There is little recognition of the potential value of historical research for studying health services and for influencing health care policy. Responsibility for the lack of use of history in formulating policy lies both with policy makers and historians.
Policy makers have generally either shown little interest in historical evidence or rejected it. At least three reasons have been suggested by one historian (1). First, policy makers think that the information that historians contribute is not relevant, the more so the further back in time they study. Second, the fact that historians offer different interpretations of the same events undermines their credibility. This reaction contrasts apparently with policy makers’ views of epidemiologists or economists, who can also provide conflicting interpretations of data, but still some how have their contributions accepted. Third, policy makers find it difficult to admit that their cherished ‘innovative’ policy has been tried before (and maybe found wanting). The challenge facing historians in changing such views is not always helped by the other disciplines that contribute to health services research: the current assessment of university performance in HSR in the UK does not acknowledge history as a relevant contributor (2).
Meanwhile, historians have not always furthered their own cause. There has been a tendency to regard ‘applied history’ as “suspect and inferior” (3). Apprehension about being seen in this light by their colleagues has led historians to produce papers that are inaccessible and over elaborate for busy policy makers (1). Many historians have also been reluctant both to gain an understanding of contemporary policy issues and to learn how to address policy makers. The latter requires appreciation of their perspective, priorities and the competing pressures they face.
Discouraged by health care policy makers’ lack of interest in history or, at best, a highly selective use of historical evidence, historians have tended to feel unvalued and disadvantaged. Difficulty in getting published in leading health care journals is seen by historians as further evidence of exclusion (1). While such grievances might be on occasion be justified, others, such as qualitative sociologists, have faced similar difficulties and successfully overcome them. History is certainly not unique in having its output either ignored or used selectively by policy makers.
Despite such discouragement, some historians have tried to contribute to contemporary policy debates. One recent example looks at current attempts in England to incorporate staff and public representatives in the running of foundation trusts (semi-independent public hospitals), a policy that draws on a supposedly successful model from the first half of the 20th century in which representatives of contributors to social insurance schemes were involved in the governance of voluntary hospitals (4). However, the historical evidence shows that in reality the majority of contributors did not participate actively and that those who did had their views largely ignored. This suggests that current policies may end in disillusion unless considerable effort is made to encourage participation and clear ground rules for influencing hospital policy are established.
Instead of responding to emerging policies, history can also help set the policy agenda. By drawing on the past, present day policies can be challenged. At the very least, history can remind people that health services have been organised, managed and financed differently in the past and could be again. For example, a case can be made that the increasing difficulties faced in the running of large general hospitals – hospital-acquired infections, poor patient safety, patient dissatisfaction, low morale of staff – stem from the gradual usurpation of nurses’ control of the running of hospitals over the past 50 years (5). Such research challenges a well-established policy of medical and managerial domination of hospital management, and tries to set in motion a new debate. In doing so, it tries to shift attention from solely seeking superficial changes in behaviour (such as issuing guidance on hand-washing) to also considering the management arrangements which, it is suggested, underlie the weaknesses in hospital performance.
While history’s contribution complements those from other disciplines, it has an additional unique role. It can help policy makers understand the limitations they inevitably face and in doing so, can help them maintain realistic expectations. Carefully formulated policies to shape the future are always going to be limited by unpredictable events. History demonstrates that health services will be influenced by a multitude of forces, most of which lie outside the control of health care policy makers. The development of services in London illustrates some of these diverse factors: the arrival of refugees, such as French Huguenots in the late 17th century who introduced the concept of voluntarism; the introduction of horse-drawn trams in the 19th century, which required street-widening and thus the demolition and relocation of hospitals; the Napoleonic war, during which the supply of leeches was cut off causing a rise in health care costs which threatened the survival of some hospitals; the vocational commitment of religious nursing sisterhoods, whose high quality led, from 1856, to the governors of many hospitals contracting out their nursing services to such organisations; and the increasing numbers of single working people in rented accommodation from the late19th century, who had no family to care for them when they fell ill, stimulated the establishment of private hospitals (6). Policy makers who fail to appreciate the limitations of their powers risk becoming frustrated and disillusioned. History can help them realise the constraints they face and help them plan accordingly, a situation well-expressed by Antonio Gramsci (7) in the 1920s:
“man can affect his own development and that of his surroundings only so far as he has a clear view of what the possibilities of action open to him are. To do this he has to understand the historical situation in which he finds himself: and once he does this, then he can play an active part in modifying that situation.”
Historians are starting to recognise the need to change the way they operate if they are to exert greater influence on policy (1). Evidence that historians are starting to take on the challenge of influencing policy in the UK can be seen in the establishment of a website, History and Policy, which aims to make historians and their expertise more accessible to policy makers and the media (8). But there also needs to be greater understanding by historians of how to communicate with policy makers. As with other disciplines, skills in transferring knowledge from academia to practitioners and policy makers need to be developed. One possibility is to develop a cadre of historical knowledge brokers who understand and can span the boundary between the two worlds. What is clear is that the contribution that history can make to policy is too important to be neglected for want of better communication.
- Berridge V. History matters? History’s role in health policymaking. http://www.historyandpolicy.org/Health%20policymaking.pdf
- Tosh J. In defence of applied history: the History and Policy website. http://www.historyandpolicy.org/archive/policy-paper-37.html
- Gorsky M. Hospital governance and community involvement in Britain: evidence from before the National Health Service. http://www.historyandpolicy.org/archive/policy-paper-40.html
- Black N. Rise and demise of the hospital: a reappraisal of nursing. BMJ 2005; 331:1394-6
- Black N. Walking London’s Medical History. London: RSM Press, 2006.
- Gramsci A (trans Marks L). The Modern Prince and other writings. New York: International Publishers, 1968
This first appeared in Journal of Health Services Research & Policy 2007; 12(4), 194-6