Chapter 16. Influencing and implementing policy
Chapter Contents
Making and influencing local and national health policy224
Implementing national health policies at local level224
Challenging policy226
Developing and implementing policies228
Campaigning232
Summary
The focus of this chapter is on how health policy at local and national level is made, how it can be influenced and how health promoters can challenge health damaging policies. The characteristics of power and the politics of influence are discussed and illustrated with a case study. There are sections on developing and implementing policies, a case study on the politics of influence and an exercise on policy implementation. The chapter ends with a section on planning a policy campaign.
See Chapter 7, section on linking your work into broader health promotion plans and strategies, for information on national and local public health strategies and plans.
Health promoters have an important role in influencing and implementing policies that affect health. A policy is a broad statement of the principles of how to proceed in relation to a specific issue and can be at a number of levels, from international (see Duncan 2002 for a debate on the way EU health policy impacts on UK policy), to national, regional and organisational level.
In order to influence policy you need to understand how power is distributed and exercised between people at various levels and be able to use that knowledge to further your work and shape policy decisions. In other words, you need to be political.
Another relevant and important aspect of policy is managing change, discussed in Chapter 8.
Being a policy activist involves working with statutory, voluntary and commercial organisations to influence the development of health promoting policies. It also includes working for healthy public policies (see Scriven 2007 for a detailed overview of healthy public policies) and economic and regulatory changes that might require campaigning, lobbying and taking political action.
Making and Influencing Local and National Health Policy
Working for policy change is an integral part of health promotion action, with health promoters able to press for the introduction of policies at both national and local levels and influence how they are implemented. The development of local health policies cannot be divorced from the central government’s policies that shape the organisation and funding of health service, local authority and voluntary agency work at a local level. National policy is in turn influenced by consultation with and representations from health services, local authorities and voluntary agencies.
Other bodies such as national health promotion agencies and public health organisations such as the Royal Society for Public Health (http://www.rsph.org.uk) are also highly influential in the field of policy development. For an example of a national agency contribution to policy, see the report of the 20-year legacy of the Health Promotion Agency (HPA) of Northern Ireland (HPA 2009).
Local Health Policy
At a local level, during the last decade healthy public policies and priorities have increasingly been jointly agreed by health, local authority and voluntary agencies. This has been made easier through national policy initiatives such as the implementation of local strategic partnerships (LSPs), where health and partner agencies are required to deliver joint plans for health and wellbeing. This means that policies have to be agreed by local authorities, primary care trusts (PCTs) and other relevant community organisations.
The structure of the NHS, including PCTs and strategic health authorities, is outlined in Chapter 4; see Figure 4.2.
Some health organisations and local authorities undertake health impact assessments (HIAs) or environmental impact assessments of their services and related policies. The Association of Health Observatories Health Impact Assessment gateway has many examples of HIAs at http://www.apho.org.uk (see, for example, Health Inequality Impact Assessment into the Leicester LIFT project). HIA involves examining the impact on health and/or the environment of all current and planned policies and activities. The purpose is to develop practical ways in which current health and environmental impact of services could be improved and to inform the development of a corporate approach to new health and environmental policies.
See Chapter 7, section on health impact assessment.
Health Policy in the Nhs
The task of commissioning health services and programmes was undertaken by health authorities until 2002, when it passed to PCTs. Commissioning health services means deciding what health services, policies and programmes are needed to improve the health status of the local population and ensuring that they are provided.
PCTs provide opportunities for the public to comment on health service plans. There are representatives of the public on PCT management boards (usually called lay representatives) and PCTs generally consult the public on any significant proposals for policy change. Individuals, groups, professional associations and others are able to express their views on, for example, the balance of money spent on treatment and care compared with health promotion and disease prevention. Some PCT board members have responsibility for ensuring that the PCT properly addresses specific policy areas such as inequalities in health.
Implementing National Health Policies at Local Level
National strategies for health are outlined in detail in Chapter 7 and referred to in Chapters 1 and 4.
National strategies for health have been in place since the early 1990s with targets that set specific health outcomes. PCTs and partner agencies from the public, private and voluntary sectors translate these national targets into local ones, and may add other local targets. These targets, and the priorities and objectives they are derived from, are an important influence on policies and on health promotion programmes and activities.
