The quality of diabetes care in the community: practice, policy and culture

Aim: Diabetes is an important barometer of health system performance. This chronic condition is a source of significant morbidity, premature mortality and a major contributor to health care costs. There is an increasing focus internationally, and more recently nationally, on system, practice and professional-level initiatives to promote the quality of care. The aim of this thesis was to investigate the ‘quality chasm’ around the organisation and delivery of diabetes care in general practice, to explore GPs’ attitudes to engaging in quality improvement activities and to examine efforts to improve the quality of diabetes care in Ireland from practice to policy. Methods: Quantitative and qualitative methods were used. As part of a mixed methods sequential design, a postal survey of 600 GPs was conducted to assess the organization of care. This was followed by an in-depth qualitative study using semi-structured interviews with a purposive sample of 31 GPs from urban and rural areas. The qualitative methodology was also used to examine GPs’ attitudes to engaging in quality improvement. Data were analysed using a Framework approach. A 2nd observation study was used to assess the quality of care in 63 practices with a special interest in diabetes. Data on 3010 adults with Type 2 diabetes from 3 primary care initiatives were analysed and the results were benchmarked against national guidelines and standards of care in the UK. The final study was an instrumental case study of policy formulation. Semi-structured interviews were conducted with 15 members of the Expert Advisory Group (EAG) for Diabetes. Thematic analysis was applied to the data using 3 theories of the policy process as analytical tools. Results: The survey response rate was 44% (n=262). Results suggested care delivery was largely unstructured; 45% of GPs had a diabetes register (n=157), 53% reported using guidelines (n=140), 30% had formal call recall system (n=78) and 24% had none of these organizational features (n=62). Only 10% of GPs had a formal shared protocol with the local hospital specialist diabetes team (n=26). The lack of coordination between settings was identified as a major barrier to providing optimal care leading to waiting times, overburdened hospitals and avoidable duplication. The lack of remuneration for chronic disease management had a ripple effect also creating costs for patients and apathy among GPs. There was also a sense of inertia around quality improvement activities particularly at a national level. This attitude was strongly influenced by previous experiences of change in the health system. In contrast GP’s spoke positively about change at a local level which was facilitated by a practice ethos, leadership and special interest in diabetes. The 2nd quantitative study found that practices with a special interest in diabetes achieved a standard of care comparable to the UK in terms of the recording of clinical processes of care and the achievement of clinical targets; 35% of patients reached the HbA1c target of <6.5% compared to 26% in England and Wales. With regard to diabetes policy formulation, the evolving process of action and inaction was best described by the Multiple Streams Theory. Within the EAG, the formulation of recommendations was facilitated by overarching agreement on the “obvious” priorities while the details of proposals were influenced by personal preferences and local capacity. In contrast the national decision-making process was protracted and ambiguous. The lack of impetus from senior management coupled with the lack of power conferred on the EAG impeded progress. Conclusions: The findings highlight the inconsistency of diabetes care in Ireland. The main barriers to optimal diabetes management center on the organization and coordination of care at the systems level with consequences for practice, providers and patients. Quality improvement initiatives need to stimulate a sense of ownership and interest among frontline service providers to address the local sense of inertia to national change. To date quality improvement in diabetes care has been largely dependent the “special interest” of professionals. The challenge for the Irish health system is to embed this activity as part of routine practice, professional responsibility and the underlying health care culture.

