Values and policy
7.) There are alternative positions on:
Policy is not primarily an empirical or pragmatic
pro- cess of assessing evidence and identifying
effective options, although such rational concerns
may feed into the policy process. Instead, policy is
clearly driven by underlying values. A value is ‘an
enduring belief that a specific mode of conduct
or end-state of existence is personally or socially
preferable’ (Rokeach 1973,
p. 5). In Foundations for Health Promotion
(Naidoo and Wills 2009) we discussed the way in
which certain values may influence the way in
which people prac- tise. In Chapter 1 we showed
how assimilation of spe- cific professional values
(e.g. respecting service users; appreciating people’s
quality of life) is included within professional
training and the adoption of a professional identity.
In any society, but especially in a diverse
democracy such as Britain, there will be a broad
range of values that people hold with regard to
these spe- cific issues. Different groups will hold
different val- ues with respect to these topics,
and often (but not always) there will be coherent
groupings of value posi- tions. Ideology is the term
used to describe a coherent body of interrelated
ideas and values.
The development of public health reflects
differ- ent political ideologies and political
systems. (These
Box 4.17 Example
The third way – key values
• Active civil society – to combat political
indifference suggested by low voter
turnout, for example teaching citizenship in
schools.
• Communitarianism – to try to rebuild societal
links, for example New Deal for Communities.
are discussed in Naidoo and Wills 2009, Chapter
• the role of the individual and that of the state
• the nature and extent of the ties that
bind communities
• whether or not the economy should be
managed or controlled
• the extent of legitimate state intervention
in people’s lives.
The spectrum of political values which underpin
policy has been characterized in many different
ways, and ranges from socialist to individualist,
and from laissez-faire economics to green
environmen- talism to managed economies
(Baggott 2007). At one end (the far right) of the
spectrum are those advocating free market
economics, individual liber- ties and minimal
state regulation. At the opposite end (the far
left) are those supporting a regulated economy,
collective responsibilities and active state
intervention. The middle ground that the Labour
government in the UK tried to colonize as the
‘third way’ embodies values of individual rights,
duties and responsibilities, as well as social justice
and fairness. In the field of economics, a
generally free economic market is tempered by
social constraints and welfare expenditure on key
services and the encouragement of joint private-
public initiatives. Public sector ser- vices are to
be strengthened by firm performance
management coupled with a simultaneous move
to devolved services, a shift from the centralized
hier- archical structure or market competition of
the late twentieth century.
• Democratic family – to give stability, for
example more generous paternity and
adoption leave as well as maternity leave.
• Mixed economy – to encourage private
funding of public services, for example
Private Finance Initiative and foundation
hospitals within the NHS.
 Box 4.17 Example—cont’d
• Equality as inclusion – equality of opportunity
rather than equality of outcome, for example
support for looked-after young people and
children.
• Positive welfare and opportunity rather
than the over-dependency fostered by
a commitment to protect citizens from
the cradle to the grave, for example the
establishment of the minimum wage.
• Cosmopolitan nation – celebrating diversity,
for example organizations committed to equal
opportunities and anti-discrimination policies.
Source: Giddens (1998)
These values give rise to specific strategies or
policies:
• public involvement with greater user
participation and involvement in
services
• increased investment in public services
• mixed economy with a growing involvement
of the private sector in public services
• devolved services allowing local flexibility
and freedom, with additional ‘earned
autonomy’ for best performing services
• quality assurance through clear standards
and performance criteria
• partnership working to erode professional
barriers and enable the delivery of seamless
services
• a positive focus on disadvantaged or
excluded groups
• community focus to build capacity and
encourage communities to be active providers
as well as users of services
• leadership qualities of vision, flexibility
and adaptability are valued above the old
style of bureaucratic managerialism.
Box 4.18 Activity
How many of these terms are you familiar with
from your workplace? How are they interpreted
and used within your workplace?
Contemporary debates and dilemmas
One way of viewing policy is as the arena where
competing ideological values jostle for
dominance (George and Wilding 1985; Malin et al
2002). There
are several areas where currently different ideologi-
cal values compete for dominance in the policy
arena. An understanding of these helps the
practitioner to identify an individual policy’s
drivers in terms of val- ues, ideology and natural
advocates. This will help the practitioners to
reflect on their own value posi- tion and the
logical interconnectedness (or not) of different
policies. In practical terms the practitio- ner may
then be better able to lobby for support for a
preferred policy. Such reflection will also enable
practitioners to identify those policies to which
they feel most motivated and committed, and
able to implement in an effective manner.
Individual responsibility versus collectivity
• To what extent are people in charge of their
own destiny?
• To what extent are people bound
together through ties of kinship and
community?
• What are the proper limits to individual
self- determination and agency?
• How can the needs of individuals
and communities be balanced?
Neoliberal politics emphasize the role of individ-
ual free will in determining health. Recognition
of socially patterned inequalities in health and
seeing individuals as one partner amongst many
(including communities and the state) is a
hallmark of Labour’s ideological standpoint. In
many policy initiatives relating to health
behaviour there is an assumed ‘contract’ between
the individual (whose responsibil- ity is to make
healthy choices) and the state (whose
responsibility is to provide the opportunities for
the individual to make healthy choices).
 employment policies that make employment
Box 4.19 Example more economically beneficial than welfare. The
Choosing health – an individual or social employ- ment of specialist workers is one
responsibility? strategy designed to include marginalized groups.
Choosing Health: Making Healthy Choices Easier
(DH 2004) embraced an individual and community Box 4.20 Discussion point
focused policy that aimed to promote better
health. Six main action areas were identified:
health inequalities, smoking, obesity, sexual What are the advantages and disadvantages of
health, mental health and well-being, and sensible focusing on equal opportunities to participate
drinking. In 2006, the House of Commons voted rather than equal outcomes?
for legislation for smoke-free zones in all public
and work places. It was argued that besides
Proponents of inclusive policies argue that such
protecting people from second-hand smoking,
the ban would also enable many smokers to an approach is empowering and enables people
quit. The policy has been welcomed by many to ful- fil their own potential and make choices
stakeholders as a means of reducing deaths and about their lives. A criticism of such policies is
ill health arising from smoking (ASH 2007), and that they do not necessarily reduce inequalities.
tackling health inequalities, since social class The section on poverty and income in Chapter 5
differences in smoking rates is a key driver of discusses the problems associated with a strategy
social class differences in health status (Jarvis of inclusion that uses geographical targeting based
and Wardle 2005). This example demonstrates on socio-economic indicators.
that even when there is a focus on individual
choice, policy is vital to ensuring that people are
empowered to make healthy choices. Policy also
has a role to play in protecting the public from the
detrimental effects of some people’s unhealthy
choices.