For example, the National Service Framework for Coronary Heart Disease (Department of Health (DoH) 2000a), a policy document setting out the standards for services about prevention and treatment, has national targets for reduced death rates and changes in risk behaviour, such as smoking. These targets are translated into local targets that include health promotion programmes on smoking prevention, such as providing smoking cessation help as part of maternity services. In this way, national policies and strategies influence directly local interventions. For an assessment of the impact and progress toward implementing the Coronary Heart Disease National Service Framework in the 8 years since its publication, see DoH 2008.
See also Chapter 7, section on local health strategies and initiatives, for more on local plans and strategies.
Local Authority Contribution to Health Policy
The local authority contribution to health policy is made at a strategic level through LSPs and the development of local area agreements (LAA). LAAs simplify some central funding, help join up public services more effectively and allow greater flexibility to develop policies to meet local health needs (for further details on LAAs, see http://www.communities.gov.uk).
LSPs bring together people from the public, private and voluntary sectors. They aim to avoid duplication and to rationalise partnerships and plans to make it easier to deliver policies around health improvement, education and crime. The Neighbourhood Renewal Strategy (Social Exclusion Unit 2001) is a catalyst for these partnerships and plans and has a direct impact on health gain (see Leathard 2003, for a critical overview of the link between NHS LSP and community strategies).
See also Chapter 7, section on local health strategies and initiatives, for more about local plans and strategies.
Another important way in which health services and local authorities can work together at local level is through cooperating in implementing international agreements such as the UN Agenda 21 and Millennium Development Goals (http://www.un.org). These are agreements forged by governments at international levels, which focus on ways of achieving sustainable development in relation to the environment and the wider determinants of health.
Local authorities have to work with a broad range of agencies and consult their communities about developments in relation to implementing international polices at a local level. Health promoters, in both their working role and their role as private citizens, can play their part.
The Voice of the Consumer in the Nhs
In The NHS Plan (DoH 2000b) the government made a clear commitment to being responsive to the needs of all citizens by allowing their voices to be heard in relation to health-related public policies, planning and provision of services.
A number of steps have been taken to enable consumers to express their views. One example of this is the NHS Constitution for England (DoH 2009) which makes important pledges in relation to how people access NHS services, what commitment people can expect from the NHS and what their rights and responsibilities are in terms of influencing policy and service provision. A patient advice and liaison service (PALS) (http://www.pals.nhs.uk) was set up in every NHS trust for patients to get their concerns addressed. Other measures introduced to ensure that citizens and patients have more influence at all levels of the NHS include:
• Increased lay representation, such as on the National Leadership Network for Health and Social Care (http://www.nationalleadershipnetwork.org) and the Care Quality Commission (http://www.cqc.org.uk). See Voices into Action (Care Quality Commission 2009) for details of how lay voices are heard.
• A new Citizens’ Council, to advise the National Institute for Health and Clinical Excellence (NICE). The Citizens Council brings the views of the public to NICE decision making about guidance on the promotion of good health and the prevention and treatment of illhealth. A group of people drawn from all walks of life, the Citizens Council tackles challenging questions about values, such as fairness and need (http://www.nice.org.uk).
While the means for lay involvement are in place, a recent review by the government select committee on health (House of Commons Health Committee 2009a, b) suggests that there is a risk the NHS may still not be engaging the public in a meaningful way.
Challenging Policy
As a heath promoter you may find you are expected to implement policies that you perceive as health damaging or contrary to health promotion principles. This can be difficult because such policies can emanate from national government or your employing organisation or even your direct manager. To challenge may create a conflict of loyalty between wanting to press for what you see as right and what is decreed to be right by your employing authority. To protest may be seen as too political. There is no easy answer to this issue, but there are some positive steps worth considering.
• Use your vote. At the next general or local election, look at the health implications in the policy manifestos. Raise questions about health policy with doorstep canvassers, at public meetings and by writing to candidates. All this can be done in your capacity as a private citizen rather than a health worker.
• Use your professional association or trade union. These groups can raise issues at a national and local level, and can be a powerful voice. You can play your part by joining and supporting their activities, and raising the issues you feel strongly about.
• Use your representative. There are many people whose job is to represent your interests. At European Union or national level, it is your Member of the European Parliament (MEP) or your MP. So if you want to raise an issue at these levels, lobby your MEP or MP: send letters, telephone, attend politicians’ surgeries. At local level, do the same with your local councillor. You could also contact your professional association or union local branch representative.
• Use your collective power. If you are concerned about an issue at your place of work, it may help to find out if colleagues feel the same. If they do, join together so that you raise the issue collectively: this can give it more impact. Or at a national level, join with others who share your concern to improve health and challenge health damaging policies. For example, members of the UK Public Health Association (UKPHA) aim to widen the focus of health policy in the UK towards creating a healthy environment, reducing inequalities and improving quality of life.
