, alternatively, how one force could dominate the dynamic in each cycle. The more active each or all of the forces were, the harder it was to neutralize the tensions inherent in their interaction in the political arena. Existence of that rivalry made it more difficult to generate stable political conditions, which were, on the face of it, a necessary condition for producing reliable policy outcomes within the timetable required by existing law. Some level of stability is a necessary condition for producing these outcomes in a timely manner; it follows that high levels of conflict and rivalry should result in untimely outcomes that might not resemble what was originally sought in early drafts of the budget. A further interesting question was whether or to what extent this untimeliness and lack of neatness were inevitable touchstones of an ‘American model’. Yet another interesting question was whether the new process that Congress created in 1975 could accomplish its goals, or whether an older and continuing politics would reenter through these existing loopholes and subvert the process. The conclusion was that politics was the dominant variable in the framework, and that the process was constantly being changed to suit the fashion of the political season. Is a similar analytical framework, or model which provides a metaphor for human political behavior, possible for the United Kingdom? In the United Kingdom, I have identified a number of variables that drive outcomes. It seems that the outcome is single-pronged, rather than three-pronged, as it is in the United States. According to one senior official, the main focus of variable identification should be the manner in which national priorities are set in the United Kingdom. ‘The PESC [budget] debate is driven by social security, which takes up 33 pence on every pound spent.’8 In his estimation, the other variables used in the American model (the timeliness quotient and deficit reduction) should be exogenous to this specific framework. In the first place, the timeliness quotient is not an issue in the United Kingdom because budgets always get out on time. What is it about the process that ensures this will be the case? In the second place, it is analytically unwise to focus on deficit reduction, because in the words of another senior official, it ‘is a nonsensical way of looking at the world’.9 Such a focus provides more of a moral or political orientation, ‘a sort of puritan morality’

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that has nothing to do with the economics of arriving at rational decisions. What is it about the political culture of Britain that makes deficit reduction an apolitical issue? It could be that the simplicity of the output side of the framework will be counter-balanced by a more complicated set of inputs. Again, is it power, influence, process or politics, or a combination thereof, that dominate the outcome? One thing is certain. In both systems, decision-making falls to an elite group of players. One big difference between the two countries is that it is a regular practice for decision-making to occur behind closed doors in Britain. Because of ‘sunshine laws’, it may occur on television in the United States. The closed and secretive nature of Britain’s political culture makes it difficult to determine if any variety of my qualitative model provides analytical purchase across the two political systems, or rather, if it can be tested successfully in the British system.

Britain’s budget process timetable Unlike the rather difficult-to-tame American process, much of the British budget process, which is referred to as the ‘public expenditure control mechanism’, occurs within an efficient six-to-eight-month cycle. This process covers not just central government expenditure, but also local government expenditure, making it a very large section of the entire economy. One of the key decisions that has to be made by the government early on is designating a clear policy for how the economy will stagnate, contract or expand; what proportion of measurable growth is national output; and precisely how that output will be used for public expenditure. In recent history, Conservative governments have tried to limit public expenditure growth as a proportion of the growth of the overall economy. The goal was to keep public spending down. These very political policy approaches had a substantive impact on the development of economic policy for a nation, which at least since the Second World War, had been accustomed to the existence of a broad social safety net. This emphasis was particularly true during the Thatcher years. It is from this key macro-economic point that much subsequent policy derives. It provides the locus classicus of a powerful approach to pushing government spending down. 10 The Chancellor of the Exchequer and the Cabinet make the broad decisions about how this spending will be allocated annually. Parliament receives proposals or annual estimates from the executive, and members pass

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bills that authorize the money after the Annual Estimates debate, which is similar to the debating and voting on the Budget Resolutions in the United States Congress each year. The legislature receives the Annual Estimates proposals from the executive and then that body authorizes the money. This simple arrangement is the key to all British democracy, the role of government, and the role of Parliament in controlling and voting on public expenditure. It continues to exist nowadays largely as a relic rather than a formal process, in that it clearly controls an old-fashioned auditing function without providing real information about what the value or usage of the authorized programs are.11 In preparing the Public Expenditure Survey (the package that contains the budget details), the Treasury Department conducts negotiations on how the money will be meted out to various departments. Departmental reports are issued in mid-March or in April. New survey guidelines are issued soon after that. May and June are when the options for the ‘remit’, or task that has to be done, are considered. This is also the period within which the Finance Bill should be completed; legislation has to be passed on those tax changes during the following months. In early July, the Cabinet sets its remit. Also at that time, officials prepare papers for the EDX committee,12 comprised of high-powered ministers who act as a final ‘court of appeals’ on budget allocations. During September and October, the EDX committee frames its recommendations for departments with which there have been particular difficulties in reaching budget agreements. In early November, the Cabinet agrees to the package. Finally, in late November, the Chancellor of the Exchequer presents the budget to the public. The point of the budget survey is to expose the real choices available to policy-makers and to achieve consensus between ministers, Cabinet members and the prime minister. One official commented that he admired the system as the nearest to rationality in human affairs and politics that you are likely to get. And there is quite a lot of rationality, but in the real world, the pressures are simply overwhelming. You scratch a Treasury official and he will almost always want to cut the inputs, however much he or she may talk about or profess to going with the outputs and the outcomes. Their instant goal is to cut the inputs, because that traditionally is what finance departments have had to do.13

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Its strengths are that it is clear on the relationship between spending, taxing and borrowing; its assessment of priorities is achieved collectively through numerous meetings and discussions with officials about how national priorities should be set, and finally, the arrangements related to that decision-making process are top-down and bottom-up. In short, there are inputs at every level and stage of the process from all of the players. The process has weaknesses as well, in that it focuses on the marginal benefits, or the rate on the last pound earned. It also exposes (and arguably exacerbates) tension between the availability of capital and actual cash flow. Its primary focus is on three out years, or three years beyond the instant budget cycle, which means that the estimates may not always be accurate. It is an unstable process, in part because it is confrontational. Some experts see no problem with that arrangement, because it is necessary for Treasury officials to stand firm against departments to prevent ‘an immense upsurge of public spending which will greatly damage the economy’.14 Indeed, the politics of a specific government sets the tone for the manner in which the process of devising budgets occurs. The civil servants can, in some ways, use their influence to neutralize the tendency toward overpoliticization of the budget process by using process to make sound policy recommendations. Budgeting under the New Blair government In 1997, Gordon Brown, the new Chancellor of the Exchequer, issued his summer economic forecast in July, an unusual arrangement which probably occurred because of the change in government. This change in budget process approaches points to the fact that Britain’s budget process timetable is not necessarily static and that it can be altered at any time, if the government feels that it is necessary. This arrangement is not viewed as being startling or surprising, but rather responds to the fluid arrangements that characterize budgeting at the highest levels in Britain. Changes such as these do not preclude the budget from getting out on time. In fact, Britain has an almost 100 per cent success rate in meeting its timetable. That is rarely the case in the United States. Timetable changes, which are commonplace, result from Congress’s right of implicit repeal, which means that the national legislature can unmake a law as soon as it makes it. Budget process timetable changes do not go unnoticed or uncriticized, though. The idea is that in the United States, a country of laws and procedural formalism,

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top-level government officials are supposed to follow the rules of the budget game. High levels of trust in government or in top government officials is not common in the United States, partially because in full view of the public, officials often fail to follow budget procedures that are codified in law. In Britain, the Chancellor of the Exchequer’s November budget announcement marks the end of a continual round of negotiations between Treasury ministers and senior officials who spend much of an ongoing twelve-month cycle shaping and re-shaping macroeconomic strategy, spending objectives, and the coordination of expenditure policies. It is a fait accompli in the British world of budgeting. On the other hand, in the United States, the president’s January State of the Union Address and the February budget announcements, both of which contain policy objectives of the chief executive, in fact mark the beginning of a yearly soap opera of deals, counter-deals, missed opportunities, and occasional triumphs. Unlike in the United States, one does not hear of government shut-downs in Britain, because the budget always goes through on time. There is clear agreement on the parameters within which national priorities will be set before the cycle starts. The resultant executive document is drafted according to the dictates of the political objectives of the party in power. This approach provides clarity about how the debate will proceed from the beginning of the cycle. The interesting thing about Britain’s instant transition is that career officials or bureaucrats in Whitehall (as well as some experts no longer in Whitehall)15 will produce numerous briefs for government ministers. Those documents contain information on the specific financial status of each department, what new ministers can expect on the legislative front with reference to funding for their departments, and a statement on outstanding problems with public finance within the department. The latter refers to how much money a minister will actually have to work with, and how much the minister needs to keep each program solvent. One pressing concern is the perceived shortfall of money within many of the departments. The Labour government, in power at the time of writing, will have to address this. The briefing papers also contain the public expenditure survey, which contains calculations for the present fiscal year plus two out years. Ministers have a short period of time to get up to speed on these substantive issues within their departments. This is why they must, of necessity, depend on the expertise and goodwill of the career bureaucrats who remain in their jobs regardless of

