History and policy a typology of approaches and its uses2


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History and policy a typology of approaches and its uses2

  1. 1. This paper is part of the proceedings of the 2ndAnnual conference on Qualitative Research for Policy Making, 26 & 27 May 2011, BelfastHistory and PolicyA Typology of Approaches and Its UsesEllen van Reuler1Centre for the History of Science, Technology and MedicineThe University of ManchesterUnited Kingdom AbstractThe relevance of historical studies for policy is a topic that has become increasinglydebated over the past few years. In this paper, I develop a typology of modes of policyrelevant history that helps us classify and apply historical scholarship in the policyenvironment. This typology is based on distinctions along two dimensions. The first dimension isthe concept of history applied, because history can be ‘the past’ or a method to studydevelopments over time. The second dimension is the primary aim of the study, whichcan be either problem-oriented or understanding-oriented. These two dimensions arecombined into a typology of four modes of history for policy. Central to this model is thateach of the four modes requires specific ‘translational devices’ if we want to transfer theresults of the historical analyses to the policy process. Several elements of this typologyare illustrated drawing from my research on the contemporary history of cancer care andpalliative care in England and the Netherlands. 1. IntroductionWhy should the policy community pay attention to history? The following two quotesprovide suggestions. The first is from a noted historian of medicine, the second from aphysician who was the English Chief Medical Officer from 1998 to 2010.Policy is always history. Events in the past define the possible and the desirable, settasks, and define rewards, viable choices, and thus the range of possible outcomes. As wemove through time those choices reconfigure themselves and trends may establish1 I would like to thank John Pickstone from the Centre for the History of Science, Technology and Medicine in Manchester for the stimulating discussions that shaped the typology presented in this paper. The research reported in this paper is funded by a Wellcome Trust Doctoral Studentship.
  2. 2. themselves - but at any given point the ‘actionable’ options are highly structured. It is thehistorian’s disciplinary task to define those likelihoods. Most important, what history canand should contribute to the world of policy and politics is its fundamental sense ofcontext and complexity, of the determined and the negotiated. Rosenberg (2006, p.28)I never ever heard a discussion during my twelve years in post - although I tried manytimes to raise it - where people would sit down and say: Now, have we ever doneanything like this before? What tools did we use? What worked well? What didn’t workwell and how are we going to take that learning into the change programme that we arenow going to introduce?’ People reached for the tools almost absent-mindedly. Say,we’ve got to have a few regional road shows, we’ve got to do some legislation, we’ve gotto do this, we’ve got to do that, but not thinking fundamentally about change the way thatI believe is done in many of the most innovative organisations in other sectors.Donaldson (2011, 37:43 - 38:30).Rosenberg and Donaldson both maintain that history can be useful for policy, but theirconcepts of history and their aims for the use of history differ. These differences and theirconsequences for the transfer of insights from historical studies to policy making arediscussed in this paper.2 2. Literature reviewAlthough not a main focus in social sciences, history-conscious approaches are certainlynot unknown. But most of the effort relates history to fields like sociology andanthropology, rather than to ‘applied’ social sciences such as policy studies (for example,Hodgson, 2001; Mahoney & Rueschemeyer, 2003; McDonald, 1996; Monkkonen, 1994).Nevertheless, the case for the use of historical evidence to inform policy making has beenmade convincingly (Berridge, 2008; The British Academy, 2008). Examples ofarguments for the value of historical perspectives for policy are:1. Long-term perspective allows for a sense of chronology and the identification of continuity as well as change;2. Diachronic attitude supports the identification of slowly developing and temporally distant causes of current problems;3. Historical analyses allow for combinations of various types of source material, levels of interpretation, and theoretical perspectives;4. Contextualisation of issues under investigation provides insight into a wide range of influences lying behind the immediate issue (See Berridge & Strong, 1991; Berridge, 1994, 2000, 2001, 2008, 2010; Hacker, 2005; Pollitt, 2008; Stevens, Rosenberg & Burns, 2006; Tilly, 2006; Zelizer, 2000).2 An important distinction can be made between policy history and histories that are of use for policy. On the one hand, accounts of the first type describe and analyse, for instance, the decisions that led to a particular policy document or governmental intervention. This does not imply that that these histories are always relevant for current policy. On the other hand, policy relevant histories need not be concerned with policy as such, but provide insights of use to policy makers. This paper deals with these policy relevant histories.
