POLICY AS NARRATIVE: NEW LABOUR’S REFORM OF THE NATIONAL HEALTH SERVICE
| Published date | 01 June 2006 |
| Date | 01 June 2006 |
| DOI | http://doi.org/10.1111/j.1467-9299.2006.00006.x |
| Author | KEVIN MORRELL |
Public Administration Vol. 84, No. 2, 2006 (367–385)
© Blackwell Publishing Ltd. 2006, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street,
Malden, MA 02148, USA.
POLICY AS NARRATIVE: NEW LABOUR ’ S
REFORM OF THE NATIONAL HEALTH SERVICE
KEVIN MORRELL
Beginning with a brief review of the governance literature, a defi nition of governance
in the National Health Service of England and Wales (NHS) is offered. This intro-
duces an analysis of NHS reform, as presented in the recent policy literature. Using
narrative theory, I critique this literature with reference to three key actors: the new
organizational form of the ‘ Foundation Trust ’ , NHS staff, and NHS patients. For each
actor, a motif is identifi ed and examined: ‘ freedom ’ for Foundation Trusts, ‘ clinical
governance ’ for staff, and ‘ choice ’ for patients. Each of these motifs is instrumental
in the narrative on NHS reform, whose main themes are emancipation, progress and
duty. These are common to other political projects. This critique makes the rhetoric
underpinning the recent policy literature more explicit, and underlines the created,
contingent nature of New Labour ’ s account of NHS reform.
INTRODUCTION
Since the phrase ‘ NHS reform ’ is almost a tautology, periodic evaluation of
policy in this context can make a specifi c contribution, in terms of under-
standing NHS governance (see, for example, Kitchener 1998; Harrison and
Wood 1999; Locock 2000 ). Analysis of the recent policy literature is perhaps
timely, given: the creation in the UK of new organizational forms, such as
Primary Care Trusts, and latterly Foundation Trusts; large increases in in-
vestment; the introduction of a new regime of payment by results; and an
agenda of patient choice (DH 2002, 2003a, 2004a, b, c, d). The pace of recent
healthcare reform has been described as both ‘ frenetic ’ and ‘ frantic ’ ( Greener
2004 ), but the Wanless Report (2004) argues that future demographic and
technological change, together with rising public expectations, mean that
‘ sustained action ’ is needed, otherwise, ‘ health care services will continue to
run faster and faster and stand still ’ ( Wanless 2004 , p. 4).
There is also scope for such an analysis to make a more wide ranging
contribution. The policy literature offers a rich opportunity to examine the
way in which reform is presented. Since the inception of the NHS in 1948,
there has been a fi rm and widespread commitment to it by the public
( Marnoch et al. 2000; Syrett 2003 ). This legacy means that ‘ NHS reforms are
a potential electoral liability ’ ( Sheaff and West 1997 , p. 189) and so analysing
the way in which NHS reform is presented can inform understanding of the
policy process.
Kevin Morrell is a Senior Research Fellow at Warwick Business School, The University of Warwick.
368 KEVIN MORRELL
© Blackwell Publishing Ltd. 2006 Public Administration Vol. 84, No. 2, 2006 (367–385)
I begin by developing an account of what governance means in the NHS
and this introduces discussion of recent policy. Using narrative theory, I ana-
lyse the recent policy literature with reference to three principal actors: the
new organizational form of the Foundation Trust; NHS staff; and NHS
patients. For each actor, a motif is identifi ed and examined: ‘ freedom ’ for
Foundation Trusts; ‘ clinical governance ’ for staff; and ‘ choice ’ for patients.
Together, these constitute instrumental motifs in the narrative on NHS
reform; the main themes of this reform are: emancipation; progress, or telos ;
and duty. These different elements constitute a reform narrative, a justifi ca-
tory framework that is contingent and created. They furnish New Labour ’ s
programme of reform with credibility and novelty, and these are features of
effective narrative ( Barry and Elmes 1997 ). The narrative is told in such a
way as to gloss over tensions and ambiguities implied by the likely outcomes
of such reform.
GOVERNANCE
Notwithstanding problems of defi nition ( Jessop 1998 ; Lynn et al. 2001; Bache
2003 ), the term governance remains popular. It is at the heart of contempo-
rary debates in many fi elds, including: business ethics ( Daily et al. 2003 );
development studies ( Leftwich 1994 ); economics ( Campbell et al. 1991 ); glo-
balization studies ( Kooiman 1993 ); international relations ( Smouts 1998 );
political science ( Pierre and Peters 2000 ); and public administration ( Rhodes
2000; Flinders 2004 ). More specifi cally, it is employed as an analytical con-
cept in particular areas of interest, for example, in corporate governance
( Sundaramurthy and Lewis 2003 ); in modelling the relations between boards,
chief executives and directors ( Farrell 2005 ); either in understanding the
implementation and adoption of public policy in general ( Gaudin 1998 ) or
in terms of the effectiveness of particular policies and reforms ( Newman
2001 ); in describing new forms of organization, two examples being net-
works ( Jones et al. 1997 ) and partnerships ( Pierre 1998 ); in describing new
forms of service delivery, such as ‘ co-production ’ , or ‘ co-management ’
( Gaudin 1998 p. 53); and, in the NHS, as ‘ clinical governance ’ ( Scally and
Donaldson 1998 ; McColl and Roland 2000 ) and ‘ research governance ’
( Clough 2002 ; DH 2001b).
A number of features of public sector work make it diffi cult to apply
stable defi nitions of governance, one such being: ‘ objectives and outcomes
of transactions are less transparent … power of direction and control is widely
dispersed … goals of actors are multifarious and often in confl ict ’ (Lynn et al.
2001, pp. 5 – 6). Differentiating between public and private sector organiza-
tions becomes harder if we acknowledge that private sector fi rms can sub-
scribe to a doctrine of social responsibility and democratic principles ( Jones
and Goldberg 1982 ). It is also argued that one consequence of changes in the
way society is governed mean that the distinction between the public and
private becomes blurred (Teisman and Klijn 2002). However, certain features
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