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which party is in power. One aim of this study is to ascertain whether it is the apparent power of the ministers, or the real influence of their advisors, which determines the way that budgetary outcomes appear at a macro level in the United Kingdom, and what effect the hidden, non-public approach to decision-making has on the final appearance of budgetary outcomes. Life in Whitehall: political culture and the culture of discretion Prime Minister Tony Blair and his top ministers were sworn in by the Queen at Buckingham Palace on 3 May 1997. The oath binds each official to serve the nation and ‘to keep secret the affairs of state’. 16 If my experience in trying to interview these top officials’ surrogates serves as an accurate gauge, the ministers and their assistants take the oath very seriously. Many of them have not been forthcoming with information about their portfolios, nor are they willing to talk about the specifics of how they do their jobs, or make decisions related thereto. Puzzled by the pervasiveness of the non-responses, I asked a colleague what it was about the social and political culture of Britain that made this the norm. Why, for example, would someone invite me to their office in Whitehall, and then tell me virtually nothing about the way that it operates? Or, alternatively, why would someone feign interest in the project, and then fail even to grant me an audience? ‘They’ll help you to a point, but they do not have a freedom of information act here. So it would be considered imprudent and definitely injudicious for them to tell you anything. In fact, it would be foolish for them to tell you, an outsider, anything at all.’17 A porter in my Oxford college, who definitely represents what is good and decent about this country, was even more blunt: ‘The people at the top, they look after their own’, he said: That’s how they’ve always been. It’s gone further since Margaret Thatcher. She made it worse. She wanted the Victorian values and the Victorian ways. And you know how it was in the Victorian times. [T]he wealthy were wealthy and the normal, average person had to scrape by. [T]he civil servants are going to look after themselves. They’re going to give advice where it’s going to secure their jobs. I think Blair, the way he’s talking, he’s going to change that. He’s going to take away some of the power of the civil service – well, at least that’s what he said. This is what was in

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their [Labour’s] manifesto. And if they take away some of these civil servants’ top jobs, that’ll help the people and shake them up a little bit. Because the civil service in this country – they can do what they like. They’re laughing. The top civil servants – they’re the ones who really run this country, not the ministers.18 This view, of course, is not supported by all. A colleague, an authority on British government, is emphatic in his belief that ‘policy comes from the ministers and the careerists help him’.19 It is true, however, that the theory of civil service is of the Victorian servant to his master. ‘You don’t talk to a servant behind the master’s back’, my colleague commented by way of explanation for the reticence and diffidence of the careerists I have talked to in Whitehall.‘ If they talk, it can jeopardize their careers. They probably think that you know this.’20 In short, it violates the rights of a minister for a civil servant to talk. The same is true for the relationship between a minister and the prime minister. Tony Benn, a colorful and often controversial minister who later led the Labour left, confirms this position when he recounted being lectured in 1976 by Prime Minister James Callaghan on the merits of collective responsibility of Cabinet officers to the government in power. Callaghan was incensed about a newspaper leak which reported Benn’s disagreement in Cabinet about a sensitive policy position.21 Culturally, it is unacceptable for a minister to ‘go public’ about in-house disputes. Those constraints certainly apply to civil servants, who advise senior ministers, and this commitment to secrecy permeates even the most banal discussions that experts may have with the general public about decision-making in Whitehall. Yet another view is that the only reason civil servants ‘want to keep things secret is to improve their own power and position and to save themselves from embarrassment. The rest is bullshit. These people want to exercise their power without the risk of exposure.’22 Given the disparities of viewpoint and very passionate allegiance to them, it is hard to know which claims are accurate. That being said, one commentator provides compelling evidence of the unprecedented and wide-ranging power of Prime Minister Margaret Thatcher’s press spokesman, Bernard Ingham. Critics accused him of setting government policy, rather than merely reporting it, as tradition said that a good, impartial civil servant should.23 One unexpected theme of this project has become the difficulty of finding

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out what actually goes on in a system of confidentiality like the one in which Ingham operated. What is the nature of those power relationships and why is it such a secret? It will also be interesting to discover whether the difficulty of illuminating those points will wane if the Blair government adopts a Freedom of Information Act. One thing is certain. Regardless of social class, everyone that I interviewed was passionate about the role of government and its effect on their lives. 24 The culture of discretion Ministers in the Treasury receive much of their help from civil service officials, who are somewhat disparagingly referred to as ‘mandarins’, or very senior public officials with expertise on various parts of the budget. They occupy a distinct position in government. They cannot be fired easily and their specialized knowledge of budgetary matters makes them almost indispensable to Cabinet officers who have to balance and consider the possibility of falling out of favor with party leaders. The official function of the civil service is multifaceted and substantive: to inform ministers and Parliament by providing accurate data about policy issues of the day; to provide ministers with advice, via data analysis and discussions, on how they should best respond to those issues; to implement the decisions that ministers make; to administer the legislation that comes from those decisions; and finally, to report to ministers and Parliament about the impact of policy decisions on the general health of the economy. 25 During a transition, these officials are almost indispensable, providing newcomers with information on the inner workings of the Treasury during an intense period when the ministers have to become knowledgeable very quickly about the intricate workings of government: ‘In the mythology, Treasury mandarins are powerful, yet silky smooth; influential but strangely unknown; clever, devious, inscrutable and not a little self-satisfied.’ 26 I can vouch for the validity of the foregoing description. I began working on this project in November 1996, after the American presidential election. I came to Britain excited about conducting a comparative research project on the budget process. Through the Atlantic and Harkness fellowship networks, I met a number of people working in the Treasury. Each of them expressed a willingness to help with this project, partially in exchange for the help that they had received when they were visitors to my country.

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When I followed up on their seemingly geunine invitations for meetings and for interviews, I encountered what I perceived as a callous disinterest in helping me with the project at all. I had not grown up in England, so I had absolutely no sense of what a culture of secretiveness or discretion in policy-making was. After months of re-scheduled or cancelled meetings and encounters with officials who seemed pained to talk about government in even the most general of terms, I was convinced that mandarins were trained in double-speak and obfuscation, even in their most informal social interactions. One senior official, by way of explanation for a colleague’s repeated non-responses to my numerous phone calls laughingly said, ‘Oh, not to worry. X never returns phone calls’.27 I quickly learned that the communication divide was almost impossible to cross. Another colleague attempted to explain the difficulty of communicating with mandarins: You have to listen to the subtext. There is something odd about talking to these guys. They begin to act strangely when they are not talking to someone in their circle. The body language is incredible. Their eyes glaze over, and they cross their legs and send messages to remind you that you are not a part of the closed community that they operate in. In sociological terms, you have a genuine power elite fixated with its own power.28 In spite of this explanation, I still wondered if there were other reasons for the mandarins’ diffidence. Many of my inquiries occurred in the period after the former Chancellor of the Exchequer had issued his November budget figures and when deadline pressures within the Treasury were waning. The truth of the matter is that the government was in transition after Prime Minister John Major’s defeat in the national election, and many top officials were in the process of losing their jobs. If nothing else, this factor contributed to a general feeling of transition and perhaps instability in Whitehall in the waning days of 1996. A former senior official confirms that position and describes it as being a response to the pressure for civil servants to ‘be willing and able to serve whatever government is in power with equal zest and effectiveness. After all the case for a permanent civil service depends on the validity of that claim’.29 That being said, I remained puzzled and somewhat intrigued by the manner in which government officials communicated. An expert on the machinations of civil servants commented that

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‘someone needs to do a study de-coding the meanings’ of what these people say: ‘They even use a different language. Everything is coded and has a double meaning. The whole arrangement supports their membership in a club that no one can enter through their own will. They are sort of disconnected from the people they serve. They are less concerned with the efficacy of a policy pronouncement but more interested in whether implementing it will bolster their careers.’30 And certainly talking to an American researcher would not, at first glance, provide promotional advantage for a mandarin clawing his way up the civil service ladder. Not surprisingly, my database ended up being drawn from interviews with very senior officials no longer in government, an unexpected spillover effect of the existence of this mandarin culture of discretion. Even those interviews were on deep background, which explains why some of my references are noted as ‘private information’. Methodologically, it is possible to extrapolate present ideas about the workings of Britain’s civil service from their wealth of expertise on the inner workings of Whitehall during earlier political eras. I remain, however, a creature of my culture, where the sun shines brightly on many, though not all, budget negotiations, some of which I have been privileged to witness in the executive branch since my return to the United States.31 That being said, after I began to understand what the British culture of discretion was and why it was important, I was pleasantly surprised by officials’ allegiance to this code of honour, long after they had left government. Unlike the younger, untried mandarins, they explained the genesis of that cultural rule and the environment in which they continued to adhere to it. Indeed, that code permeated every aspect of their lives, which I found refreshing. It stands as a testament to their undying love for their country and the institutions their service to it helped to create. What follows is my analysis of how, within a culture of discretion, budgetary outcomes are affected by power, influence, politics and process. It is a story of how human personalities and the political process interact within a complex system of rules. It also seeks to illustrate how the democratic process exercises its power through those who have been elected. I will begin by taking a snapshot of a sound Home Office policy initiative which, in spite of support by senior civil servants, and even some successive Home Secretaries, was not adopted.

