Speaking Truth to Power: Two Decades of Analysis in the Department of Health

226 Pages·2016·3.11 MB·English

by  Staff

Speaking Truth to Power

Two decades of analysis in the

Department of Health

Clive Smee

Radcliffe Publi shi ng

Oxford • Seattle
CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742

© 2005 by The Nuffield Trust
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Version Date: 20160525

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Co nte nts

Preface
About the author
The Nuffield Trust
List of Trustees iv
v
vi
vii
1 Introduction 1
2 Determining the NHS budget l l
3 Alternative funding mechanisms 2 9
4 Planning human resources 43
5 How efficient is the NHS ? 5 9
6 'Doing the right thing' : allocative efficiency i n the NHS 79
7 Measuring and managing performance 1 0 1
8 Discovering the patient 1 3 1
9 Organisational change 1 47
1 0 Learning from ourselves: policy and programme evaluation 1 6 1
1 1 Learning from others : international comparisons 1 7 5
12 C oncluding reflections 1 9 1
Index 2 1 7

iii
Preface

The idea for this book came from John Wyn Owen, Secretary o f the Nuffield
Trust. I am grateful to him and to the Trust for funding its production through the
offer of a Queen Elizabeth the Queen Mother Fellowship.
The book was written while I was living in New Zealand. Thanks are due to the
New Zealand Treasury for allowing me to use their facilities to print out numerous
drafts of each chapter, and to colleagues in the health section for listening patiently
to several presentations . I am also grateful to the New Zealand Ministry of Health
for providing a counterpoint from which I could appreciate more clearly the
distinctive features of English health policy making and the role of analysis in that
process. A very special thank you is due to Annette Evans who typed out the first
drafts of 1 0 of the 1 2 chapters with great efficiency, speed and charm.
Although I take responsibility for the book's errors of omission and commission,
in many ways it reflects a j oint effort by past and present members of the
Economics and Operational Research Division of the Department of Health. All
contributed in some way, if only by providing subj ect matter. Those who
contributed comments and materials for individual chapters include Robert
Anderson, Keith Derbyshire, Peter Dick, Frances Dickinson, Richard Gibbs,
Maria Goddard, Andre Hare, John Henderson, Leslie Hughes, Howard Malin,
Barry McCormick, Richard Murray, Geoff Royston, Becky Sandhu and Nick York.
I am grateful to them all.
Two former colleagues (and I hope friends) read and provided stimulating
comments on early drafts of every single chapter. They are Jeremy Hurst and
Mike Parsonage . If the book has any merits it is almost certainly due to their
contributions. I cannot thank them enough for their patience and encouragement.
Drafts of Chapters 2 to 6 were discussed at a workshop organised by the Nuffield
Trust in October 2 0 0 3 . I appreciate the comments of the Department of Health
and academic colleagues who attended and commented at the time and/or
subsequently in writing.
The book is built round my 18 years as Chief Economic Adviser in the
Department of Health and, prior to 1 989, in the Department of Health and
Social Security. Many colleagues contributed to the experiences and opportunities that I enj oyed during those years. Among senior officials who opened doors
for me I am particularly grateful to Sir Patrick Nairne, Sir Christopher France, Sir
Graham Hart, Sir Alan Langlands and Sir Joe Pilling. It was also a privilege to
work for eight Secretaries of State . Unsurprisingly, some were more interested in
or supportive of the contribution of analysis than others . Three who were
particularly receptive to, or tolerant of, the role of economics and operational
research were Sir Norman Fowler, Virginia B ottomley and Alan Milburn. Their
recognition of the virtues of a 'challenge' function - of the value of alternative
evidence -based views - was essential for ensuring that analysts were able to
'speak truth to power' during this period.
Finally, I am grateful to my wife, Denise, and my children, Anna, David and
Elizabeth, for their continued encouragement and support.

Clive Smee

July 2005

iv
Abo ut the autho r

From 1 984 to 2 002 Clive Smee was Chief Economic Adviser and Head of
Analytical Services in the UK Department of Health. During this period he
served eight Secretaries of State . He has a particular interest in health reforms,
both national and international . He led the NHS National B eds Inquiry and was
part author of the 2 000 NHS Plan. He has acted as a health economics consultant
for a number of countries and from 1 987 to 1 990 he chaired the OECD's Social
Policy Working Party. He has also been a long term member of the C ommonwealth Fund's International Program in Health Policy and Practice Coordinating
C ommittee . In 1 997 he was made a C ompanion of the Order of the Bath ( C B ) for
services to health.
Earlier in his career Clive worked as an economist for the UK Treasury, Cabinet
Office, DHSS and Ministry of Overseas Development. From 2002 to 2 004 he was
principal adviser on social policy in the New Zealand Treasury. He has been a
Visiting Professor of Economics at the University of Surrey since 1 99 5 .
This book was written when Clive was the Nuffield Trust Queen Elizabeth the
Queen Mother Fellow.