Ireland's knowledge economy policy: beliefs, drivers and prospects

This dissertation critically examines Ireland’s knowledge economy policy, the country’s basis for economic recovery and growth, to enhance future policy decisions and debate. Much has been written internationally on the ‘knowledge economy’ with its emergence closely related to globalisation and technological progression in the 1990s. Since the late 1990s, Irish policy-makers have been firmly committed to positioning Ireland as a leading knowledge economy. Transforming the country’s competitive base to a knowledge economy is pivotal, directly shaping the course of Ireland’s economy and society. Given Ireland’s current economic crisis, limited resources, global competition from leaders in science and technology and growing challenges from emerging economies, a systematic study of Ireland’s major competitive policy is imperative. Above all, this study explores the processes behind the policy and the multiple actors from different institutions who follow and seek to influence decisions. The advocacy coalition framework is used to identify the advocacy coalition operating in the knowledge economy policy subsystem. The theoretical insights of this framework are also combined with other public policy approaches, providing complementary insights into the policy process. The research is framed around three elements - the beliefs underpinning the policy; who is driving the policy; and the prospects of the policy. Primary information is collected by way of semi-structured in-depth interviews with 49 Irish elites (politicians, senior bureaucrats, academics and business leaders) involved in the formation and implementation of the policy. This study finds that a strong advocacy coalition has formed in this policy subsystem whose members are collectively driving the policy. Both exogenous and endogenous forces help frame a common perception of the problems the policy addresses and the solutions it offers. Evidence suggests that this policy is a sustainable option for Ireland’s economic future and the study concludes with policy recommendations for advancing Ireland’s knowledge economy.

Examining Participatory Governance in a Devolving UK: insights from national parks policy development in Northern Ireland

This paper provides a contemporary examination of policy making and participatory practice in the context of devolving governance in the UK. The paper takes Northern Ireland as its focus and is particularly timely considering the context of devolved governance, the ongoing transition from conflict to relative peace and the potential for rejuvenating democracy through participatory
governance. The paper concentrates on one particular policy process, namely the attempted designation of a national park in the Mournes Area of Outstanding Natural Beauty. A thematic analysis of qualitative data is drawn upon to analyse the structural factors that framed the policymaking process, in particular the role of power in determining how consultation processes were 2 initiated, designed and undertaken. Using Lukes’ model) as an analytical framework, power is shown to manifest at multiple levels within the policy-making process to influence policy outcomes. The paper reveals how the persistence of a top-down approach to policy development combined with a highly parochial political outlook undermined attempts to designate a Mourne National Park. The paper concludes that, given the immaturity of recently devolved government in
Northern Ireland, in this instance, the democratising intentions of devolved governance have not been met. This has implications for Northern Ireland’s recent reform of public administration which devolves certain planning powers to local authority level and the management of the internationally significant Mournes landscape.

A critical examination of the involvement of Canadian high-performance athletes in the development of anti-doping policy

The use of certain perfonnance enhancing substances and methods has been defined as a major ethical breach by parties involved in the governance of highperfonnance sport. As a result, elite athletes worldwide are subject to rules and regulations set out in international and national anti-doping policies. Existing literature on the development of policies such as the World Anti-Doping Code and The Canadian antiDoping Program suggests a sport system in which athletes are rarely meaningfully involved in policy development (Houlihan, 2004a). Additionally, it is suggested that this lack of involvement is reflective of a similar lack of involvement in other areas of governance concerning athletes' lives. The purpose ofthis thesis is to examine the history and current state of athletes' involvement in the anti-doping policy process in Canada's high-perfonnance sport system. It includes discussion and analysis of recently conducted interviews with those involved in the policy process as well as an analysis of relevant documents, including anti-doping policies. The findings demonstrate that Canadian athletes have not been significantly involved in the creation of recently developed antidoping policies and that a re-evaluation of current policies is necessary to more fully recognize the reality of athletes' lives in Canada's high-perfonnance sport system and their rights within that system.

Policy ‘framing’ and evidence-based planning: ‘epistemic communities’ in the multi-jurisdictional environment of an enlarged Europe

The following paper builds on ongoing discussions over the spatial and territorial turns in planning, as it relates to the dynamics of evidence-based planning and knowledge production in the policy process. It brings this knowledge perspective to the organizational and institutional dynamics of transformational challenges implicit in the recent enlargement of the EU. Thus it explores the development of new spatial ideas and planning approaches, and their potential to shape or ‘frame’ spatial policy through the formulation of new institutional arrangements and the de-institutionalization of others. That is, how knowledge is created, contested, mobilized and controlled across governance architectures or territorial knowledge channels. In so doing, the paper elaborates and discusses a theoretical framework through which the interplay of knowledge and policymaking can be conceptualized and analyzed.