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Prison reform: an ongoing fight in the home office The Home Office is the government department responsible for the internal affairs of England and Wales. To that end, it seeks ‘to secure individuals’ rights and freedoms under the law and to provide for the protection and security of the public’.32 It has oversight of the nation’s prisons, which, throughout the country, continue to face increasing criticism about overcrowding, violence, lack of rehabilitation programs, and poor physical maintenance of buildings and facilities. The prison population as of 30 June 1997 was 61 467, the high point of an upward trend which began in 1993. This reflected increased usage of custodial services by magistrates’ and Crown Courts, as well as higher average sentencing rates at Crown Courts. Additionally, the population rise reflected overall increases in each of the following cohorts: juvenile; adult female; adult male; and ethnic offenders. 33 Since 1993, the Prison Service has also weathered numerous public relations fiascos. Prison escapes from the high-security facilities of Whitemoor and Parkhurst were followed by two reports that attacked the Prison Service for poor performance. Director Derek Lewis’s highly publicized firing and the commitment of larger amounts of public money, by the government and later by Parliament, to improve security systems in prisons left the political impression that, at least at some levels, the Prison Service had been in serious administrative disarray. Additionally, the increase in funding for security did not offset the overall 13.5 per cent general decrease in annual funding over the next three years. This was an example of how politics could simultaneously drive the outcome in one part of the budget, when, in reality, the overall line item for prisons was being cut substantially. That decrease, which was in line with other parts of the public sector, was clearly a process-related outcome, dictated by the party in power. It represented an economic sleight-of-hand which allowed the politicians to appear to be ‘tough on crime’ while at the same time honoring the overall budget reductions mandated by the government in power. At an earlier point in history, one famous Secretary of State for the Home Office, the Rt Hon. William Whitelaw, had categorized such unstable conditions as ‘direct consequences of the mismatch between the demands made upon the Prison Service and the resources available to it; a mismatch which the government has

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acknowledged and which it is the aim of government policy to correct’. 34 He made that observation in 1982. The situation clearly continued to worsen from then to 1997 despite widespread support among civil servants for changes that would ameliorate these institutional problems. Why has the call for prison reform, which is widely supported by civil servants in the Home Office and in the Treasury Department, 35 not been accepted by politicians and the people who elected them? What factors have affected this policy? How exactly has the power of ministers, the influence of civil servants, the political inclinations of ministers and prime ministers, and finally, the actual budget process itself, produced inaction on prison reform? As with the framework for analysis in America alluded to earlier in this chapter, the comparative influence of four factors – process, politics, power and influence – on the setting of national priorities is the central question for this case study. It seeks to illustrate how the effect of each of the factors waxed or waned while the prison policy was being developed. The more active each or all of the forces were, the harder it would be to neutralize the tensions inherent in their interaction in the political arena. Existence of that rivalry would make it more difficult to generate stable political conditions, which appeared to be a necessary condition for producing reliable and non-conflictual policy outcomes at the end of a cycle. Some level of stability is a necessary condition for producing these outcomes; it follows that high levels of conflict and rivalry have resulted in outcomes that have not made operational sense for the Prison Service. The importance of the prime minister in shaping policy initiatives The culture of the Home Office is characterized by ‘its humane attention to individual liberties [and] for its efficiency’.36 It follows that a progressive approach to prison reform would at least be on the minds of some civil servants. Unfortunately, the biggest problem facing the Prison Service – a shortage of financial resources – has not been addressed adequately during the Thatcher, John Major, or even the Blair administrations. That development is a result of the politics variable dominating an outcome about setting national priorities. That is, a political decision was taken that the power of the prime ministers and of their own ministers would not be used to ameliorate the situation created by recurrent financial

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shortfalls. According to one former senior official, ‘Under the Thatcher government, one great shame it seemed to me, was that there was no preparation of the public mind for changes in policy’,37 a tacit admission that without the support of the prime minister, it is difficult for mandarins to push social policy changes on to the agenda, much less to see those changes reach the implementation stage. Prime Minister Margaret Thatcher’s lack of sympathy for prison reform was not surprising, as she often espoused a libertarian view against the state intervening and spending more on social services, specifically in the area of prison reform. She was, to coin an American phrase, ‘tough on crime’, arguing that ‘[t]he state must uphold the law and ensure that criminals [are] punished’, but she remained uneasy ‘that our streets [are] becoming more not less violent, in spite of large increases in police numbers and prison places’. In her estimation, ‘the root cause of our contemporary social problems – to the extent that these did not reflect the timeless influence and bottomless resources of old-fashioned human wickedness – was that the state ha[s] been doing too much’. Her Conservative social philosophy defined a society comprised of individuals and communities which should not be discouraged and disoriented by the state intervening in decisions ‘which should properly be made by people, families and neighborhoods’. Any other social policy approach would make problems grow rather than diminish.38 Increasing funding for prisons fell into that category, a clear indication that her own politics, rather than policy pronouncements produced by experts within the fact-finding process of the Home Office, directed the outcome at this juncture. That view made it difficult for mandarins to push for reform, and even harder to get the minister of state to take those concerns to Cabinet meetings. ‘As a senior civil servant, you can only do so much. You can produce all of these arguments, but you’ve got to have a realistic appreciation of how far they are likely to succeed’, remarked one former official. This position acknowledges the reality of the constraints that mandarins may face when there is a strong prime minister and strong department minister overseeing government policy. And Thatcher, one of the clearest ideologues in modern British politics, was known to be completely unyielding in her view of this topic. According to another senior official, ‘Mrs. Thatcher had, you know, the seven deadly prejudices [of which prison reform was one], and you knew exactly what she wanted . . . Everybody knew what the prejudices were. You no longer had a

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discussion. I mean, to discuss some things with her would just be plain silly. All you’d end up getting was the sack. It was as simple as that. There was no doubt at all about it.’39 Another senior official from the Treasury department remarked that he had left government during the Thatcher years after almost three decades because of this rigidity: ‘The collegialism that had characterized government service when I entered it as a young man ceased to exist.’40 The power of ministers in putting forward a policy view In spite of the characterization of Thatcher’s management style at the Cabinet level as heavy-handed, the mood at the Home Office, while somewhat restricted, was more open. During William Whitelaw’s tenure, it was possible for officials to argue their position on prison reform without fear of reprisal. One official who controlled the flow of policy alternatives to Whitelaw commented that the Home Secretary was at least amenable to debating various viewpoints, even if Thatcher never heard the positions. It was clearly understood, then, that intra-department conflicts were never aired outside the Home Office: ‘If I wanted the Home Secretary to know that we disagreed, what I would do was to take someone who completely disagreed with me [to the meeting]. [We] were very, very lucky, because we had Willie Whitelaw. He was one of the best ministers that I ever worked for.’ 41 Whitelaw was viewed in this way by people on his team because he welcomed debate. He was also very realistic with his staff about policy alternatives which would never ‘see the light of day’ in Cabinet meetings, largely because of Prime Minister Thatcher’s views about a minimalist state. With respect to prison reform, then, the environment within the Home Office was clearly conducive to presenting methods of achieving this policy goal. However, the power of Margaret Thatcher’s view was too dominant; senior civil servants could not use their influence to get the Home Secretary to push the issue to the forefront of mainline policy debates. Additionally, at a later point, Home Office senior officials would be more restrictive in allowing civil servants to air opposing policy views. This development points to the non-static nature of the manner in which information can reach the top of the policy agenda.42 With specific reference to our analytical framework, it is clear that the power of the prime minister’s policy view exerted hegemony over the influence of her top civil servants’ desires regarding

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agenda-setting. The influence variable was unable to dominate politics; it could therefore have little or no effect on the process of providing expert information on the policy alternative at issue. The influence variable, then, proved weaker than process, politics, and certainly power. Certainly in recent British history, civil servants have had to respond to party politics in preparing reports for ministers, which again highlights the dominance of the politics input over yet another variable in the framework – process. By the end of the Major administration, the atmosphere of a ‘people-friendly’ Home Office had shifted considerably. Home Secretary Michael Howard advanced much more restrictive, and even self-described ‘radical’ approaches to handling criminals in the run-up to the national election. An example of this was his ‘Review of Delay in the Criminal Justice System’,43 which contained 33 recommendations aimed at reducing implementation backlogs in the criminal justice process, and which, among other things, advocated trying 17-year-olds at adult courts rather than at youth courts. Clearly, this approach was tougher on young offenders than many Home Office experts advocated.44 There are additional claims that Mr Howard allowed partisan politics to drive his decision to push for an increase in incarceration efforts by police and judges, using the ‘spurious’ claim that these actions would not cause cost overruns in the budget while simultaneously benefiting the public by deterring crime. One former official categorizes these developments as ‘an extraordinary example of political dishonesty’.45 The approach highlights a brand of partisanism which provides an object lesson in how the political power of a strong minister can dominate the well-informed influence of careerists on developing a policy pronouncement, an example of how politics and power often trump process and influence in the policy arena. As in most areas of politics, reform is usually driven by disaster.46 The post-Second World War increase in crime, questions about court procedures and jury trial access, community-based sentencing, how the Prison Service is organized, over-crowding and in-house stability within prisons continued to dominate public policy debates during the 1980s and 1990s. While the government developed some programs to address these problems following the influential Woolf report on prisons,47 the Criminal Justice Act of 1991, and finally, the White Paper Custody, Care and Justice,48 by 1993 many of the reform efforts had been discredited or abandoned. The new

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emphasis stressed criminalization, detection, conviction, and punishment, rather than rehabilitation as a means of curbing the negative spillover effects of antisocial behavior. Experts complained of there being ‘a serious void at the centre of the criminal justice system. There is no clearly understood set of purposes which it is meant to achieve or principles which it is meant to observe, and no effective and acceptable system of accountability for its operation.’49 Was the proper emphasis to build more and more jails, to house more and more prisoners, or rather, to rehabilitate and educate offenders so that they could become productive members of society when they were free? The implementation problems associated with the spending of public funds related to these issues could only have surfaced as a result of cloudy policy developments at the ministerial level. This atmosphere explains a recent observation that ‘[l]ife in the Prison Service is totally dominated by money, or rather the lack of it and the effect of cutbacks in the resources required to carry out the tasks outlined in Custody, Care, and Justice’. The resultant cutback in capital availability has stopped virtually all prison strategic planning.50 What circumstances at the departmental level and in the planning stages created this policy logjam? The waning influence of civil servants in driving the debate on prison reform It has been difficult for Home Office civil servants to satisfy the governmental mandate requiring Public Expenditure Survey (PES) cuts in the Prison Service. Prison Service headquarters operatives claim that the changes can only be made by passing them on to individual establishments, because it is difficult to arrive at specific costings for regime activities and the maintenance of healthy and safe environments for inmates and staff. This lack of information has reached the Home Secretary through officials within the Home Office charged with the responsibility of identifying precisely where waste within the Service occurs. Arcane management systems, as well as a general environment of non-support for the cuts within the Service,51 and perhaps within the Home Office itself, help identify the locus of this information bottleneck. There is a view that if civil servants do not support a policy emphasis, such as the instant one related to cutting funding for prison reform, they can hold up the policy initiative by burying information related to it deep within the bowels of the bureaucracy. 52 It could very well be that this dynamic is occurring in this