However, many areas of policy development are not controversial, and can be a positive and rewarding part of the day-to-day work of health promoters. The main thrust is likely to be in developing, changing and implementing local policies. To do this you need to understand the characteristics of power and influence and be competent at exerting influence when necessary.
Characteristics of Power and Influence
Power is the ability to influence others. There are four generally recognised types of power that are relevant to health promotion work:
1. Position power is the power vested in someone because of their position in an organisation. For example, a Director of Public Health has position power.
2. Resource power is the power to allocate, or limit, resources, including money and staff. It often goes hand-in-hand with position power. For example, a senior health service manager has both position power and the power to regulate the use of resources. You have a source of power if you have the authority to control the allocation of any resources. Every health promoter will have some power because people want the skills or services on offer.
3. Expert power is power related to expertise. Directors of Public Health have the expert power associated with their specialty.
4. Personal power is the power that comes from the personal attributes of a person, including strong personality, charisma and ability to inspire. It is closely related to leadership qualities and intelligence, initiative, self-confidence and the ability to rise above a situation and see it in perspective. However, effective leaders are not always charismatic, and what makes a leader effective in one situation may cause them to be less effective in changed circumstances. The classic example of this is Sir Winston Churchill. The attributes that made him effective in wartime were not so appropriate in peacetime.
You may sometimes be in the position of wanting or needing to exert influence on people who have a stronger power base. For example, a health visitor may wish to influence a general practitioner to adopt a policy of supporting the running of antenatal clinics in the local ethnic minority group’s community centre, or a community worker may want to lobby local councillors about the need for more recreational facilities for young people on a housing estate. To do this requires skills in influencing and negotiation (see Cialdini 2007 and 2008 for overviews on the science and practice of influence and the power of persuasion).
Before attempting to influence someone who has position or resource power, first consider the basic questions in the planning process, such as: What are your aims? What resources do you need? Is the investment of your time in influencing others going to be worth it? Could the aim be achieved more easily another way?
See Chapter 5, Planning and evaluating health promotion.
The Politics of Influence
There are four key elements of a strategy aiming to change policy:
1. planning
2. making allies
3. networking
4. making deals and negotiating.
Planning
Three particular aspects of planning are useful to consider: undertaking a force field analysis, identifying stakeholders and considering your timing.
Undertake a force field analysis
A force field analysis identifies the helping and hindering forces and helps to pinpoint how you can influence the process to make progress towards change. You identify how you can increase the power of the helping forces and decrease the power of the hindering forces.
There is an example of a force field analysis at the end of Chapter 4, Exercise 4.2.
Identify the stakeholders
The stakeholders are those people with a vested interest in the issue, who wish to influence what is done and how it is done. They are obviously powerful forces in the situation. It could be difficult to identify all the stakeholders, because some of them may not wish to be visible and try to work covertly through others.
Time your action
It is also important to consider when to introduce a proposal or when to delay. If people are already preoccupied with other major issues, it might not be the right time to make a new proposal. On the other hand, if a proposal will help other people to attain their own objectives, it will be a good time.
Making allies
Identify which of the stakeholders could be allies, and gain their trust and confidence in order to establish and maintain an alliance. It helps to pay attention to their concerns, values, beliefs and behaviour patterns, and to see what you need to do in order to form an effective working alliance.
For example, if you are concerned about the way in which people with disabilities are treated in an organisation, you might identify the person in charge of human resources as a key stakeholder. So find out if they are concerned about it and if they think it is important for the organisation. What kind of way do they work, are they likely to respond best to a lively discussion on the subject or to a well argued paper on the need for policy, backed up with facts and figures? Do they like time to make decisions? Will they be happy to leave you to take the lead, or will they want ownership of the initiative?
Networking
Many people working in organisations belong to one or more interest groups who meet to discuss, debate and exchange information on issues that concern the members. By playing an active role in these networks, people can extend their influence. Networks provide access to information that can help with making a case, to people with experience of successful influencing, and to other resources. There are different types of networks:
Professional networks
Members are from the same profession. Professional networks may attempt to influence employers and organisations to reconsider their policies or to develop new policies for the future. Professional networks institute criteria for professional practice and are active in the professional development of their members.
Elitist networks
Members of an elitist group can join by invitation only. The network operates by personal contact and personal introduction. Members of such networks may have considerable power and influence, often through their position in organisations.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