Framing evidence: policy design for the zero carbon home

In 2006 the UK government announced a move to zero carbon homes by 2016. The demand posed a major challenge to policy makers and construction professionals entailing a protracted process of policy design. The task of giving content to this target is used to explore the role of evidence in the policy process. Whereas much literature on policy and evidence treats evidence as an external input, independent of politics, this paper explores the ongoing mutual constitution of both. Drawing on theories of policy framing and the sociology of classification, the account follows the story of a policy for Zero Carbon Homes from the parameters and values used to specify the target. Particular attention is given to the role of Regulatory Impact Assessments (RIAs) and to the creation of a new policy venue, the Zero Carbon Hub. The analysis underlines the way in which the choices about how to model and measure the aims potentially transforms them, the importance of policy venues for transparency and the role of RIAs in the authorization of particular definitions. A more transparent, open approach to policy formulation is needed in which the framing of evidence is recognized as an integral part of the policy process.

Fairness, Justice and an Individual Basis for Public Policy

Prior models of the policy process have examined how human characteristics can affect policy decision-making in such a way that it leads to aggregate effects on policy outcomes as a whole. I develop a model of the policy process which suggests that emotions related to fair and unfair experiences in the same policy domain are utilized by decision-makers as policy criteria. In the lab, I empirically tested this, and find that emotions and experience related to fairness do influence the policy decision to move away from the status quo alternative. Based upon this result, I simulated the evolution of a society of agents engaged in decision-making using similar criteria. The simulation suggests that incentives have an important role in leading to cooperation and social success. The external validity of the simulation also implies that it can act as a platform for future evolutionary policy experimentation.

Exceptional or just well connected? Political entrepreneurs and brokers in policy making

Policy brokers and policy entrepreneurs are assumed to have a decisive impact on policy outcomes. Their access to social and political resources is contingent on their influence on other agents. In social network analysis (SNA), entrepreneurs are often closely associated with brokers, because both are agents presumed to benefit from bridging structural holes; for example, gaining advantage through occupying a strategic position in relational space. Our aim here is twofold. First, to conceptually and operationally differentiate policy brokers from policy entrepreneurs premised on assumptions in the policy-process literature; and second, via SNA, to use the output of core algorithms in a cross-sectional analysis of political brokerage and political entrepreneurship. We attempt to simplify the use of graph algebra in answering questions relevant to policy analysis by placing each algorithm within its theoretical context. In the methodology employed, we first identify actors and graph their relations of influence within a specific policy event; then we select the most central actors; and compare their rank in a series of statistics that capture different aspects of their network advantage. We examine betweenness centrality, positive and negative Bonacich power, Burt’s effective size and constraint and honest brokerage as paradigmatic. We employ two case studies to demonstrate the advantages and limitations of each algorithm for differentiating between brokers and entrepreneurs: one on Swiss climate policy and one on EU competition and transport policy.

Policy Change in Comparative Contexts: Applying the Advocacy Coalition Framework Outside of Western Europe and North America

The advocacy coalition framework (ACF) is one of the most frequently applied theories of the policy process. Most applications have been in Western Europe and North America. This article provides an overview of the ACF, summarizes existing applications outside of Western Europe and North America, and introduces the special issue that features applications of the ACF in the Philippines, China, India, and Kenya. This article concludes with an argument for the continued application of the ACF outside of Western Europe and North America and a research agenda for overcoming challenges in using the ACF in comparative public policy research.