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policy area.53 Regardless of the validity of such speculation, increased funding for reform does not appear to be the way of the future for Britain’s prisons, even though aspects of reform remain at the fulcrum of the political debate. That development illustrates the waning influence of Home Office civil servants in setting the general direction that the government has chosen to take on prison reform, even though recent reports on women’s prisons and on developing new methods for deterring young offenders, preventing repeated crime commissions, and addressing punishment guidelines within that cohort54 illustrate that the Blair administration has some concern for the issue. That concern has opened the way for civil servants to develop policies to address reform. Innovations in the youth program could cost as much as £22 million per year, provided that Parliament passes spending bills to support the initiatives.55

Analysis The key point here is that the power of the prime minister and various secretaries of state, rather than the influence of civil servants, drives initial policy formulation on prison reform. I have also shown how the power variable links to the politics variable and generally subverts the influence and process variables. Indeed, the influence and process variables often conjoin and create collectivist failures, as civil servants attempt to exert their influence through process. Instead, the function of producing budgetary outcomes is dominated by prime ministers who exert their wide-ranging power through politics. Unless a mandarin is willing to flaunt convention, overstep institutional boundaries, and enter that game, his effect on policy outcomes becomes secondary. These arrangements were certainly the case during the Thatcher administration, and that position remained true during the Major administration when Home Secretary Michael Howard pushed for radical reform of the criminal justice system and attempted to use the prison debate to further his partisan political agenda. It has continued to be the case in the early years of the Blair administration, with its emphasis on addressing the fate of young offenders and women prisoners. These developments support the view that at least at the level of power politics, the influence of the civil service in setting the agenda has, in fact, been waning, or may have always occupied a secondary position to the political power of ministers. This arrangement holds true in spite of evidence of

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the bureaucracy’s power to address policy concerns which, because of prime ministerial support, have emerged at the forefront of the agenda. This appears to have remained constant during the Thatcher, Major, and even the Blair administrations. Finally, the general parameters of using governmental processes to arrive at policy consensus between ministers and civil servants also appear to have been constant with reference to the agenda items addressed above. The processes inform the manner in which political outcomes are arrived at; they never dominate politics, power or influence, the other variables on the input side of the conceptual framework. They never drive, in a direct way, the final appearance of the dependent variable (the setting of national priorities). In some regards, then, process is the weakest of the four variables. The four variables (power, influence, politics and process) are interdependent, and each of them has been active at various stages in policy development, even though politics clearly dominates the outcome in each example of the development of administrative outputs. Moreover, the relationships between each of the variables is symbiotic. While it is clear that the power of the prime minister drives agenda-setting, the influence of the civil service determines the ‘voice’ through which policy pronouncements will be expressed. As in most systems, politics frames the environment within which the public and private debates take place. It also frames the iterative process of policy formulation, the beginning stages of which are driven by ministerial power politics. In later stages that formulation must, of necessity, occur within the recesses of the civil service and resurface at higher levels before being articulated by secretaries of state or the prime minister. None of these functions can operate properly independently of the other functions. These are the grand summary elements of the variables which drive the setting of national priorities in Great Britain. Notes 1 Apple, R. W. (1997) ‘Government Overzealous on Secrecy, Moynihan Says’, New York Times, 5 March, p. 1. 2 Ibid. 3 Interview with anonymous voter, 3 February 1997. 4 Interview with university professor, 17 February 1997. 5 This is the final ‘court of appeals’ for ministerial budget requests. Ministers appear before this committee of 7 or 8 top government officials in the very last stages of a budget cycle usually to request higher funding levels for their departments. These meetings can be contentious.

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164 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

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32 33 34 35 36 37 38 39 40 41 42 43

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The Making of British Budgets Thain and Wright (1995), pp. 96–7. See Edwards (1997) pp. 81–109. Interview with former government official, 12 May 1997. Interview with former government official, 9 May 1997; see also HM Treasury (1997), p. 1. Interview with Treasury official, 26 March, 1997. Interview with Treasury official, 9 May 1997. In the new Blair administration, this is now called the PS(X) committee. It considers final ministerial requests for budget increases. Interview with former government official, 9 May 1997. Ibid. Interview with a former government official, 2 May 1997. Elliot (1997), p. 2. Interview with anonymous citizen, 6 May 1997. Interview with university employee, 4 May 1997. Interview with Oxford don, 5 May 1997. Ibid. Winstone (1996), pp. 360, 378–9. Interview with Oxford don, 10 May 1997. See Harris (1990). In the aftermath of the brutal murder of British-raised Afro-Caribbean teenager Stephen Lawrence by a white gang, Home Secretary Robin Cook was sharply criticized for trying to keep aspects of the case’s investigation secret and for using his power to suppress leaks. Perhaps these developments serve as a signal that the Blair government will not depart from traditional arrangements as far as government secrecy is concerned. Interview with Oxford don, 9 March 1999. Stowe (1992), pp. 387–94. Young and Sloman (1983), p. 7. Interview with former government official, 10 October 1997. Interview with former civil servant, 10 October 1997. Private information. Interview with former government official, 10 October 1997. For more on the very public nature of budget disagreements between party leaders and related threats of government shut-downs in the United States, see Raum (1997), p. 1; Yang and Pianin (1997), p. A1; Broder (1997), p. A1. Home Office (1997a), p. 1. Home Office (1997a, 1997b and 1997c). Cf. Whitelaw (1982). Interview with former government official, 9 October 1997. Morgan (1997), p. 409. Interview with former senior official, 16 October 1997. Thatcher (1993) p. 626. Private information. Interview with former senior official, 9 May 1997. Interview with former official, 16 October 1997. Private information. See Home Office (1947d).

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Private information. Private information. Interview with former official, 28 October 1997. See Home Office (1991a). Home Office (1991b); Faulkner (1993), p. 3. Faulkner, ibid., p. 3. Home Office (1997e), p. 17. Private information. Benn (1980), pp. 9–11. Private information. Home Office (1997). Ibid., ch. 10.

References Primary Public Expenditure White Papers (1996–97). Departmental Reports (1996–7). Reports of the Treasury and Civil Service Committee of the House of Commons on Presentation of Information to Parliament (1996–7). Anonymous interviews with political experts, current and former government officials.

Secondary Barberis, P. (ed.) (1996) The Whitehall Reader (Buckingham: Open University Press). Barnett, J. (1982) Inside the Treasury (London: Andre Deutsch). Beer, S. (1957) Treasury Control: The Co-ordination of Financial and Economic Policy in Great Britain (Oxford: Clarendon Press). Benn A. (1980) ‘The Case for a Constitutional Civil Service’, Lecture, Royal Institute of Public Administration at Chatham House, St James’s Square, London, 28 January. Bridges, Sir Edward (1964) The Treasury (London: Oxford University Press). Brittan, S. (1964) The Treasury Under the Tories 1951–1964 (Harmondsworth: Penguin). Broder, D. (1997) ‘While Rethinking Tactics, Speaker Advises Conservative Not to Resume the Worst’, Washington Post, 20 June. Castle, B. (1980) The Castle Diaries, 1974–1976 (London: Weidenfeld & Nicolson). Crossman, R. (1975) Diaries of a Cabinet Minister, Vol. 1 (London: Hamish Hamilton). Edwards, L. L. (1997) ‘Budget Wars: The Failure of Congressional Budgeting 1974–1986’, in C. Barnes, S. Moseley and J. Steele (eds.), American National and State Government: An African American View of the Return of Redemptionist Politics (Dubuque, Iowa: Kendall-Hunt). Elliott, V. (1997) ‘Privy Council Sets Seal on Cabinet’, The Times, 3 May. Harris, R. (1990) Good and Faithful Servant: The Unauthorised Biography of Bernard Ingham (London: Faber & Faber). Faulkner D. (1993) ‘All Flaws and Disorder’, The Guardian, 11 November.