  3. 3. At a time in which publications in public policy ‘remain present and future oriented,and history-lite’, historical studies emphasise aspects that differ from mainstream policyanalyses (Pollitt, 2008, p.13; also Raadschelders, 1998; Zelizer, 2000).. Given the development of the British History & Policy website from 2002 onwardsand the publication of books and articles, such as, Pierson (2004; 2005), Pollitt (2008),Stevens et al. (2006), and Zelizer (2005), it might seem that the value of history forpolicy is an issue that has emerged only recently.3 However, concepts like dynamics ofpolicy and inheritance in policy appeared in earlier studies (Rose, 1976; Rose & Davies,1994). Worth mentioning are also the books on the uses of history by decision makersand social history and social policy by May (1973), Neustadt & May (1986), andRothman & Wheeler (1981). Some of these authors, most notably Rothman and Wheeler, mention that thetranslation of historical studies for policy audiences is a complex endeavour. Insight intothe different modes of history for policy and the strategies that can be used to maximisetheir potential to inform policy is crucial, but this is an issue hardly addressed in theliterature. 3. Research MethodThe primary aim of this paper is to present a simple typology of forms of historicalanalysis which are useful for policy and the strategies for translation of these analyses toa useful input for policy making. In subsection 4.1, I sketch the typology, while thesubsequent subsection discusses the relationship between the modes of history and policyissues. Subsection 4.3 contains a note on the presentation of the outcomes of historicalstudies for policy. I give some examples to illustrate the typology and the ‘translationaldevices’ that can be used to transfer the results of the historical analysis to the policyprocess in subsections 4.4 and 4.5. These examples are based on my ongoing research onthe histories of palliative care4 and cancer care in England and the Netherlands during the3 See http://www.historyandpolicy.org.4 Notions of palliative care have changed over time and several closely related terms, such as hospice care, palliative medicine and terminal care, are in use. The term currently dominating English governmental policy is end of life care (see Department of Health, 2008). A well-known definition of palliative care is provided by the World Health Organisation: ‘Palliative care improves the quality of life of patients and families who face life-threatening illness, by providing pain and symptom relief, spiritual and psychosocial support from diagnosis to the end of life and bereavement. Palliative care: - provides relief from pain and other distressing symptoms; - affirms life and regards dying as a normal process; - intends neither to hasten or postpone death; - integrates the psychological and spiritual aspects of patient care; - offers a support system to help patients live as actively as possible until death; - offers a support system to help the family cope during the patients illness and in their own bereavement; - uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated; - will enhance quality of life, and may also positively influence the course of illness;
  4. 4. post war era. These histories are grounded in a variety of primary and secondary writtensources, such as policy reports and parliamentary proceedings, as well as (oral history)interviews.5 4. Discussion4.1 A typology of modes of policy relevant historyThe quotes in the introduction stress the importance of history for policy, but they presentdissimilar modes of history. It is helpful to conceptualise these differences bydistinguishing the approaches on two dimensions:A. The concept of history applied: a. History as ‘the past’; b. History as a method to study the social world and its development over time.B. The focus of the study: a. Problem-oriented studies, which start with a particular problem in mind and aim to contribute to a solution for this issue; b. Understanding-oriented studies, which increase our comprehension of policy and its contexts.Illustration 1 shows the typology of modes of history for policy that emerges if wecombine the two dimensions discussed in the previous paragraph. In this typology,investigations following Donaldson’s suggestions would result in a mode 1 analysis,while Rosenberg’s ideas match with mode 4 histories for policy. - is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications’ (World Health Organisation, 2006).5 For reasons of readability, I decided to exclude references from these examples to avoid densely referenced accounts. Further references are available from the author upon request. For a discussion of the debates about the regional concentration of cancer care, see also Van Reuler (2008). For a brief analysis of the position of hospices in the health care system in England and the Netherlands, see Van Reuler (2010).