Equality versus inclusion
• Should the policy focus be on equal outcomes,
or equal opportunities to participate?
A fundamental tenet of social democracy in the
UK is to focus on equal opportunities. The
current emphasis is to stress the need to combat
social exclu- sion and develop an active
citizenship. Equal out- comes through, for
example, greater entitlement to more generous
benefits have been rejected as cre- ating welfare
dependency. Instead, the focus has been on
strategies designed to bring marginalized and
excluded communities (e.g. homeless people,
minority ethnic groups or indigenous populations)
into the mainstream of society. There are
numerous policies aimed at doing this, including
economic and
Consumerism versus empowerment
• To what extent should the public be viewed
as consumers of services?
• To what extent should consumers’ views
shape the services we have?
• To what extent should service users be viewed
as empowered?
Box 4.21 Activity
Do you think your workplace subscribes to a
consumerist or empowerment view of service
users? What policies or practices support your
view?
Chapter 6 discusses the drive to involve patients
and the public and the emergence of the concept
of the service user. One explanation for this is to
see services as more accountable and their users
as hav- ing market choices, as do consumers of
other prod- ucts. Services need to provide
information which
enables consumers to make a choice in
imperatives. However, the arguments for
healthcare – hence the plethora of comparative
partnership working – to provide coherent and
data showing how services perform in relation to
seamless services that meet clients’ needs
set targets. Services need to be responsive to
without duplication – are very sound. Genuine
local views so that they are appropriately used.
partnership working need not mean a dilution of
However, critics argue that such information does
professional expertise. What part- nership
not provide an adequate basis on which to
working does require is the recognition and
compare quality of service, merely number
valuing of areas of knowledge and expertise of
crunching statistics. Genuine empowerment, such
other professionals, practitioners and service
as service users’ decision making at the
users.
executive level, is often resisted by organizations
and profes- sionals on the grounds that service
users have specific concerns and lack the Box 4.23 Practitioner talking
necessary strategic overview. A consumerist
notion of health service users under- pins the I came into community nursing to make
establishment of the Patients’ Advocacy and a difference, to help people, but no one
Liaison Service (PALS) and the scrutiny role of seems to acknowledge or respect this. I’m
local government. surrounded by different initiatives requiring
me to do x y and z before getting stuck into
the real business of caring. There’s so many
Partnership versus professionalism boxes to tick, not just about clinical practice
• Should professional identities and skills and targets, but consultation, and with so
be protected? many different parties … it’s exhausting, and
• Or should there be moves to inter- I feel it detracts from the real business of
professional working and strategic nursing.
partnerships? Commentary
Chapter 7 discusses the challenges of partnership Service user involvement has become an
working. Partnerships require partners to respect essential part of healthcare practice. Public
each other’s views and skills and recognize that consultation and engagement became a
each brings equal value to the partnership. duty for Primary Care Trusts and NHS Trusts
However, many professionals are unclear as to the under the Health and Social Care Act 2001
role and skills of other professionals, especially if and Foundation Trusts also have a duty to
they are employed by different organizations. engage with local communities. A plethora of
initiatives have been introduced to guarantee
Professionals may also feel uneasy about
service user involvement in service delivery
acknowledging service users as equal partners,
(see Chapter 6 on participation, involvement and
leading to defensiveness about their own engagement).
territory and remit.