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Heclo, H. and A. Wildavsky (1981) The Private Government of Public Money (London: Macmillan). Hennessy, P. (1990) Whitehall (London: Fontana). Hennessy, P. (1996) The Hidden Wiring: Unearthing the British Constitution (London: Indigo). Hennessy, P. (1997) Muddling Through: Power, Politics, and the Quality of Government in Postwar Britain (London: Indigo). HM Treasury (1997) Reposing for the Budget (London: HMSO). Home Office (1991a) Prison Disturbances in April 1990: Report of an Inquiry by the Rt Hon Lord Justice Woolf (Parts I and II) and His Honour Judge Stephen Tumim (Part II), Cm. 1456 (London: HMSO). Home Office (1991b) Custody, Care and Justice, Cmnd. 1647, September (London: HMSO). Home Office (1997a) Annual Report 1997, Cm 3608 (London: HMSO). Home Office (1997b) The Prison Population in 1996, Home Office Statistical Bulletin No. 18/97, 31 July (London: HMSO). Home Office (1997c) Prison Statistics: England and Wales 1996, Home Office Command Paper 3732, 31 July, (London: HMSO). Home Office (1997d), ‘Home Secretary Unveils Radical Review of Criminal Justice System’, Press Release #53, 27 February. Home Office (1997e) Annual Report of Her Majesty’s Chief Inspector of Prisons (London: HMSO). Home Office (1997f), No More Excuses: A New Approach to Tackling Youth Crime in England and Wales, Cmnd. 3809, November (London: HMSO). Lynn, J. and A. Jay (eds.) (1987) Yes, Prime Minister: The Diaries of The Right Hon. James Hacker, Vol. 1 (London: Guild). Morgan, K.O. (1997) Callaghan: A Life (Oxford: Oxford University Press). Raum, T. (1997) ‘Budget Deals Being Made in Secret’, Washington Post, 30 April. Roseveare, H. (1969) The Treasury: The Evolution of a British Institution (London: Penguin). Skeoch, K. (1996) ITN Factbook: Budget ‘96 (London: HSBC James Capel). Stowe, Sir Kenneth (1992) ‘Good Piano Won’t Play Bad Music’, Public Administration, vol. 70. Thain, C. and M. Wright (1995) The Treasury and Whitehall: The Planning and Control of Public Expenditure, 1976–1993 (Oxford: Clarendon Press). Thatcher, M. (1993) The Downing Street Years (New York: HarperCollins). Tyrie, A. (1996), The Prospects for Public Spending (London: Social Market Foundation). Yang, J. and Pianin, E. (1997), ‘Divisions Widen in House GDP: Army “Not Bound” by Budget Deal, Doesn’t Defend Gingrich’, Washington Post, 18 June. Whitelaw, W. (1982) ‘Foreword’, First Report of Her Majesty’s Chief Inspector of Prisons, Home Office, Cmnd 8532, March. Winstone, R. (ed.) (1996) The Benn Diaries (London: Random House). Young, H. and A. Sloman (1984) But, Chancellor (London: British Broadcasting Corporation).

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9 Measuring Quality in Health Care Paul G. Shekelle and Martin Roland

The National Health Service (NHS) is embarking on an ambitious new program to measure the quality of health care within the service. A framework has been published outlining the principles that will be used to drive quality improvement. 1,2 This is an important step in improving the transparency of the policies affecting the NHS and new policies will be much more inclusive involving all doctors in quality improvement. In the past, quality has been measured in a piecemeal way, and the results have rarely, if ever, been made available to the public. In 1998 the government announced that there soon will be publicly available data on the hospital-specific death rate for coronary artery bypass surgery. This is a major change in the accountability to the public of the NHS and its providers. Still, the changes proposed in quality measurement have their own dangers. As the NHS sets about this task, we think it appropriate to look across the Atlantic to the USA, where researchers, government, and the purchasers of health care have twenty-five years of experience in assessing healthcare quality. We believe that some lessons learned in America are relevant to the task at hand for the NHS. In order to understand what is currently happening, we must first review the forces responsible for the development of quality assessment in the USA and the NHS. The system in the USA grew up around the concept of private health insurance that used a retrospective, fee-for-service-based mechanism for payment. This led to the need to generate a bill for each service rendered, and the development of information systems to handle these data. Quality assessment arose from the desire of the purchasers of health services (insurance providers and self-insured companies), who are third 167

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parties to the clinician–patient relationship, to ensure that their money was being spent wisely. This linked the assessment to the users of health services, and the individual patient encounter became the unit-of-analysis. A consequence of assessing users of health services was the emphasis on the assessment of the medical appropriateness of services already delivered. The data sources for this assessment were in general two: large datasets created by the need to track healthcare charges; and medical record review. Providers, both hospitals and clinicians, were subject to random review. Contrast this situation with the NHS, which was created as a publicly-financed system available to the whole population. In general, no charges are generated, so there are no routinely collected data on each patient encounter. General practitioners (GPs) are responsible for a defined population, and hospitals are responsible to purchasers who also have responsibility for defined populations. Consequently, quality assessment efforts have assessed the delivery of services to a population (rather than individuals who happen to use services), and in general focused on the delivery of medically necessary services. The unit-of-analysis is the population. Studies of the quality of practice have, in general, relied on volunteer doctors. The recent move to managed care in the USA has begun to change the focus of quality assessment from individuals to populations, and has completely changed the financial incentive from the delivery of services to the withholding of services. In the UK, since the advent of giving an explicit prioritization scheme, now both countries have a need to assess the quality of care for populations and individuals, and in particular to ensure that all members have access to medically appropriate health services. While the USA has twenty-five years of experience with systematic quality assessments, this concept is relatively new to the NHS. The experiences in America have valuable lessons, both positive and negative, for the NHS as it embarks on the current reforms. We believe that there are four key lessons that the UK could learn from the USA.

Develop indicators of quality that match appropriateness to clinical need One of the goals of the new framework is the ‘effective delivery of appropriate care’. This will require that the UK develops clinically defensible measures of quality. All people do not benefit equally

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from health services. Quality measures must take into account the health needs of patients. Measures that do not have sufficient clinical detail are unlikely to be fair assessments of quality. Consider the following differences in the approach to assessments of the use of grommet (typanostomy tube) surgery in children. This procedure is commonly performed, yet there is conflicting evidence supporting its use. In the USA, a team of researchers and a private quality assessment company convened a multi-disciplinary group of clinical experts, provided them with a systematic review of the literature, and developed a set of indicators for grommet insertion. This described in clinical detail which patients are likely to have favorable or unfavorable risk-to-benefit ratios. The risk-to-benefit ratio is felt to favor the operation (that is, it is medically appropriate) for children who present with persistent effusion, have a documented hearing loss of more than 20 dB, who have received one or more courses of antibiotics, and whose effusion has persisted for at least ninety days. The risk-to-benefit ratio is felt to be adverse (that is, medically inappropriate) for children who have an effusion of less than thirty days’ duration, have no recurrent otitis media, have a documented hearing loss of less than 20 dB, and who have not been treated at all with antibiotics. These criteria were used to assess the medical appropriateness of tympanostomy tube placement in a large population; 41 per cent of proposed operations were for reasons judged clinically appropriate, and 27 per cent of proposed operations were for reasons judged clinically inappropriate. 3 Contrast this with the way the same procedure has been handled in the United Kingdom. Here, reports have been limited to descriptions of the number of procedures performed over time in various health districts, 4 and the current consultation document proposes that a criterion for the assessment of quality of health authorities be the aggregation of hospital admissions for grommet surgery, with the rationale that ‘low is good’. The incentive for physicians and health authorities to show year-on-year improvement on this criterion may result in the withholding of grommet surgery from children who would benefit from it. Physicians and the public should rightfully be suspicious of such quality criteria, since they know such criteria do not take into account differences in clinical need among patients. Other examples of differences in clinical defensibility between US and UK criteria are the use of cataract surgery, hysterectomy, coronary angiography, and hospital admissions for congestive heart failure and asthma.

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Clearly, some people benefit from these services and some do not. The past approach of the NHS can be summarized as making a decision whether on average such a service is currently under- or over-utilized, and then assuming that aggregate rates will account fairly for differences in clinical presentation across health regions, or practices, or over time. Aggregated data are unhelpful to health authorities unless they can enter into a meaningful discussion with clinicians. Clinicians have wisely resisted the use of clinically insensitive measures which ignore the match of the measure to clinical need.

Assess quality on a representative sample of providers Consider the care of diabetic patients. There exists substantial evidence and clinical consensus that certain routine maintenance items, such as the monitoring of glycated hemoglobin and examination of the fundi, are important in decreasing the rate of development of complications.5 An assessment of the quality of diabetic care in 388 practices in south London found that in the previous two years about 40 per cent of diabetic patients had received a glycated hemoglobin test, and about 65 per cent had received a fundoscopic examination.6 What would surprise American doctors is the knowledge that all the practices that submitted to this audit were volunteers. This characterizes the measurement of quality in the UK – in most circumstances the practices and providers assessed do so voluntarily, and if any practice or provider strenuously objects then they may not be included in the assessment. Not so in the USA. There, virtually every provider has some likelihood that he, she or they will be assessed for quality. Again considering diabetes, the following is one approach published in the USA. There, investigators used the Medicare Claims database to assess the care of nearly 100 000 diabetic patients residing in three states. Because each health service is billed separately, the investigators were able to determine that 15 per cent of patients had received a glycated hemoglobin test in the previous year, and 46 per cent of patients had received an ophthalmologic examination.7 In these three states, all the providers who cared for at least one Medicare patient potentially contributed data to the sample. In other US applications, random sampling is used to assure a representative sample. In either case, the results are relevant to the performance of the entire system.

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Past quality assessments in the NHS have, in general, used providers who volunteer; and they almost certainly are different (and probably of better quality) than providers who refuse audit. Such data are not a fair assessment of the system. Since one of the key principles underlying the proposed changes to the NHS is to renew it as a ‘national service . . . [where] patients will get fair access to consistently high quality . . . across the country’, in the new NHS some method to ensure data on a representative sample of providers will be needed. The concept of clinical governance will, in theory, involve all doctors in the UK in quality assessment and improvement.