  5. 5. Illustration 1 - Typology of history for policy modesAs shown in Illustration 1, each of the modes of history for policy is characterised by aspecific set of questions. Histories of the ‘problem-oriented - past type’ (mode 1), forinstance, show whether a similar problem occurred before and how it was dealt with atthat time. This knowledge informs current decision making, because the strategies thatwere successful can be repeated and past failures give an indication of avoidable coursesof action. Mode two histories focus on the position of the problem under investigation intime. Questions are asked about the emergence of the issue, distant causes and causesthat developed slowly over time. Also issues of path dependency play a role in mode 2analyses. In mode 3 histories, history is conceptualised as past, while the focus of the studyis understanding-oriented. The inclusion of multiple cases allows us to compare thecontent and the context of the instances. Moreover, the similarities and differences of thecauses of the problem are researched. This analysis helps us to understand how similarthe current problem is to past situations. Another possible outcome is that we canidentify which of the previous instances shows most resemblance to the current issue. Mode 4 histories, which are understanding-oriented and apply historical thinkingas a method, analyse additional issues. In these studies, a problem is seen as a dynamicconstruct with causes that developed over time according to various trajectories.Moreover, the relation to earlier instances of comparable issues and the changes thatoccurred are relevant. These histories may also show to what extent past developmentswere actually shaped by policy and which other forces were of influence.
  6. 6. Illustration 1 also shows possible moves from mode 1 studies to more complexmodes of policy relevant history. If we want to progress vertically from problem-orientedto understanding-oriented studies, we multiply the number of cases analysed and wecontextualise them. By contrast, the horizontal move from history as past to history asmethod entails a temporalisation of the phenomenon under investigation. In other words,we move from a static view of the subject to a dynamic conceptualisation of the issue andits causes. The arrows in Illustration 1 do not imply that every history for policy study has tostart with a mode 1 analysis and add layers of complexity to move to mode 4. It ispossible to develop a mode 2, 3 or 4 historical analysis immediately. Moving from mode1 or mode 2 to mode 4 has the benefit that the problem around which the questions inmode 1 and 2 studies are centred remains present in understanding-oriented modes ofhistory for policy. This implies that a link to a current policy debate will exist. Bycontrast, many historians start their studies for other reasons than its direct policyrelevance and will carry out a mode 4 analysis. Nevertheless, these analyses may holdlessons that can inform current or future policy making. The moves from the four modesof history to policy are elaborated on in the following subsection.4.2 Translational devicesThe intellectual projects of historians and policy makers do not align naturally. Policymakers focus on knowledge to inform actions, whereas historians develop their analysesmainly as knowledge for understanding. Therefore, we need strategies, which I call‘translational devices’, to ensure that the insights from policy relevant histories areframed in a way that enables their transfer to the policy process. Illustration 2 shows the same typology as Illustration 1, but now the policy issuefor which the histories are relevant is placed in the centre. We can see that the policyissue is closer related to the problem-oriented modes of history than to the understanding-oriented modes. Each of the four modes of history for policy sketched in the previoussubsection has its own specificities. Consequentially, the transfer from insights from eachof the modes of history to inform policy has its own characteristics. These relationshipsare indicated with the arrows A to D in Illustration 2. I sketch the ‘translational devices’that can help us to maximise the potential of each of the modes of history to informpolicy in the following paragraphs.
  7. 7. Illustration 2 - The modes of policy relevant history and their relation to policy issuesMode 1 histories are closely linked to Donaldson’s suggestion to consider whether we didsomething comparable in the past and to what extent the outcomes were favourablebefore opting for a policy tool. The reasoning strategy behind the identification of these‘good guides from the past’ for current practice is based on the analogy. The answers tothe questions for this mode of history for policy often result in clear suggestions forpolicy makers (See Rose, 2005, p.42-47 for a discussion of learning policy lessons fromanalogies). In mode 2 history for policy analyses we place an issue in the flow of time and thencome back to the specific issue. Which insights for the policy process can we gain fromthis work? Examples are an understanding of sequences of developments, insight in theduration of episodes, identification of temporally distant causes and influencesdeveloping gradually over time, and knowledge of differences in the pace of variousdevelopments. Some of these outcomes of mode 2 histories for policy analyses, transferto policy relatively easily. Temporally distant causes, for instance, can be treatedsimilarly to causes that developed recently in the sense that policy makers can try todevelop strategies to deal with them to reduce the problem. An understanding of thesequence of developments provides insight into cause and effect relationships beyond thelevel of statistical correlation. Duration and pace of developments are particularly