Box 4.22 Activity

What is your experience of strategic

partnerships? What factors contribute to the
success of such partnerships?

The drive for partnership working may be Need versus rationing

interpreted as another attack on professionals’
• How can the idea of universal needs that
expertise in a situ- ation where they already feel
deserve to be met be reconciled with the
beleaguered by mana- gerialism, evidence-based
reality of a limited budget and rationing of
practice and shifting policy
services?
One strategy is to define core services and
aspects of such service provision as
universal, implying uni- versal needs that
deserve to be met in a similar way
throughout the country. Examples of such
policies are the National Service
Frameworks which outline
what service users can expect of services for
different conditions (such as coronary heart
disease) or pop- ulation groups (such as older
people). However, in reality funding is always
limited and hard deci- sions have to be taken
about which services to fund and which to
withhold. One casualty of rationing is infertility
and reproductive services, which have been
rationed and withdrawn in various areas at dif-
ferent times as a result of funding constraints.
This dilemma is likely to become more
problematic due to the ageing population, as it is
generally accepted that an ageing population will
have a greater level of health and social care
needs. Already there have been instances of
ageist policies and practices when service
providers have been accused of failing to meet
elderly clients’ needs solely on account of their
age. Chapter 6 discusses how public involvement
has been extended to priority setting for
healthcare services.
Managerialism versus professionalism
• Should services be controlled by management
or professionals?
• Which form of authority is most transparent
and trustworthy?
The modernization agenda in the UK has priori-
tized managerialism over professionalism.
Strategies such as performance targets and
quality audits are intended to make practice
transparent and account- able. While these aims
are laudable, it is questionable whether the
increasing use of numerical data actu- ally
provides the relevant information. Professionals
complain that such monitoring leads to a ‘tick
box’ mentality where quantity is valued over
quality. This shift has been widely interpreted as
an attack on professional autonomy.
Box 4.24 Activity
Within your workplace, do managers or
professions wield the most power? Is the
balance of power static or a constantly shifting
battleground?
Centralized versus devolved services
• Should health and social care services
be nationally run?
• Or should the planning and delivery of
services be locally organized?
There is a tension between providing centralized
services that are the same for everyone, and
providing locally sensitive services which may then
vary nation- wide. Equity underpins the NHS and
is part of its perennial popularity – the same
service for everyone, according to need, not social
or geographical status. Yet local services which
are responsive to local cir- cumstances are also
popular and a politically sensitive issue. At least
one local election has been fought and won on
the issue of retaining a local hospital threat-
ened with closure. The existence of pressures to
both centralize decision making and devolve
services may make it difficult for practitioners to
work in a way that supports both strategies.
Practitioners may end up feeling torn between
contradictory demands and as a consequence
become demoralized and disillusioned.
Conclusion
The policy context is one of the most important
fac- tors affecting practitioners’ focus, priorities
and work- load. Although the policy process may
appear to be remote from everyday work, this
chapter has sought to demonstrate that
practitioners are a key stakeholder group (alongside
service users). Practitioners can have an impact on
policy through networking, professional and local
lobbying groups, and research evidence. Policy is
often presented as a rational result of weigh- ing up
the evidence, but this chapter has underlined the
importance of values and ideology in the policy
process. Practitioners who reflect on their own
values and ideological position will be able to locate
policies in terms of underpinning values, and also
to identify stakeholders’ views and positions. This
understand- ing will enable practitioners to
maximize their input through effective lobbying
with like-minded partners. Policies may set the
overall context and direction, but there is ample
scope for local and individual
flexibility in the frontline implementation of
poli- cies. An understanding of the power
relationships of key partners enables practitioners
to reflect on their own and others’ contribution to
policy implementa- tion. For the reflective
practitioner, an understand- ing of how the
policy process works and impacts on day-to-day
work is fundamental for enhancing effec- tiveness.
Policy, alongside theory, research and evi- dence,
is a key driver for public health and health
promotion practice. While there are links
between all these elements, policy may also act as
an indepen- dent and value-based driver for
practice.
Further discussion
• In what ways, both positive and negative, does
policy affect your practice?
• Policy is a preferred driver for practice when
compared to:
a. economic cost-effectiveness criteria
b. professional experience and
knowledge. Critically discuss this statement.
• Consider an organization with which you
are familiar. How, if at all, is policy
resisted or transformed on the ‘front line’?
Recommended reading
• Baggott R: Understanding health policy,
Bristol, 2007, The Policy Press.
A user-friendly text that examines the
processes associated with policy making,
and the role of different stakeholders
in the policy process. The focus is on the
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