Do not ignore the possibility of overuse of some health services Another of the underlying important principles is efficiency. We can re-phrase this goal as the desire to eliminate waste. Therefore, it is surprising that relatively little attention has been paid to the possibility of continuing inefficiency caused by the delivery of medically inappropriate services. This is apparently so because of the widespread belief that the NHS is marginally or greatly underfunded, which creates the impression that it is unlikely that some services are overused. Yet all the experience in the USA is that constraining resources does not materially decrease the proportion of inappropriate care delivered, 8 and that overuse and underuse frequently co-exist. 9,10 When it has been looked for rigorously, inappropriate overuse of health services has been found in the NHS, even for major items such as cholecystectomy,11 coronary angiography, and coronary artery bypass surgery.12 For example, when the clinical reasons were examined why persons in the Trent area received angiography or bypass surgery, 21 per cent and 16 per cent, respectively, were judged inappropriate by a panel of UK doctors.

Physicians must assume responsibility for improvements in quality The situation confronting UK physicians is similar to that faced by US physicians thirty years ago: mounting evidence about variations in care, public concerns about quality of care, and governmental requirements for improving value for money. In the USA, physicians did not take these concerns seriously, and reacted far too

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slowly to satisfy the public or the government. The result was the rise of third parties who measured healthcare quality, with the consequent relinquishment by physicians of a large measure of their professional autonomy. The level of micromanagement that is going on in the late 1990s in most US offices and hospitals would scarcely be recognizable to most UK physicians. If a US physician wishes to order a thallium treadmill test to diagnose ischaemic heart disease, frequently an outside party must first approve it. If he or she wishes to prescribe a statin to lower a patient’s cholesterol, the managed care company dictates which statin the patient will receive. If coronary revascularization is indicated, an outside party frequently will decide which hospital and surgeon the patient should see. In each physician’s office, hours are spent dealing with the paperwork involved in obtaining pre-authorization or post hoc explanations of the clinical need for health care. The UK government has outlined the principles of clinical governance that should run through the NHS.13 UK doctors should regard this as an important professional responsibility. British physicians must be able to demonstrate that a professionally-led effort can result in meaningful improvements in quality. British physicians must be willing to be accountable to both the government and the public. The lesson from America is that abdication of this responsibility will undoubtedly lead to third parties assuming these tasks, with a resultant loss in physician autonomy. How well placed is the NHS to learn from the lessons of the USA? In many ways, the government’s proposals offer the right first steps in a national strategy for quality improvement. However, the lessons we have outlined that the UK needs to learn from the US cannot be implemented in the NHS at present, as it runs almost free of information. Virtually no data are routinely available on individual patient encounters. If clinicians are to move beyond aggregate measures of uncertain applicability, then much more information is needed about the quality and appropriateness of care of individual patients. This will be heavily dependent on new information systems, which need to be designed by clinicians. Information will not be cost-free. However, without good information doctors will be unable to take control of the quality agenda in a way that is meaningful to them, and, ultimately, to their patients.

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Notes 1 2 3 4 5 6 7 8 9 10 11 12 13

Department of Health (1998). McKee and Carr Hill (1998), p. 332. Kleinman et al. (1994), pp. 1250–5. Black (1995), pp. 234–7. American Diabetes Association (1998). Chesover et al. (1991), pp. 282–5. Wiener et al. (1995), pp. 1503–8. Lohr et al. (1986), pp. S1–S87. Froehlich et al. (1997a), pp. 690–7. Froehlich et al. (1997b), pp. 13–19. Scott and Black (1992), pp. 97–101. Gray et al. (1990), p. 517. Department of Health (1997).

References American Diabetes Association (1998) Clinical Practice Recommendations 1998 Diabetes Care, vol. 21; Supp. 1. Black, N. (1995) ‘Surgery for Glue Ear: The English Epidemic Wanes’, Journal of Epidemiology and Community Health, vol. 49, pp. 234–7. Chesover, D., P. Tudor-Miles and S. Hilton (1991) ‘Survey and Audit of Diabetes Care in General Practice in South London’, British Journal of General Practice, vol. 41, pp. 282–5. Department of Health (1997) The New NHS: Modern, Dependable, Cm 3807 (London: HMSO). Also available on the Internet at http:// www.officialdocuments.co.uk/document/doh/newnhs/newnhs.htm. Department of Health (1998) The New NHS Modern and Dependable: A National Framework for Assessing Performance (London: HMSO). Also available on the Internet at http://www.open.gov.uk/doh/newnhs/consult.htm. Froehlich, F., Pache, I., Burnaud, B., Valdez, J. P., Fried, M., Kosecoff, J., Koloday, M., Dubois, R. W., Brook, R. H., and Gonvers, J. J. (1997a) ‘Underutilization of Upper Gastrointestinal Endoscopy’, Gastroenterology, vol. 112, pp. 690–7. Froehlich, F., Burnaud, B., Fried, M., Schneider, C., Kosecoff, J., Koloday, M., DuBois, R. W., Brook, R. H., and Gonvers, J. J. (1997b) ‘Overuse of Upper Gastrointestinal Endoscopy in a Country with Open-access Endoscopy: A Prospective Study in Primary Care’, Gastrointestinal Endoscopy, vol. 45, pp. 13–19. Gray, P., J. R. Hampton, S. J. Bernstein, J. Kosecoff and R. H. Brook (1990) ‘Audit of Coronary Angiography and Bypass Surgery’, Lancet, vol. 336, p. 517. Kleinman, L. C., J. Kosecoff, R. W. DuBois and R. H. Brook (1994) ‘The Medical Appropriateness of Tympanostomy Tubes Proposed for Children Younger than 16 Years in the United States’, JAMA, vol. 271, pp. 1250–5. Lohr, K., R. H. Brook and C. Maberg (1986) ‘Use of Medical Care in the RAND Health Insurance Experiment: Diagnosis- and Service-specific Analyses in a Randomized Controlled Trial’, Med Care, vol. 24, pp. S1–S87.

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McKee M. and R. Carr Hill (1998) ‘Measuring Performance in the NHS: Good That It’s Moved Beyond Money and Activity, but Many Problems Remain’, British Medical Journal, vol. 316, p. 322. Scott, E. A. and Black, N. (1992) ‘Appropriateness of Cholecystectomy: the public and private sector compared. Am R Coll Surg Engl, vol. 74: (suppl. 4), pp. 97–101. Wiener, J. P., S. T. Parente, D. W. Garnick, J. Fowles, A. G. Lawthers and R. H. Palmer (1995) ‘Variation in Office-based Quality: A Claims-based Profile of Care Provided to Medicare Patients with Diabetes’, JAMA, vol. 273, pp. 1503–8.

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Index Aaron, H. J., 23, 24, 30 Accident and Emergency Unit (A&E), 116, 118–22, 125, 126, 129, 133 Accountability mechanisms for, in education policy, 33–50 and quality measurement in health care, 167–72 versus transparency, in health care policy, 28–9 Acute Hospital Trusts, 120, 122 Acute myocardial infarction (AMI), 115, 134, 135 A&E, see Accident and Emergency Unit Ambulance Review, 132 Ambulance Service Trusts, 120, 126, 129, 131–2, 132, 134 Ambulance UK, 126, 140 American Association of Transplant Physicians, 88 American Association of Transplant Surgeons, 88 American Diabetes Association, 173 AMI, see Acute myocardial infarction Analytic procedures, for health care policy, 20–1 Annest, J. L., 110 Anti-Vietnam War movements, 62 Ash, P., 99, 110 Assessment, in education, 37–9 Atlanta, Georgia, 99 Audit Commission, 45, 49, 51, 115, 116, 140, 141 Baker, R., 24, 30 Ball, S., 39, 48, 51, 55, 68 Barberis, P., 165 Barnett, J., 165 Barton, S., 16, 32

Baskett, P., 134, 140 Beecham, L., 22, 30 Beer, S., 165 Bell, S., 55, 68 Benn, A., 152, 165 Best practice solutions, 3 Binding mandates, and environmental policy, 58–60 Black, N., 173, 174 Blair, Tony, 151 Blair government, 149–1, 153, 157, 162, 163 Bottomley, V., 13 Bowe, R., 39, 48, 51 Bowling, A., 16, 30 Boyer, B., 68 Brady Bill, 98 Brehony, K., 42, 51 Brickman, R., 68 Bridges, Sir Edward, 165 British Environmental Information Regulations, 57 British Medical Association, 24 British Planning and Compensation Act, 53 Brittan, S., 165 Broder, D., 165 Brown, Gordon, 149 Budget process, American model of, 146 Budget process, British analytic categories in, 145–7 and Blair government, 149–51 and culture of discretion, 153–6 and political culture, 151–6 and prison reform, 156–62 timetable of, 147–9 Bureau of Alcohol, Tobacco, and Firearms, 98 Burns, E., 31

175

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176

Index

C–SPAN television network (USA), 12 Callaghan, James, 152 Calman, K., 116–18, 121, 140 Campbell, R. J., 37, 51 Carr Hill, R., 174 Castle, B., 165 Catchment areas, 79–80 Centers for Disease Control, 95 Central government and restrictions to innovation, 42–3 role of, in British education policy, 34–43, 48–9 role of, in British healthcare policy, 12–13 Central Health Outcomes Unit (Department of Health), 20 Centre for Educational Research, 47, 51 Centre for the Analysis of Social Policy (University of Bath), 19 Chancellor of the Exchequer, 12, 148–50, 154 Chesover, D., 173 Citizen juries, 139 City and Hackney Health Authority, 14 Civil rights movements, 62 Civil servants, waning power of, 161–3 Class, 85–6 Clinicians, individual, and healthcare policy, 23 Coast, J., 14, 20, 21, 24, 25, 27, 30, 31 Cochrane, M., 14, 31 Cohen, M. A., 111 Commission of the European Communities, 68 Community Trusts, 122 Confidentiality, 152–3 Conley, S., 45–6, 51 Conservative government, 147, 158 see also Conservative party