  8. 8. relevant for policy makers to develop a feeling for the time scale that might be needed toimplement a solution to the problem. Arrow C represents the move from mode 3 histories to policy. As mentionedbefore, the lessons from understanding-oriented histories for policy are harder todetermine. In this case, we have to make an adaptation for the differences in context ofthe instances studied. A possible outcome can be that we can say that the contexts of twosituations are relatively comparable, while differences with the third and the fourth caseare substantial. In drawing lessons from mode 3 histories for a policy issue, it isimportant to assess the consequences - either favourable or unfavourable - of differencesin context. However, significant contextual differences need not imply that the pastinstance has nothing to offer to the current policy issue. Even if the context differs, a pastinstance may, for example, help policy makers to generate alternative solutions. Mode 4 histories have to be adapted for time as well as context if the outcomes areto feed into policy (Arrow D in Illustration 2). Since these two operations enabled themove from mode 2 and 3 histories to policy, most ideas presented in the previousparagraphs can be of use to mode 4 histories. However, the combination of characteristicsin mode 4 histories lends itself to three further uses in a policy context.- Reasoning about continuity and change in contexts: This translational device combines an analogy with a force field analysis (see Lewin, 1951; Daft, 2003). The application of this ‘extended analogy’ means that you search for historical antecedents of current problem. For each of the instances, you plot the major factors stimulating and restraining change in a force field diagram. A comparison of these force fields provides an indication of the feasibility of the implementation of a proposal and will hold clues about the main barriers for change.- Policy evaluation: Mode 4 histories are particularly suitable for the evaluation of policies with a focus on context, long time spans, and unintended consequences. The average evaluation of policy interventions by mainstream policy analysts takes place within a few years after implementation. Consequentially, long-term influences cannot be taken into account. Another strength of history is contextualisation. For long-term policy evaluation this means that external factors that interfered with the implementation of the policy and the outcomes that were achieved can be identified.- Search light: Offering mode 4 histories to policy makers can help them to incorporate a feeling for developments over time and context in their future problem solving. In addition to the Arrows A to D, Illustration 2 also includes four dotted arrows.They indicate that relatively complex histories can be reduced to simpler, policy relevanthistories by stripping away layers of complexity. Is it worth the effort to develop complexmodes of history if we might want to reduce them to simpler forms to increase theirpotential to inform policy making? My answer would be affirmative. Mode 1 studies, forexample, can be enriched if a mode 3 study is carried out, because this allows you toselect not just a case in the past, but the ‘best case’ - i.e. the case with the most similarcontext.
  9. 9. 4.3 A note on presentationIn addition to the dissimilarities of the intellectual projects of policy makers andhistorians, the standards for presenting research differ as well. Historians generally preferdetailed narratives, whereas policy makers favour a list with recommendations for action.Therefore, historians who want to present their work to the policy community, shouldthink carefully about the language and format they use. The further one moves away frommode 1 histories, the more pressing this issue becomes. Historians might not want to position themselves as advisors who advocate a certainaction. In that case, the transfer of mode 2, 3 and 4 histories to policy making can besupported by reducing the histories to a summary of the main changes, stabilities, causes,trajectories and contextual influences. An overview of these issues is likely to be a moreusable input for policy than a (long) historical narrative. Not only the presentation of the research results, but also the way in which they areframed matters. For mode 2, 3 and 4 studies, it can be useful to frame the histories inconcepts and theories policy makers are familiar with. This approach helps to make theoutcomes of historical studies more accessible to policy makers. Moreover, these models,such as Kingdon’s model of policy streams, can help historians to articulate clearerwhether actual practice converged on or diverged from what policy makers would haveexpected on the basis of these models (Kingdon, 1984).64.4 Example 1: The regional organisation of Dutch cancer careIn this subsection, I illustrate the typology using the case of the current debates on theregional organisation of cancer care in the Netherlands. I will first give an overview ofthe current Dutch health care system to provide the context for this debate. Since theexample in subsection 4.5 relates to developments in English health care, I now describethe two health care systems briefly from a comparative perspective. Four main areas of differences between the English and the Dutch health caresystem can be identified.1. Funding arrangements. The English National Health Service (NHS) is funded by the government from tax revenues. In the Netherlands, however, inhabitants are obliged to insure themselves against health care costs.2. Ownership. Whereas the British state is - in the end - responsible for NHS premises, the Dutch health care infrastructure is owned privately. Most health care providers in the Netherlands operate on a not-for-profit basis.3. Governmental influence. In comparison to the situation in the Netherlands, the influence of the British government on the NHS is relatively direct and far-reaching.4. Reform and stability. Many observers perceive the English NHS to be in a continuous flux since the reforms of the early 1990s. The Dutch health care system is comparatively stable and changes are implemented more gradually (for example, Boot & Knapen, 2005; Ham, 2004; Rivett, 1997; Schäfer, Kroneman, Boerma, van6 In this way, histories for policy can not only influence policy making, but they might also have an impact on the academic study of policy.
