‘Policy’ is a vague term used in different ways to describe the direction of an organization, a decision to act on a particular problem, or a set of guiding principles directed towards specific goals (Titmuss 1974). The policy-making process has been defined as ‘still the only vehicle available to modern societies for the conscious, purposive solutions for their problems’ (Scharpf p. 349 cited in Hill and Hupe 2002, p. 59). The concept of policy therefore operates at different levels, describing both a specific input on a specific topic, and the values and ethos (the policy context) that inform specific goals and targets. The policy context includes values that are broadly consensual, such as democracy, and also values that are contested, such as managerialism versus professionalism. The policy context is therefore dynamic, charting public debates and the views of different lobbying and interest groups. Traditionally, public health policies are related to medical policies of disease surveillance and control. The programme of pre-school childhood immunizations and vaccinations and cervical and breast cancer screening programmes are examples of traditional public health policies. The broader concept of ‘healthy public policy’ has been defined by the World Health Organization (WHO 1988) as the creation of ‘a supportive environment to enable people to lead healthy lives’. This broader concept means that most policy areas are implicated in the goal of better health for all. This is a reflection of the many different and complex factors that influence health and illness. The consequences of this are discussed in Chapter 11 in our companion volume (Naidoo and Wills 2009). Policy areas that impact on health include education, employment, neighbourhood renewal and regeneration, environmental issues, for example clean air, transport, food security and quality, and housing. At the international level, policies on an equally broad range of topics have a profound impact on health.

The policy context and broad macro-economic, environmental and demographic changes are major drivers of public health and health promotion. Practitioners tend to see public policy as beyond their remit, but policy exerts a powerful influence on practice.

Practitioners have to meet specified targets or requirements which have been identified in policy documents, for example to reduce waiting times in hospitals, or the requirement on health trusts and boards to work in partnership with local authorities. In some cases, this may mean diverting resources from established and effective practices, or innovative but well thought out strategies, to meet the new targets or goals. In other cases, the direction of an organization may be changed because of a new priority. For example, Primary Care Trusts (PCTs) in England now have a duty to oversee public health.

As we outlined in our companion book Foundat-ions for Health Promotion (Naidoo and Wills 2009, Chapter 7), the development of health policy is an agreement on how health problems should be add-ressed, which involves a compromise between the following factors:

Policies are also informed by rational economic and evidence-based principles. For example, the Wanless (2002) Review on funding the NHS outlined three possible future scenarios. The third scenario, the ‘fully engaged’ model, posits services and a population which is informed and enthusiastic about protecting and promoting its health, and where research is productive in identifying effective communication and implementation of messages. Crucially, this fully engaged model is proposed within the Review as the most effective and lowest cost scenario in the long term. Within this scenario, public health investment is sound economic good sense, because better health leads to more productive employees and a stronger economy.

There have been calls for policy to be based on sound evidence about what works (Cm 4310 1999). However, there is a lack of evidence about effective public health and health promotion interventions (Macintyre et al 2001). For example, there is a solid research basis about the existence of inequalities in health, but very little research into comparing the effectiveness of different kinds of intervention aimed at tackling inequalities in health. A UK review of evidence-based health policy reported that only 4% of public health research focused on interventions, of which only 10%, or 0.4% of the total, focused on the outcomes of interventions (Milward et al 2001). In part, this is due to a traditional model of evidence based on individual cases and randomized controlled trials (see Chapter 3). This model is inappropriate for macro policies that are targeted at populations or communities. The evaluation of such policies is complicated because finding control populations that are not exposed to policy is difficult. Evidence-based policy is still in its infancy, due to competing influences and the lack of appropriate evidence.

As we have seen in earlier chapters, practitioners need a solid base on which to practise. The drive to evidence-based practice, quality standards and theory-driven interventions should make practitioners feel competent and secure. Yet many feel buffeted by policy initiatives and constant change. Policy takes place in a political arena, and many practitioners feel politics is removed from their core concerns. This may mean they do not engage with the political debates and feel policy makers are divorced from the reality of service delivery. People responsible for implementing policy may not be enthusiastic, and their frontline decisions may be crucial in dissipating the intended effect of policy. Conversely, enthusiastic and committed practitioners who feel they have had a valued input into policy formation can play a key role in achieving the intended outcomes of policies. To have a voice and be able to impact on policy making and implementation, practitioners need to be familiar with, and able to understand, health policy – its origins, its goals, the process, and its effects, both intended and unintended.

Policy making has been defined as ‘the process by which governments translate their political vision into programmes and actions to deliver “outcomes” – desired changes in the real world’ (Cabinet Office 1999). National governments set the fundamental policy direction, while locally, policies develop incrementally. Walt (1994) identifies four phases in policy making that may occur at any level, whether national or local, and also shape any policy analysis:

There is an assumption that policy is the result of rational decision making in which choices are evaluated and a solution is chosen to achieve objectives. Yet this rational process rarely takes place. As Simon (1958) argued, real world decision makers are not ‘maximizers’ who select the best possible course of action but ‘satisfiers’ who look for the course of action that is good enough for the problem at hand. Sutton (1999) also refers to other models of policy making:

Another way of theorizing the policy-making process is to distinguish between ‘top down’ and ‘bottom up’ models. Top-down theories propose a linear policy process whereby commands from higher up are seamlessly translated into practice on the ground (Buse et al 2005). Bottom-up theories recognize that practitioners are constantly modifying and creating policy on the ground, and that the policy process is collaborative and iterative rather than linear (Walker and Gilson 2004).

Dunsire (1978) first coined the phrase ‘implementation gap’ to describe the gap between planned policy and real life outcomes. The implementation gap is another way of describing the power of street level bureaucrats, and lends support to bottom up theories of the policy-making process.

None of these models describes the policy-making process accurately, although each model refers to elements of the process. Policy making mixes the scientific and the pragmatic; the broad vision with the narrow. The degree to which each element contributes to policy making differs according to the general political environment and the specifics of the policy under consideration.