Scottish Independence: What are the implications for health policy?

[This now appears in Total Politics http://www.totalpolitics.com/opinion/427827/scotland-special-nhs-new-healthy-scotland.thtml]

Most health and public health policy has been devolved since 1999, so maybe the potential for major policy change is not as great as in novel policy fields. Instead, we might see the acceleration of differences in key areas.

The first is healthcare. The NHS has always been a little bit different in Scotland, which enjoyed administrative devolution – through the Scottish Office (a UK Government Department) – before 1999 and maintained its own links with professional groups. Scotland has traditionally trained a disproportionate number of UK doctors and maintained an unusually high presence of Royal Colleges. This greater medical presence in Edinburgh (and Glasgow) boosted the Scottish Office’s policymaking image as ‘professionalised’, or more likely to pursue policies favoured by the medical profession than the Department of Health. For example, it appeared to be less supportive of reforms based on the ‘marketisation’ of the NHS. Devolution turbo boosted this position. While the UK Labour Government furthered the ‘internal market’ established by its Conservative predecessors, the Labour-led Scottish Government seemed to dismantle it (for example, there are no Foundation hospitals). It also bought (and effectively renationalised) a private hospital, which had a symbolic importance way above its practical effect. Since 2007, the SNP-led Scottish Government – often supported publicly by UK-wide groups such as the British Medical Association (and nursing and allied health professions) – has gone big on this difference between Scottish and UK Government policies, criticising the marketization of the NHS in England and expressing, at every opportunity, the desire to maintain the sort of NHS portrayed by Danny Boyle at the Olympics opening ceremony. This broad approach is generally supported, at least implicitly, by the important political parties in Scotland (the SNP is competing with a centre-left Labour Party and the Conservatives are less important). It is also supported by a medical profession and a public that, in practice, tends to be more committed to the NHS (in other words, opinion polls may not always show a stark difference in attitudes, but there is not the same fear in Scotland, as in the South-East of England, that doctors and patients might defect to the private sector if the NHS is not up to scratch). So, we might expect independence to maintain or accelerate these differences.

The second is public health. Scotland won the race to ban smoking in public places and is currently trying to introduce a minimum unit price for alcohol. It has also placed particular emphasis on the wider determinants of health and made the right noises about the balance between public health and acute care. Independence is less likely to have a major difference on tobacco control because the UK already tops the European league table on that score. However, it would help its alcohol control agenda, since key measures (raising the price of alcohol through taxation pricing and further limiting the advertising and promotion of alcohol) would be under greater Scottish Government control.

The third is mental health. To some extent, early Scottish Governments developed an international reputation for innovation in some areas relating to wellbeing. It also reformed mental health and capacity legislation in a relatively quick and smooth way – at least compared to the UK Labour Government, which had a major stand-off with virtually all mental health advocacy groups on psychiatric-based reforms. Part of the difference relates to the size of Scotland and its government’s responsibilities which can produce a distinctive policy style; it often has the ability to coordinate cross-cutting policy, in consultation with stakeholders, in a more personal way. However, this is a field in which there tend to be often-similar policies beyond the Sun-style headlines. Further, independence won’t give the Scottish Government many relevant powers that it doesn’t already enjoy.

These differences should be seen in the context of a shared history and some major similarities. Both NHS systems are primarily tax-funded and free at the point of use, with the exception of some charges in England (which should not be exaggerated – for example, 89% of prescriptions in England are tax-funded). Both governments have sought to assure the public in similar ways by, for example, maintaining high profile targets on waiting times. Both systems face similar organisational pressures, such as the balance between a public demand for local hospitals and medical demand for centralised services. Both governments face similar demographic changes which put pressure on services. Both have similarly healthy (or unhealthy) populations.

Much depends on the bigger picture, including the economic context, government funding and the new attitudes and relationships which develop when a government is responsible for the political system as a whole. As in many areas, health policy in Scotland seems relatively consensual, but new forms of government – and a much harsher economic reality – may open up new forms of conflict and cooperation.

The Psychology of Policymaking

We have long been interested in the psychology of policymaking, but there is a remarkable dearth of work which combines the two disciplinary approaches in a meaningful way. In psychology, a small number of people make big claims about how policymakers think and behave, based on small experiments in places such as their local canteen. In policymaking, we talk about bounded rationality, which is little more than a truism: people cannot consider all information, all possibilities, all solutions, or anticipate the consequences of their actions.

