Introduction

There does not appear to be a dominant approach to conceptualising or measuring change in health systems (Beland and Powell, 2016; Powell 2016), which makes it difficult to differentiate evolution from revolution. In other words, there is no clear dependent variable of change, but rather multiple and sometimes incommensurate criteria that defy attempts to come to neat conclusions.

There are many possible ways to examine these issues (Beland and Powell, 2016; Powell 2016), but this chapter draws on the influential account of Hall (1993) which differentiates between first, second and third order change. It views policymaking as a process that usually involves three central variables: the overarching goals that guide policy in a particular field, the techniques or policy instruments used to attain those goals, and the precise settings of those instruments. Hall regards change in settings as first order change; changes in instruments and settings as second order change; and changes in all three components – instrument settings, the instruments themselves and the goals – as third order or paradigm change. There are, however, a number of problems with this approach. First, it is not clear that first order change is always necessarily less important than second order change. For example, if the level of health spending was doubled or halved, this large first order change may be more important than a second order change in instruments. Second, it does not really capture outcomes, and so cannot explore the impact of ‘change’, which is complicated by issues of time lag and of causality and attribution.

This chapter tracks some of the main policy measures introduced by the Coalition's Health and Social Care Act (HSCA) of 2012 backwards to the Conservative government of 1979, which introduced market mechanisms into the NHS, using the framework of orders of change (Hall, 1993).

Orders of change: the challenge of evaluation in a complex service

This section explores some of the main changes since the Conservative government of 1979 (for details see, for example, Klein 2013a; Timmins, 2012; Powell, 2003, 2015a) in terms of first, second and third orders of change. Table 2.1 sums up the main points, which are developed in more detail below.