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Conservative party and local education authority (LEA), 43–5 and NHS reforms, 11 Cook, P. J., 98, 110 Cramshaw, R., 10, 31 Creemers, B. P., 49, 51 Criminal Justice Act of 1991, 160 Crossman, R., 165 Crown Court, 58, 156 Cullen, Lord, 100, 101, 110 Cullen Report, see Public Inquiry into the Shootings at Dunblane Primary School on 13 March 1996 (Cullen) Cultural values, and environmental standards, 60–4 Culture of discretion, 151–6 Culture of secrecy, 143–4 Custody, Care and Justice (Home Office), 160–1 Decision-making American distrust of professional, 86 and shared decision-making in health care policy, 26–7 Deem, R., 42, 51 Deficit reduction, 146–7 Delbridge, T., 114, 140 Department for Education and Employment (DfEE), 34, 44, 51 Department of Health (United Kingdom), 14, 16, 29, 78, 116, 127–8, 131–2, 137–8, 140, 173 Developing Emergency Services in the Community (Calman et al.), 119 Developing Emergency Services in the Community (White Paper), 121 Devolution, and deference in British system of organ allocation, 78–84

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Index

Directive on Freedom to Environmental Information, 57 Discretion culture of, 151–6 at school-site level, 46–8 Dixit, A. K., 110 Dixon, J., 138, 140 Donovan, J., 14, 21, 22, 24, 25, 27, 30 Douglas, Mary, 62, 63, 68 Doyal, L., 19, 28, 31 Dudley, N. J, 24, 31 Dunblane massacre, 100 EC, see European Commission Education policy central control of decisionmaking in, 34–43 changing role of local education authority (LEA) in, 43–5 reform in, 33–4 and site-based management, 45–50 Education policy, accountability mechanisms in and assessment, 37–9 and local management of schools (LMS), 41–2 and National Curriculum, 35–7 and Office for Standards in Education (OFSTED), 39–41 Education Reform Act (1988), 33, 34, 44, 50 Edwards, L. L., 3, 143, 165 EDX Committee, 145, 148 EEB, see European Environment Bureau Elliott, V., 165 Emergency Healthcare in Scotland (Scottish Office Policy Review), 118 Emergency medical care and attributes of emergency versus urgent care, 124 and attributes of event-driven medical problems, 121

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177

demand dilemma in, 114–17 management dilemma in, 123–9 pathway to care problems in, 123–9 priorities in, 138–40 and provider and organization-induced demand, 118–23 public expectations and political imperatives for, 129–35 and reasons for increased demand, 125 transparency in, 136–8 Emergency Medical Service (EMS), 130, 133 EMS, see Emergency Medical Service End-Stage Renal Disease Program (ESRD), 76, 86 English Nature, 53 Entwhistle, V. A., 31 Environment Act 1995, 57 Environmental Agency, 55–6 Environmental policy and regulation and citizens’ suits, 58 consensus-based British approach to, 54–5 cultural and historical factors in, 60–4 and increased access to information, 56–8 institutional and legal structures affecting, 52–3 legal and institutional structure of, in the United States, 54–8 public participation in, 53–4 and public participation in pollution control decisions in the United Kingdom, 54–8 EPA, see United States Environmental Protection Agency EU, see European Union European Commission (EC), 56–7, 58

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178

Index

European Court of Justice (ECJ), 56–7 European Environment Bureau (EEB), 58, 59 European Union Council of Ministers, 56 European Union (EU), 56, 57, 64, 100 European Union Fifth Action Program, 57 Evans, J. G., 24, 31 Evidence-based medicine, 20, 26 Faulkner, D., 165 Federal Firearm License (FFL), 97, 98 Federal Register, 77 FFL, see Federal Firearm License Fifth Action Program (EU), 57, 58 Finkelstein, Neal D., 1, 33, 34, 51 Firearm regulation and firearm acquisition, 97–102; in Great Britain, 99–102; in United States, 97–9 information and policy on, 102–7 and information on firearm misuse, 94–102; in Great Britain, 96–7; in United States, 94–6 Firearms Consultative Committee, 110 Firearms Law: Guidance to the Police, 110 Fisher, J., 134, 140 Fitz, J., 42, 51 FOIA, see Freedom of Information Act Frankel, S., 25 Freedom of Information Act (FOIA), 59, 60, 153 Froehlich, F., 173 Gellhorn, E., 68 General Certificate of Secondary Education (GCSE), 37

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General practitioners, 13–14, 114, 127–8, 168 Gertz, M., 96, 111 Gewirtz, S., 39, 48, 51 Goldstein, L. B., 24, 31 Goodacre, S., 133, 140 Gough, I, 19, 31 Government secrecy, 143 GPs, see General practitioners Gray, P., 173 Greenfield, L. A., 110 Grubb, W. N., 34, 51 Guly, H., 131, 141 Guly, U. M., 138, 140, 141 Gun violence, costs of, 105 Haldridge, P., 142 Halpin, D., 42, 51 Ham, C., 12, 16, 17, 22, 31 Handley, A. J., 129, 140 Hargarten, S. W., 110 Harris, J., 18, 31 Harris, R., 165 Harrison, A., 116, 139–41 Harrison, S., 29, 31 Hawkins, K. H., 68 Health Authorities, 13–20, 120, 122 justification for excluded services in selected, 15 and most commonly excluded services in 1996–7, 17 prioritization schemes in selected, 18 Health Committee of the House of Commons, 14, 16, 29 Health Policy and Public Health Directorate, 117, 118, 141 Health policy decisions by central government, 10–30 transparency of, 10–30 Health Service Journal, 128 Healthcare policy, British analytic procedures in, 20–1 and decisions made by central government, 12–13

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Index

and decisions made by individual clinicians and patients, 23 and decisions made by local authorities, 13–20 devolution of, to providers, 22 and evidence-based medicine, 26 implicit rationing in, 23–6 measuring quality in, 167–72 priority setting in, 18–20 and public input, 21–2 shared decision-making in, 26–7 Healthcare providers, devolution of policy to, 22 Heath, S., 42, 51 Heclo, H., 166 Heginbotham, C., 13, 21, 22, 31 Hemenway, D., 110 Hennesseey, P., 16 Her Majesty’s Inspection (HMI) system, 34, 40 Her Majesty’s Inspectorate of Pollution, 55–56 Hession, M., 69 HM Treasury, 166 HMI, see Her Majesty’s Inspection system Hoffenberg, R., 24, 25 Home Office, 156–61 Home Office Research and Statistics Directorate, 110 House of Commons, Home Affairs Committee, 101, 103, 104 How You Can Make a Difference, 16 Howard, Michael, 160, 162 Hungerford mass murder, 100 Hunter, D. J., 28, 29, 31 Implicit rationing, 23–6 Influence, role of, in British policy, 144, 145, 159–60 Information access to, by consumers, 3–4 and EU legislation, 56–7

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on firearm misuse, 94–102 and policy on firearm regulation, 102–7 and policy production process, 3–4 Ingham, Bernard, 152 Institute of Public Policy Research, 139 Institutions, American mistrust of, 90 International Environment Reporter, 68 International Trauma Foundation, 115, 141 IRA, see Irish Republican Army Irish Republican Army (IRA), 102 Isle of Wight, 22 Jay, A., 166 Judge, T., 5, 113 Juni, Robin L., 5, 52 Kellermann, A. L., 110, 111 Kelman, S., 61, 68 Kidney Advisory Group, 79, 81 King’s Fund, 27, 138, 139 Kleck, G., 96, 111 Klein, R., 12–14, 16, 18, 19, 20–1, 23–5, 27–9, 31, 32 Kleinman, L. C., 173 Knapp, M., 131, 141 Knox, R. C., 112 Kogan, M., 41, 51 Kramer, L., 68 Kunzlik, P., 68 Labour government, 11, 28, 42, 137, 150, 151–2 see also Labour party Labour party, and local education authority, 43 Lamm, Richard D., 139, 141 Lauver, G., 111 Lawler, E. E., 45–6, 51 Le Grand, J., 12, 32 LEA, see Local education authority League tables, 38

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Leitzel, J. A., 4, 93, 110, 111 Lenaghan, J., 29, 32, 139, 141 Levacˇ ic´, R., 45–6, 51 Levitt, R. A., 11, 14, 20, 32 Lewis, Derek, 156 Limited government, versus popular government, 61 Litigation, and environmental policy, 54, 59–60 Litigation strategies, 2, 5–6 Liver, Cardiothoracic Advisory Groups, 79 LMS, see Local Management of Schools Local authorities and explicitness of priorities, 14 and justification for excluded services, 15 and well-defined reasons for excluded services, 14–15 Local education authority (LEA), 39, 42, 44, 45, 50, 51 Local Management of Schools (LMS), 34, 41–43 Lohr, K, 173 London Ambulance Service (LAS), 122 Lott, J. R., Jr., 111 Lynn, J., 166 MacCoun, R., 111 Macfarlane, R., 68 Mackenzie, M. B., 69 Maclure, S., 44, 51 Macrory, R., 69 Maine Health Information Center, 134, 141 Major, John, 154 Major Government, 2, 33, 157, 160, 163 Mandarins, 153–6 Mann, C. F., 131, 141 Manson, D., 111 Market-based mechanisms, 2–4 Massachusetts, 98 Massachusetts Hazardous Waste Facility Siting Act, 54