v
f1J

The Nuffield Trust

FOR RESEARCH AND POLICY

STUDIES IN HEALTH SERVICES

The Nuffield Trust is one of the leading independent health policy charitable
trusts in the UK. It was established as the Nuffield Provincial Hospitals Trust in
1 940 by Viscount Nuffield (William Morris ) , the founder of Morris Motors. In
1 998 the Trustees agreed that the official name of the trust should more fully
reflect the Trust's purposes and, in consultation with the Charity C ommission,
adopted the name The Nuffield Trust for Research and Policy Studies in Health
Services, retaining 'The Nuffield Trust' as its working name .

The Nuffield Trust's mission is to promote independent analysis and informed
debate on UK healthcare policy. The Nuffield Trust's purpose is to communicate
evidence and encourage an exchange around developed or developing knowledge in order to illuminate recognised and emerging issues.

It achieves this through its principal activities:

•

•

•

•

•

bringing together a wide national and international network of people
involved in UK healthcare through a series of meetings, workshops and
seminars
commissioning research through its publications and grants programme to
inform policy debate
encouraging inter- disciplinary exchange between clinicians, legislators, academics, healthcare professionals and management, policy makers, industrialists and consumer groups
supporting evidence -based health policy and practice
sharing its knowledge in the home countries and internationally through
partnerships and alliances .

To find out more, please refer to our website or contact:

The Nuffield Trust
59 New Cavendish St
London
W I G 7LP
Website : www. nuffieldtrust. org.uk
Email:
Li st of Tru stees

Patro n

Her Royal Highness The Princess Royal

Gove rn i ng Tru stees

Professor S ir D enis Pereira Gray OBE FRCP FRCGP

Chairman, The Nuffield Trust
Emeritus Professor of General Practice, University of Exeter

Professor S ir Leszek Borysiewicz FRCP

Deputy Rector, Imperial C ollege of Medicine

Professor S ir Keith Peters FRCP FRS

Regius Professor of Physic, University of Cambridge

Dame Fiona Caldicott DBE, FRCP, FRCPsych

Principal, S omerville C ollege Oxford

S ir Christopher France GCB

Formerly Permanent Secretary, Department of Health
and Permanent Secretary, Ministry of Defence

Lord Carlile of Berriew QC

Recorder and formerly Member of Parliament for Montgomery

Baroness Cox of Queensbury

Chancellor, University of B ournemouth
Vice-President, Royal C ollege of Nursing

Professor D on D etmer MD FACS FACMI FAHSR

President & Chief Executive Officer, American Medical Informatics Association

vii
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Chapter I

I ntrod u cti o n

I ntro d u ction

I n his seminal work, Speaking Truth to Power: the art and craft of policy analysis,
Aaron Wildavsky notes that:

Policy analysis must create problems that decision makers are able to handle
with the variables under their control and in the time available. 1

This book is about how analysts in the UK Department of Health (DH) helped to
find and define such problems and to suggest solutions over the period 1 9842 002 .
More precisely, the book has three main purposes:

l

2

3

to provide a history of selected analytical issues in healthcare over the last
20 years, and the role of Department of Health (DH) analysts in addressing
those issues.*
to distil lessons from that history and experience in the hope that they may be
of encouragement, interest or value to future health service analysts, particularly those thinking of working in the public sector
in passing, to provide a personal commentary on some of the more important
analytical issues in healthcare.

The book adopts a selective and subj ective approach to these aims. The next
section of this introduction discusses the coverage of the book in terms of time
period, analytical disciplines and issues. The following section provides a short
history of the way in which analysts were organised in the Department of Health.
There is then a discussion of the role of analysts in the Department, their formal
and informal relationships with Civil Service colleagues, and their contribution to
Departmental decision making.

Cove rage

The focus of this book is the time period 1 984-2002 . The dates were chosen
entirely for personal reasons . They cover the period for which I was first the Chief
Economic Adviser to the Department of Health and Social Security (DHS S ) and
then, after the split of that Department, had a similar role in the Department of
Health (DH) . Of course, 1 984 was not the beginning of a formal analytical
function in the DHS S . I inherited the mantels of three distinguished Chief

* In this book, 'analysis' involves the examination and interpretation of data and other information,
both qualitative and quantitative, in order to provide insights to improve the identification of
problems, the formulation of policy and the delivery of services.