A model of factors determining levels of public support for health care policy in the United States

Public preferences for policy are formed in a little-understood process that is not adequately described by traditional economic theory of choice. In this paper I suggest that U.S. aggregate support for health reform can be modeled as tradeoffs among a small number of behavioral values and the stage of policy development. The theory underlying the model is based on Samuelson, et al.'s (1986) work and Wilke's (1991) elaboration of it as the Greed/Efficiency/Fairness (GEF) hypothesis of motivation in the management of resource dilemmas, and behavioral economics informed by Kahneman and Thaler's prospect theory. ^ The model developed in this paper employs ordered probit econometric techniques applied to data derived from U.S. polls taken from 1990 to mid-2003 that measured support for health reform proposals. Outcome data are four-tiered Likert counts; independent variables are dummies representing the presence or absence of operationalizations of each behavioral variable, along with an integer representing policy process stage. Marginal effects of each independent variable predict how support levels change on triggering that variable. Model estimation results indicate a vanishingly small likelihood that all coefficients are zero and all variables have signs expected from model theory. ^ Three hypotheses were tested: support will drain from health reform policy as it becomes increasingly well-articulated and approaches enactment; reforms appealing to fairness through universal health coverage will enjoy a higher degree of support than those targeted more narrowly; health reforms calling for government operation of the health finance system will achieve lower support than those that do not. Model results support the first and last hypotheses. Contrary to expectations, universal health care proposals did not provide incremental support beyond those targeted to “deserving” populations—children, elderly, working families. In addition, loss of autonomy (e.g. restrictions on choice of care giver) is found to be the “third rail” of health reform with significantly-reduced support. When applied to a hypothetical health reform in which an employer-mandated Medical Savings Account policy is the centerpiece, the model predicts support that may be insufficient to enactment. These results indicate that the method developed in the paper may prove valuable to health policy designers. ^

Changing Banking Supervision in the Eurozone: the ECB as a Policy Entrepreneur. Bruges Political Research Paper No. 38, December 2014

In 2012, the European Union adopted a transformational change to its banking policy for the Eurozone. It dropped the model of decentralized supervision and regulatory competition between countries, and replaced it with a single supervisor and harmonization. Transferring banking supervision to the ECB also alters the existing constitutional order. The policy process leading to this transformational change was rapid and highly political, which was different compared to earlier incremental changes to banking policy. Kingdon's model, whereby policy entrepreneurs seize opportunities at times when the independent streams of solutions, problems and politics converge, partly explains this transformation. The study of EU banking policy suggests, however, that the multiple streams framework should pay more attention to the way in which entrepreneurs engineer fluctuations within the streams and thereby contribute to creating opportunities for change. This paper identifies the ECB as an effective entrepreneur which also played an active role in political bargaining.

Resource Efficiency Indicators for Policy-Making. CEPS Working Document No. 415/November 2015

In the EU, resource efficiency has been high on the political agenda since 2011, when the European Commission first included it as one of the seven flagship initiatives in its Europe 2020 Strategy for “smart, sustainable and inclusive growth”. Resource efficiency is not only considered an environmental necessity, but also a political, economic and security opportunity. This paper first stresses the benefits and opportunities for the EU of improving its resource efficiency. It then explains the added value of the www.measuring-progress.eu web tool, which aims to improve the way policy-makers and others involved in the policy process can access, understand and use indicators for resource efficiency. It provides practical examples of relevant indicators in the form of the EU Resource Efficiency Scoreboard and a case study showing how the web tool established by NETGREEN can be used in practice. The paper concludes with a number of policy messages.