  10. 10. den Berg, Westert, Devillé & van Ginneken, 2010; Schrijvers & Droyan Kodner, 1997).One of the workshops during the concluding conference of the Dutch National CancerControl Programme (NCCP)7 in November 2010 focussed on the regional coordination ofoncological care. The attendees agreed that the implementation of a structure in whichspecific cancer treatments are concentrated in a limited number of hospitals would bedesirable for reasons related to the quality and efficiency of care. A typical mode 1 history for policy question would be whether a regional structurefor cancer care was implemented in the Dutch health care system before. The shortanswer is that this has not been the case. A somewhat longer response is that thegovernmental planning of centres for radiotherapy on the basis of the law on specialisedmedical interventions (WBMV)8 from the 1980s onwards was an earlier instance of thecentralisation of cancer care. The implementation of this law was successful from theperspective of the central government. If we apply an analogy without giving thesituation much further thought, we could say that the introduction of a law on the regionalorganisation of cancer care would be an option. However, the inclusion of radiotherapy inthe WBMV is a topic on the political agenda, because the government wants to increasecompetition in the health care system and the central control of the availability of medicalequipment does not fit this context. The general trend in health care policy is towarddelegation of power from the government to health insurers. Therefore, legal codificationof the regional concentration of cancer care is unlikely to be a feasible option. Thesereasons show that a simple analogy is not always the best lesson history has to offer topolicy. The following paragraphs illustrate what mode 2, 3 and 4 histories might add. A mode 2 history for policy analysis would stress how the current problemdeveloped over time. Among the drivers for the recent emergence of the debate on thecentralisation of cancer care are the increased availability of data on hospital performanceand the fact that the breast cancer patients association in cooperation with the consumersassociation published a ranking of the best hospitals for breast surgery in 2005. Inaddition, insurers obtained the power to contract with hospitals on the basis of quality andprice for a governmentally defined segment of medical treatments during the recenthealth reforms. The first publicly known instance in which a health insurer used thispower to influence the place of treatment of their customers occurred in October 2010.More indirect causes for the debate on the regional structure of cancer care that ahistorian would identify are, for instance, the increasing complexity of cancer treatmentsand the availability of international, comparative statistics on cancer survival rates. A limited form of a mode 3 historical analysis took place when one of the attendeesof the NCCP conference mentioned that the regional organisation of cancer care had beendiscussed during the mid 1990s and 2000s. Her fairly short conclusion was that ‘the timewas not yet ripe for it’ in those days, but that the proverb ‘three times lucky’ would holdthis time. A historian could contextualise these developments further as part as a mode 3analysis. In that case, we would come across influences like changes in the health caresystem and treatments available for cancer. A likely conclusion of a comparison of the7 In Dutch this programme is known as the ´Nationaal Programma Kanker (NPK 2005-2010)´.8 In Dutch: ´Wet Bijzondere Medische Verrichtingen´.
  11. 11. three instances of attempts to concentrate oncological care would be that the context ofthis issue had indeed changed substantially. To a historian, however, the implications ofthis finding for the feasibility of the introduction of concentrated cancer care would notbe as obvious as for the workshop participant. As became clear from the discussion of history for policy in Subsection 4.1, mode4 analyses are the most complex form of the four. This means that a mode 4 historicalanalysis of the regional structure of cancer care would incorporate most of the issueselaborated on for the modes 1, 2 and 3. On top of that, attention would be paid to thetrajectories followed by the variables influencing the concentration of oncological care.The dynamic context of the three attempts to organise Dutch cancer care at a regionallevel would also be studied. These investigations indicate, among others, that theimplementation of the first advisory report that suggested to centralise cancer care washampered by the interests of hospitals and medical specialists who were afraid to loosepart of their work.9 Moreover, this analysis would include the fact that the centralisationof oncological care dropped from the political agenda during the second half of the1990s, because parliament had to deal with more pressing issues in health care. One ofthe conclusions about the second debate on centralisation of cancer care, which tookplace in 2004, could be that the role of the only independent, specialist cancer hospital inthe Netherlands did not contribute to building support for this idea. Although the debatefirst emerged in the context of the start of the NCCP, the publications on thecentralisation of cancer care by the directors of the cancer hospital that appeared shortlyafterwards polarised the debate. The main question for the current debate on the concentration of oncological careis: Would a renewed attempt to implement it succeed? In my view, an extended analogyis a particularly suitable translational device to help us answer this question. The forcefield analyses show that the situation remained relatively stable between the first and thesecond attempt to centralise cancer care, but that the changes between the second attemptand the current situation are significant. The shifts of the balance in the governancestructure of health care, with an increasingly central position for the health insurers,makes successful implementation of centralisation in the current circumstances moreplausible than in the past. Additionally, an extended analogy holds information thathealth insurers who aim to concentrate oncological care could interpret as the mainfactors constraining change. For example, the enumeration structure for medicalspecialists has not changed significantly and hospitals would still be afraid of loosingwork and income.9 Under the health care payment system in place at that time, loosing work meant a reduction of income for hospitals and for consultants who worked in hospitals that were not part of a university.
