In the years following 2000, the governments of England1 and New Zealand each made major changes to the governance and financing arrangements for their general practice services. The reforms were designed, among other things, to give state funders greater influence over the medical profession’s responsibility for quality and allocation of publicly funded health care, increasing the clinical and financial accountability of general practitioners to the state (King 2001 p. 11; Stevens 2004). Each country introduced a pay-for-performance scheme for general practitioners. The design of these schemes differed in size, scope and speed of implementation; consequently, the two schemes are associated with differing levels of impact upon health outcomes.
Policymakers need to know why and how policy change occurs, and why the processes or outcomes of policymaking differ between countries, in order to improve their ability to bring policy change. In the public policy literature, scholars debate whether the influence of institutions, interest groups, individuals’ rational choices, ideas or socio-economic factors are the main drivers of policy change and variation. Does structure or agency dominate in this process? Is it institutions or people who need to change in order for policy to change? John sets out five approaches or theories that can explain how policy is made and implemented (John 1998). First, institutionalist approaches emphasise the determining role of political organisations and the rules, norms and strategies associated with them. Group-based approaches contend that change arises through the interaction of institutional arrangements and groups or networks, through collective action. Rational choice explanations for policy change focus on the preferences and rational choices of individual actors. Ideas and their advocacy by actors are thought to be the primary driver of policy change by ideational theorists, transcending the influence of political institutions and interests. Finally, socio-economic theories suggest that objective social and economic conditions structure policy formation and therefore drive policy change. John finds that these single-theory approaches fail to explain policy change and variation adequately and contends that multi-theoretic approaches, such as John Kingdon’s Multiple Streams Framework (hereafter the MS Framework) (Kingdon 2010), with its mix of explanatory drivers, have greater utility to explain complex policymaking (John 1998, p. 167).
This book presents a new analytical approach. The approach synthesises all five single-theory explanations of policy change and the MS Framework into a coherent approach to assessing policy change and variation. It tests this approach through comparative analysis of policy change and variation in two similar pay-for-performance policymaking case studies in two similar structural and well-established institutional settings. The MS Framework is widely used by scholars (Jones 2015); the research underlying this book, completed in 2014, seeks to make a significant contribution to its refinement by using the insights from this research to test the respective utility of all five elements of the Framework and the sub-elements identified by Zahariadis (2007), along with the five other single-theory explanations for policy change and variation, to explain the policy change and variation which occurred. It makes recommendations for adaptation of the MS Framework on the basis of these findings.
The Setting
It can be said that “experimental” conditions existed between 2001 and 2007 in England and New Zealand, enabling the comparative study of these contemporaneous, similar policymaking episodes. The countries share similar political and health systems, an earlier similar pattern of health system establishment and a recent history of its reform, involving the application of New Public Management approaches. Both have similar majoritarian, unitary political systems with adversarial features (in which at least two parties oppose each other vigorously on matters relating to the state and the general welfare of the people; Pollitt 2010). In these systems the central government is ultimately supreme, unlike federal states (such as the USA) in which sub-national units such as states share sovereignty with the central government and have powers that the central government may not unilaterally alter. Britain has a majoritarian parliament, typically giving a majority of seats to the party with a plurality of votes in constituencies (a “first past the post” system). New Zealand had the same electoral system until 1996, when a version of proportional representation was introduced. The high executive autonomy (Mulgan 1995; Richards 2002; Shaw 2008) in both countries generally delivers strong majority government that empowers a Cabinet to make policy, often without constraint by the legislature (Blank 2006).
The national health systems of the countries are similar and are often listed in the same categories of health system typologies (OECD 1987; Laugesen 2000; Scott 2001; Burau 2006; Gauld 2009; Tenbensel 2011), having taxpayer-funded national health services in which comprehensive health services are available to all citizens. Established between 1938 and 1948, they are largely publicly funded: in 2000, 80.9 per cent of health expenditure in Britain was public and 78 per cent in New Zealand (OECD 2004, p. 268). Funding is pooled, centrally managed and allocated prospectively in annual budget appropriations. In this respect they are both national health systems in the OECD 1987 typology (OECD 1987).
Docteur and Oxley (OECD 2004, p. 22) note that the extent of public versus private coverage affects the degree of government control over health spending. Whereas the English general practice sub-system has strong hierarchical features, enabling periodic abrupt and dramatic change ordered from the top (Tuohy 1999, p. 14), New Zealand has a complex mix of ownership and governance arrangements in the general practice sub-system as a result of its largely privately provided general practice services and is assessed as providing minimal opportunities for public influence (Tuohy 1999; Davis 2000; Gauld 2003; Crampton 2004; Starke 2010; Tuohy 2012).
These differences in financing and provision arrangement...