The role of experts in policy making

As public policy issues increasingly have a technical aspect to them an interactive relationship has developed between science and policy. The aim of this thesis is to investigate the two aspects of this relationship: the influence of science on policy and the influence of policy implications on science. Most existing studies in this area treat only one or other of these aspects. Furthermore, they tend to provide interesting case study material but very little theoretical analysis. This thesis attempts to overcome these problems by dealing with both aspects of the interaction between science and policy and by providing theoretical models of this relationship. The thesis combines the theoretical development of these models with the analysis of three empirical case studies: the controversy in Britain over smoking and health; the application of educational psychology to the development of education policy in Britain; the controversy over the health effect of lead in the environment. The theoretical models are developed in Part 1. In Part 2 the empirical case studies are presented and in Part 3 the theoretical material is assessed in the light of these case studies. The main thesis of this study is that there is a fundamental mismatch between science and policy-making. Criticism is always essential in science. However, when science is involved in the policy process, either scientific claims are not subjected to a significant level of criticism or they are scrutinized so closely that no view achieves general consensus and conflicting advice results. In this situation, contrary to the traditional view, science can generate uncertainty. The role which science plays in the policy process is influenced by this level of criticism, by the context of political power and by the progress of an issue through the various stages of the policy process.

Norms and Greek foreign policy: 1981--2000

From the end of WWII to the end of the Cold War Greek foreign policy was shaped by the dynamics of the Cold War. The major issues facing Greek foreign policy decision makers in the post-cold war era are its relations with its Northern neighbors, Albania, The Former Yugoslav Republic of Macedonia (FYROM), and Bulgaria, its relations with Turkey, and Greece's future in the European Union. Although the three issues overlap there is consensus among the Greek political elite that the relationship with Turkey is the most pressing since Turkey poses the most immediate security threat. In the last twenty-five years the two countries came to the verge of war three times over the continental shelf in the Aegean and Cyprus. The latest crisis was in 1996. Since then Greek policy makers have embarked on a conciliatory road towards Turkey that has gained momentum in the last three years. The purpose of this dissertation is to describe the process of the recent change in Greek foreign policy vis-à-vis Turkey, as reflected in the words and deeds (speeches, interviews, statements, policies) of the Greek policy makers. In addition, the study seeks to understand how this change is related to rules existing at the global, regional, and domestic levels. The central question to be asked is: how do rules existing at these levels regulate and constitute the foreign policy process of the Greek government. I utilize the theoretical insights and concepts provided by constructivism in order to carry out my research. The analysis establishes the relationship between the agents (Greek foreign policy makers) and the various rules and explores this relationship as an ongoing process by ascertaining the social context within which this process is unfolding. ^

Understanding China's climate change mitigation policy development: Structures, processes and outcomes

Climate change is one of the most important and urgent issues of our time. Since 2006, China has overtaken the United States as the world’s largest greenhouse gas (GHG) emitter. China’s role in an international climate change solution has gained increased attention. Although much literature has addressed the functioning, performance, and implications of existing climate change mitigation policies and actions in China, there is insufficient literature that illuminates how the national climate change mitigation policies have been formulated and shaped. This research utilizes the policy network approach to explore China’s climate change mitigation policy making by examining how a variety of government, business, and civil society actors have formed networks to address environmental contexts and influence the policy outcomes and changes. The study is qualitative in nature. Three cases are selected to illustrate structural and interactive features of the specific policy network settings in shaping different policy arrangements and influencing the outcomes in the Chinese context. The three cases include the regulatory evolution of China’s climate change policy making; the country’s involvement in the Clean Development Mechanism (CDM) activity, and China’s exploration of voluntary agreement through adopting the Top-1000 Industrial Energy Conservation Program. The historical analysis of the policy process uses both primary data from interviews and fieldwork, and secondary data from relevant literature. The study finds that the Chinese central government dominates domestic climate change policy making; however, expanded action networks that involve actors at all levels have emerged in correspondence to diverse climate mitigation policy arrangements. The improved openness and accessibility of climate change policy network have contributed to its proactive engagement in promoting mitigation outcomes. In conclusion, the research suggests that the policy network approach provides a useful tool for studying China’s climate change policy making process. The involvement of various types of state and non-state actors has shaped new relations and affected the policy outcomes and changes. In addition, through the cross-case analysis, the study challenges the “fragmented authoritarianism” model and argues that this once-influential model is not appropriate in explaining new development and changes of policy making processes in contemporary China.