  12. 12. 4.5 Example 2: The comparative histories of English and Dutch voluntary palliative careAs described in the methods section of this paper, my project focuses on comparativehistories of palliative and cancer care. In this section, I will briefly explain the reasons forcomparative histories for policy and then related this to the typology presented in thispaper. What is to be won by including a geographical comparison in policy relevanthistories? Comparative histories can be used to develop extra analogies or comparetrajectories of similar developments at different places. More extensive use ofunderstanding-oriented modes of history for policy can be made if the issue underinvestigation is explicitly framed comparatively. These questions can relate, for instance,to the reasons why a phenomenon is present in one country, but absent at another place.Another example of a comparative history for policy question is why the first hospice thatwas similar to the English hospices was established in the Netherlands nearly 25 yearsafter St. Christopher’s hospice was founded in London in 1967.In the following paragraphs, I explore a comparative historical question of which theanswer can be of use to policy making. I will present the backgrounds to voluntarypalliative care by developing a mode 2 history for policy analysis. In a report published by the think-tank Demos in Autumn 2010, it was argued thatthe establishment of voluntary palliative care, especially in the form of home careservices, in Britain would be desirable (Leadbeater & Garber, 2010). A related,interesting comparative question is how England developed a relatively medicallyoriented system of palliative care provision, whereas a differentiated structure, includingmedically oriented palliative care as well as voluntary palliative care by home care teamsand in low-care hospices, evolved in the Netherlands. A mode 2 analysis indicates that the changing balance between voluntary and NHSdriven provision of palliative care is an important theme in the history of palliative carein England. Cicely Saunders wrote about the decision to establish St. Christopher’sHospice, the first modern hospice in England and indeed in the world, outside the NHS:‘We want to be independent because we need freedom of thought and action; we want tobe an interdenominational but a religious foundation, and we want freedom to developand expand as we are led to do so’ (quoted in du Boulay & Rankin, 2007, p.64). An arrangement with the Regional Hospital Board was, however, negotiated for St.Christopher’s. Moreover, the NHS participated in the foundation of hospices during themid 1970s. The governmental influence on providers of palliative care increased by thelate 1980s, because the government expected District Health Authorities to cooperatewith the voluntary sector to ensure that the needs of their population were met. Theserequirements were soon accompanied by ring-fenced funds for hospices. By the mid1990s, NHS managed hospices accounted for circa a quarter of the total number ofhospices. Other hospices relied on the NHS for at least a substantial part of their income.Under New Labour, governmental control of palliative care continued to increase. Whilelevels of public funding rose, the same was true for control measures, such as theapplication of targets. The most recent major policy document on palliative care inEngland is the End of Life Strategy that was published in 2008. My evaluation of this
  13. 13. plan is that the implementation would result in a further integration of palliative care intothe NHS. Thus we can see that, the introduction of voluntary palliative care would implya significant move away from the past trends in England. The first initiatives to establish palliative care in the Netherlands were volunteerled. These services support people dying at home and their relatives. Additionally, thesevolunteers created a form of palliative care, which appears to be unique for theNetherlands. In these so-called low-care hospices, volunteers provide care for a fewterminally ill persons at a time. In terms of governmental policy for palliative care in the Netherlands, it isnoteworthy that the Secretary of State for Health decided in the mid 1990s that palliativecare had to be integrated into the health care system as a whole. Therefore, she stimulatedcare homes and nursing homes to establish palliative care units, while low-care hospiceswould not be reimbursed for their housing costs. This policy was an impetus for thecreation of palliative care units in care and nursing homes, but the proliferation of low-care hospices continued. Though hardly formally debated, a new chapter in palliative carepolicy seems to have started in 2007. The Minister of State for health received a reportwhich stated that low-care hospices experienced problems with funding their housingcosts. Her response was to grant them additional resources. Currently, around 80% of thecosts of the low-care