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McAuslan, P., 53, 69 McDowall, D., 111 McKee, M., 174 Mechanic, D., 27, 32 Medicaid, 30 Medicare, 30, 86 Miller, T. R., 111 Ministers, Treasury, 153–6 Mitchell, R. G., 131, 141 Moe, T. M., 69 Monarchy, and deferential cultural values, 61 Moore, M. H., 98, 110 Morgan, K. O., 166 Moynihan, D. P., 143 Munday, R., 111 Mustalish, A. C., 133, 141 National Center for Injury Prevention and Control, 111 National Crime Victimization Survey (NCVS), 95, 96 National Curriculum, 34, 35–37, 41, 47 National Declassification Center, 143 National Environmental Policy Act (NEPA), 54 National Health Service Act (1946), 115 National Health Service (NHS), 5, 7, 10, 10–30, 78, 85–8, 113, 116, 118–20, 128, 130, 131, 137–9, 167–72 National Research Council, 69 National Rivers Authority, 55–6 National Summary of Injury Mortality Data, 1988–94, 111 National Transplant Database (United Kingdom), 80 National Union of Teachers, 40 NCVS, see National Crime Victimization Survey Needs assessment, evidencebased approach to, 20–1 NEPA, see National Environmental Policy Act

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Index

New, B., 12, 32, 140 New Deal, 61 New England Journal of Medicine, 133, 141 New York City, 98, 99 Nguyen Van Tam, 131, 141 NHS, see National Health Service NHS Ambulance Trusts, see Ambulance Service Trusts NHS Centre for Reviews and Dissemination, 27 NHS Confederation, 117, 128, 141 NHS effectiveness initiative, 30 NHS Executive, 13, 14–15, 16, 25, 26, 116, 129, 132, 133, 139, 141 NHS Management Executive, 16 NHS reforms, 11, 14 Nicholl, J., 127, 131, 138, 141, 142 999, 131 999 systems, 124–6 Odden, A., 45–6, 51 Office for Standards in Education (OFSTED), 34, 39, 40, 48, 49 OFSTED, see Office for Standards in Education Ogus, A., 69 Opacity arguments for, 27–8 and black market, 93–4 and firearm regulation, 93–107 versus transparency, 1 see also Transparency OPO, see Organ procurement organizations OPTN, see Organ Procurement and Transplantation Network Organ allocation, see Organ transplant rationing Organ procurement catchment areas, 79–80

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Organ procurement organizations (OPOs), 74–76 Organ Procurement and Transplantation Network (OPTN), 74, 77, 89 Organ transplant rationing character of, 71–4 difference between United States and British systems for, 84–6; impact of health service differences on, 86–8; impact of social forces and interest groups on, 90–1; impact of transplant system differences on, 88–90 and doctor-directed rationing, 82–4 institutional structures for, in United States, 74–8 and local institutions, 76–8 as model for rationing, 70–1 United Kingdom system of, 78–84; criteria and content in, 79–82; national processes and structures in, 78–9 United States system of: institutional structures of, 74–8; and local institutions, 78–80 Organization for Economic Cooperation (OECD), 114 O’Riordan, T., 69 Patients, and healthcare policy, 23 Patient’s Charter, The (Secretary of State for Health), 27 Patients’ Charter, 122 Pencheon, D., 118, 122–3, 130, 142 Penfold, N., 128, 142 PES, see Public Expenditure Survey Pianin, E., 166 Political culture, British, 151–6 Pollock, A., 21, 29, 32

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Polsby, D. D., 103–4, 111 Popular government, versus limited government, 61 Possession of Handguns, Home Affairs Committee report on, 104, 111 Post, C., 141 Power, role of, in British policy, 144, 145, 159–60 Power, S., 42, 51 Prime minister, and shaping of policy initiatives, 157–9 Priority setting, healthcare by local authorities, 18–20 and prioritization schemes, 18 and top ten priorities mentioned by purchasers, 19 Priority Setting in the NHS, 139 Prison reform and Home Office, 156–62 and importance of prime minister in shaping policy initiatives, 157–9 and power of ministers, 159–61 and waning influence of civil servants, 161–2 Prison Service, 156, 157, 160, 161 Privatization, 11 Professional judgment, 2, 4–5, 23–5 Prottas, Jeffrey, 1, 70 Provider demand, in emergency medical care, 118–23 devolution of healthcare policy to, 22 Public expenditure control mechanism, 147 Public Expenditure Survey (PES), 148, 161 Public input, in healthcare policy, 21–2 see also Public participation Public Inquiry into the Shootings at Dunblane Primary School on 13 March 1996 (Cullen), 100–1

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Public participation in environmental policy, 53–54 and health authorities, 21–22 in pollution control decisions, 54–58 Public sentiment and environmental policy, 55, 60–4 and healthcare rationing, 13 and health service managers, 21 and public expectations for emergency medical care, 129–35 Purchaser–provider split, 11 Qualifications and Curriculum Authority (QCA), 36 Quality measurement, in healthcare by assessment on a representative sample of providers, 170–1 and matching appropriateness to clinical need, 168–70 origins of, in private insurance, 167–8 and possible overuse of some services, 171 and responsibility for improvement in quality, 171–2 Rainer, T. H., 131, 141, 142 Rationing character of, in organ transplantation, 71–4 organ transplantation as model for, 70–1 and public sentiment, 12–13 Rationing, healthcare implicit, 23–6 and politicians, 12–13 Rationing Agenda Group, 27–8, 29 Raum, T., 166 Rawls, J., 134, 142

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Index

Redmayne, S., 15–22, 32 Regional Administrations, 120, 122 Regulatory structures, 2–3 Republic of Ireland, 81 Rescue 911, 131 Response-time interval (RTI), 132 Resuscitation dilemma, 138–9 Ridings School (Halifax), 45 Risk-to-benefit ratio, 169 Roberts, G., 142 Robertson, K. G., 69 Roland, M., 4, 167 Roseveare, H., 166 Rowbotham, E. F., 69 Royal College of Surgeons of England, 26, 78–80, 88, 129, 142 Royal Colleges Ambulance Liaison Committee, 134 St John Ambulance Service (St Andrew, Scotland), 115 School Curriculum and Assessment Authority (SCAA), 36, 51 Schwartz, W. B., 23, 24, 30 Scott, E. A., 174 Scottish Ambulance Service, 116, 131, 142 Scottish Office Policy Review, 118 Secrecy, government, 143 Secretary of Health (United States), 74–6 Serving the European Union: A Citizen’s Guide to the Institutions of the European Union, 69 Shared decision-making, in healthcare, 26–7 Shekelle, P. G., 4, 167 Sheley, J. F., 111 Single-payer systems, 29–30 Site-based management, in education policy, 45–48 Skeoch, K., 166 Sloman, A., 166

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Small Steps, Big Goals: Purchasing Policies in the NHS (Redmayne), 15, 18, 19, 32 Smith, R., 11, 25, 32 Snyder, F., 69 Special Health Authority (NHS), 78, 79 Stearns, K., 45, 51 Stevenson, J. A., 111, 112 Stowe, Sir Kenneth, 166 Sunshine laws, 147 Supplemental Environmental Projects (United States), 59 Sweden, 61 Tackling Emergency Admissions – Policy into Practice (NHS Confederation), 128 Terry, L., 68 Thain, C., 166 Thatcher, Margaret, 151, 152, 158, 159, 166 Thatcher Government, 2, 33, 147, 157, 159, 162, 163 Times Educational Supplement, The, 44 ‘Tragic choices’, 27 Transparency versus accountability, 28–9 and arguments for opacity, 27–8 in British budget process, 143–63 definition of, 1 in education policy, 33–50 and emergency medical care, 113–40 in environmental policy and regulation, 52–65 and firearm regulation, 93–107 in health policy decisions, 10–30 in organ transplant rationing, 70–91 and policy design, 2–6 and policy outcomes, 7–8 Treasury Department (Home Office), 148, 157 Tyrie, A., 166

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184

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UKTSSA, see United Kingdom Transplant Support Service Authority United Kingdom firearm acquisition in, 99–102 information on firearm misuse in, 96–7 public participation in pollution control decisions in, 54–8 system of organ allocation in, 78–84 United Kingdom Transplant Support Service Authority (UKTSSA), 78–82 United Nations Economic Commission for Europe, 69 United Network for Organ Sharing (UNOS), 74–5, 76–9 United States acquisition of firearms in, 97–9 information on firearm misuse in, 94–6 legal and institutional structure of environmental policy, 54–8 organ rationing systems in, 74–8 United States Clean Water Act, 59 United States Department of Justice, 112 United States Environmental Protection Agency (EPA), 59, 63

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University of Bath, 19 UNOS, see United Network for Organ Sharing Van Ermen, R., 69 Vogel, D., 69 Walley, T., 16, 32 Washington Post, 68 Waste Regulation Authorities, 55–6 Weber, B., 69 Weil, D. S., 112 Weiner, J. P., 174 West, R., 25, 32 West, R. J., 128, 142 Wheeler, M., 69 Whitehorn, K., 21, 32 Whitelaw, William, 156, 159, 166 Wildavsky, Aaron, 62, 63, 68, 166 Wilson, J. Q., 61, 69 Wing, A. J., 24, 32 Winstone, R., 166 Wintemute, G. J., 112 Woodhead, Christopher, 40 Woolf, Steven H., 5, 10, 69 Working for Patients (Department of Health), 11 Wright, J. D., 111, 112 Wright, M., 166 Yang, J., 166 Yardley, M., 101 Young, H., 166 Zawitz, M. W., 112

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