Studies based on bounded rationality have underpinned some important work, including punctuated equilibrium theory based on the study of how policymakers prioritise issues when they have to consider some and ignore almost all. It also highlights the important point that people make decisions in a small amount of time despite high uncertainty (based on limited information) and ambiguity (there are many ways to interpret and seek to solve a problem). Yet, for decades, we have not paid much attention to advances in psychological research, which has long since moved on from studies of bounded rationality.

So how might more recent research in psychology aid our understanding of policymaking? Let’s discuss two contenders – fluency and social intuition- considering the basic concept and how it might be used to inform, or help reinterpret, well-established policy theories. In each case, we have a choice to make – about using a new theory to replace established theories, or (my preference) to examine how this newer understanding helps us think about, and perhaps revise, more established theories of policymaking. The latter is my preference because the psychology of policymakers is only one small part of the explanation of outcomes in complex policy systems.

1. Fluency. As I understand it, the idea is that people’s decisions are influenced by their familiarity with things. For example, they will pay more attention to an issue if they already possess some knowledge of it (this is based on studies which show that people pay more attention to people when they already possess some information about them). Or, people will place more value on things they find familiar (based on studies in which people value their domestic currency more than a foreign currency; or value items that they own compared to items they would have to buy – i.e. they would hold out for more money to sell than they would be willing to pay). So, we have bounded rationality as a basic starting point, telling us that people will use short cuts to use and act on information, adding fluency to describe particular short cuts.

How might these ideas influence policy theories? Punctuated equilibrium theory provides a way to help explain why policymakers pay attention to some issues and not others. Fluency would provide a useful supplement to ‘focusing event’ explanations focused on the outside world. It would focus our analysis on why policymakers would pay attention to particular events (of which they are already familiar) at the expense of others. Similarly, when applied to multiple streams analysis, it could inform discussions of why policymakers might pay attention to some issues and ignore others, and have the motive and opportunity to adopt certain solutions at the expense of others. I’d need to think more about how it could be applied usefully to the advocacy coalition framework (ACF)which suggests that people engage in politics to translate their beliefs into action. We would need to think about the relationship between fluency and the three types of beliefs – core, policy core and secondary – and, for example, the idea that people will only pay attention to certain problems/ solutions according to their fundamental beliefs about how the world works and should work.

2. Social Intuitionism. Paul Lewis recently gave a paper on this topic at APSA 2013. The key starting point is that ‘in human decision making and moral judgment, the use of reason and rationality are subordinated to rapid, gut‐level, emotion‐laden cognition, and that people rely heavily on heuristics and narratives that often carry certain inherent biases’. Lewis argues that this is a challenge to/ replacement of the bounded rationality starting point, since we are replacing explanations based on reason/ goal orientation with a greater focus on the links between reason and emotion, particularly when ‘fast’ thinking is used more than ‘slow’.

How might these ideas influence policy theories? Lewis’ paper has an interesting account of policymakers having quick (and often changeable) gut/ emotional reactions to policy problems (and social groups) and solutions before they seek to frame them to justify action. This may inform aspects of punctuated equilibrium theory and multiple streams analysis (helping explain why people can shift between contradictory opinions/ problem frames so quickly) and the ACF’s focus on core beliefs, which can be enhanced with a focus on emotions, since ‘core’ are beliefs that people give up rarely (akin to religious beliefs).

In both cases, we may find interesting new avenues of inquiry but also recognise the need to ground them in what we know. Most importantly, a key focus of policy studies is the wider context in which decisions take place. The question of why policymakers frame problems is important, but only one piece of a bigger jigsaw which involves the socioeconomic context, the groups that policymakers consult regularly, and the system of rules in which they operate. Short term or emotional decisions made by a small number of policymakers may take place in an overall system where decisions are taken and implemented over the long term by many actors following long-established rules (although it may be interesting to (agent based) model that whole system and explore a shift in those rules). We should also consider the potential difference between the ‘thought processes’ of individuals and groups/ organisations. We are often talking about ‘rational’ processes in terms of the rules that organisations develop to provide cognitive and decision-making short cuts. Would these rules (or their interpretation) be as subject to these psychological explanations?

A final unresolved issue regards the extent to which theories in psychology are complementary or contradictory. Can we produce an overall assessment about psychology and apply it to policymaking, or do we consider different explanations? How do they relate to each other (for example, how does fluency relate to social intuitionism)? As yet, I don’t know.