hospices are on average covered by public funds. Most of the peoplein charge of low-care hospices are keen to continue to rely on private funds for theremainder of their income, because this gives them the freedom to run their low-carehospice as they want. Currently, the extent to which the voluntary sector palliative careproviders can and should be accountable for the public money they receive is beingdebated. Applying the translational device of the identification of developments over time,these mode 2 accounts show, among others, that the current structure of the provision ofpalliative care in both countries is firmly rooted in its development over time. Therefore,it is questionable whether the implementation of voluntary palliative care will besuccessful in England. It is, for instance, unsure whether potential English volunteers willperceive a deficiency in the provision of care for the dying that they want to create aservice for. Moreover, it can be expected that tensions will emerge between the currentproviders of palliative care and the new entrants. The comparative dimension of thisexample reveals that voluntary palliative care has also disadvantages from agovernmental perspective. The Dutch experiences indicate, for example, that it is hard toensure that sufficient levels of voluntary palliative care are available around the country.Additionally, quality criteria and output targets are difficult to impose on voluntaryproviders of palliative care. 5. ConclusionIn this paper, I sketched a typology of four modes of history for policy based on thedistinctions between 1) history as past and as method and 2) the focus of the study, whichis either problem-oriented or understanding-oriented. Moreover, several translationaldevices to move from histories to policy were discussed. Mode 4 and mode 2translational devices were illustrated by discussions of the debates on the regional
  14. 14. organisation of cancer care in the Netherlands and the suggestion to introduce voluntarypalliative care services in England. The typology of modes of history for policy is a stylised model. It is certainlypossible to imagine investigations that combine aspects of two or more modes of historyfor policy. Moreover, additional translational devices to move from history to policy canbe developed. Nevertheless, the examples presented in this paper show that the typologyis a useful tool to think through the various modes of policy relevant history and thetranslational devices that are needed to derive a lesson from these histories that is ofpractical use to the policy community. If history attracts interest from a policy perspective, history is often conceptualisedas the past. So, a legitimate question is: ‘Why should we move beyond these relativelysimple accounts that might hold clear lessons and apply history as method approaches?’A short answer is that the temporalisation of an issue has several benefits. A multilayeredaccount of the emergence of a problem enables us to identify, for example, temporallydistant causes or developments that unroll slowly over time. Additionally, mode 4histories for policy allow us to look at a fairly complex picture of how a topic evolvedand how it compares to earlier developments. As illustrated in the example about theregional organisation of cancer care in the Netherlands (Subsection 4.4), this enhancesour understanding of the present options open to various stakeholders. Not all issuesrequire these extensive analyses and it is the task of the historian to judge which modeand translational device are most suitable and feasible in a particular situation. ReferencesBerridge, V. (1994). Researching Contemporary History: Aids. History Workshop Journal (38), 228-234.Berridge, V. (2000). History in Public Health: A New Development for History? Hygiea Internationalis, 1 (1), 23-36.Berridge, V. (2001). History in the Public Health Tool Kit. Journal of Epidemiology and Community Health, 55, 611-612.Berridge, V. (2008). History Matters? Historys Role in Health Policy Making. Medical History, 52, 311-326.Berridge, V. (2010). The Art of Medicine. Thinking in Time: Does Health Policy Need History as Evidence? The Lancet, 375 (March 6), 798-799.Berridge, V. & Strong, P. (1991). Aids and the Relevance of History. Journal for the Social History of Medicine, 129-138.Boot, J. M. & Knapen, M. H. J. M. (2005). De Nederlandse Gezondheidszorg. [Dutch Health Care]. Houten: Bohn Stafleu van Loghum.Daft, R. L. (2003). Management (6 ed.). Mason: Thomson.Department of Health. (2008). End of Life Care Strategy. Promoting High Quality Care for All Adults at the End of Life. London: Department of Health.Donaldson, L. (2011). Presentation ‘Leadership in the NHS: Reflections of a Chief Medical Officer’ During ‘Leadership in the NHS Lecture Series’ at the Kings Fund (London, 4 April). Available at http://www.kingsfund.org.uk/events/past_events_catch_up/leadership_in_the_1.html
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