Congruence and incoherence: public health governance and policy in a devolved UK

Rob Ralston, Katherine Smith

Research output: Chapter in Book/Report/Conference proceedingChapter


Introduction As part of their influential work on interpretive analysis, Bevir and Rhodes (2003) detail the role of traditions and dilemmas in shaping the ‘webs of meaning’ of actors, expressed through ideas and discourses, which are reinterpreted and reproduced in ways that are perceived to ‘fit’ with existing traditions (Schmidt, 2011). In this chapter, we present a case study of health policy in the post-devolution UK. Although we do not engage substantively with the conceptual toolkit developed by Bevir and Rhodes, we nevertheless explore the processes through which policy actors shape, and are shaped by, ideas about the social and political context in which they operate (Schmidt, 2010). We utilise policy framing, understood here as an interpretive schema that both helps render issues comprehensible in terms of pre-existing knowledge and provides a model for action (Hajer & Laws, 2006; Hulst & Yanow, 2014; Schön & Rein, 1994). In doing so, the analysis draws attention to ideas that have ostensibly undergone a process of institutionalisation, receding into the background of policy debates as ‘taken for granted’ realities (Bourdieu & Thompson, 1991; Hall, 1993; Smith, 2013). Health policy was initially one of the most significant policy areas to be devolved in the UK so the extent to which policy experimentation and divergence has been possible is of interest. Since the first elections were held in 1999, the newly devolved administrations – the Scottish Government,1 the Northern Ireland Executive and the Welsh Assembly Government – have each2 produced a wealth of documents claiming to set out distinct approaches to health policy. However, the scope for genuinely divergent approaches has been constrained by the fact many other areas, notably fiscal policy, have continued to be determined by the UK government. Until recently, for example, none of the devolved areas have had substantial tax raising powers (the Scottish Government had the most capacity here, having initially been granted a capacity – never used – to vary income tax rates by 3 per cent tax), while all three administrations continue to have limited powers to borrow. This may well have limited policy experimentation and this might now change, as all three areas are gaining greater control of different forms of taxation: the Scottish Government and Welsh Assembly have recently been granted greater control over various taxes and associated revenue, including income tax, while the Northern Irish Executive is scheduled to take greater control of corporation taxes from 2018. Despite the initially restricted nature of political devolution, it was welcomed by many as an opportunity to create distinctive and innovative policies (see Mooney, Scott, & Williams, 2006). Reflecting the fact that health was initially held up as one of the most significant areas to be devolved (Woods, 2004), health policy has been closely studied by scholars interested in the impact of devolution (Greer, 2004; Keating, 2005). To date, most analyses focus either on healthcare policies (Greer, 2001, 2005, 2009; Woods, 2004) or on specific public health issues (Cairney, 2007; Holden & Hawkins, 2013; Smith et al., 2009). From these assessments, two discrete stories emerge. The first, is that policymakers have responded to healthcare problems and debates in ways that vary territorially, producing ‘policy divergence that matters’ (Greer, 2005, p. 501). Greer has characterised these different emphases as: a belief in markets and managerialism in England; the influence of the medical profession and the promotion of co-operation in Scotland; localism and the prioritisation of public health in Wales; and policy inertia and permissiveness in Northern Ireland. Greer concludes: ‘The four systems are heading in different directions, and in so far as policy affects the work of health systems it is turning them into four different working environments with ever more distinct cultures’ (Greer, 2009, p. 80). This characterisation of post-devolution policy is widely cited (e.g. Cairney, 2007; Keating, 2005; Connolly, Bevan, & Mays, 2010) and has led to claims that we are experiencing a ‘natural experiment’ in the efficacy of different healthcare delivery models (Bevan, 2010; Propper et al., 2009, Connolly et al., 2010). In contrast, the story emerging from analyses of public health policies (i.e. those focused on the prevention of ill health, health improvement and health inequalities) is one of greater consistency. For example, Smith and colleagues (2009) found that all four UK administrations, while initially making strong rhetorical commitments to addressing the wider social determinants of health (with Welsh policymakers providing perhaps the boldest statements), ultimately resorted to similar medical and targeted interventions (Smith et al., 2009). Similarly, while divergence was initially evident in relation to proposals to ban smoking in public places, the whole of the UK had implemented a similar ban by July 2007 (Cairney, 2009). Taken together, these two examples suggest a high degree of consistency between the four UK polities within public health policy. This analysis is supported by one of the few assessments to consider healthcare and public health policy, which argued that there remained a remarkable degree of consistency across the UK for both policy areas (Smith & Hellowell, 2012). Two years on from this analysis, policy trajectories for healthcare do not appear to have altered substantially in any of the devolved regions, though the Scottish National Party’s 2015 pledge to take forward ‘the most significant reform in health and care since the creation of the NHS in Scotland in 1948’ (Scottish Government, 2015a) suggests this may soon change. In this chapter, we first briefly outline post-devolution approaches to improving population health (section 2) and health inequalities (section 3), before drawing on data from a larger research project to explore food policy in more depth. Taking inspiration from Bevir and Rhodes’ (2012) account of governance as constitutive of both language and its performance within public and political settings, the subsequent sections contend that, while policy traditions have diverged rhetorically, policy enactment has often remained remarkably consistent across the four UK administrations.
Original languageEnglish
Title of host publicationDecentring Health Policy
Subtitle of host publicationLearning from British Experiences in Healthcare Governance
EditorsMark Bevir, Justin Waring
Place of PublicationOxon
Number of pages20
Publication statusPublished - 28 Jul 2017


  • public health governance
  • policy
  • UK
  • post-devolution


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