Introduction:
(Buse, K et al.,2005) defined agenda setting as the “process by which certain issues come into thepolicy agenda from the much larger number of issues potentially worthy of attention by policymakers”p.63. Agenda setting has been explained in the literature through different conceptual models such as Kingdon’s, Hall’s, Advocacy coalition framework, and Issues Attention Cycle. The author argue that Kigdon’s model is the most comprehensive framework that address the agenda of Improving quality of life for people with long term conditions policy (DH, 2013). The author will analyse the policy using three models Kingdon’s, Hall, and ACF instead of the four models, with a focus on Kingdon’s model.
The Policy: Improving quality of life for people with long term conditions (DH, 2013):
The department of health released a recent policy of applying telehealth for patient with long term conditions such as high blood pressure and diabetes. The aim of this policy is to enhance the quality of life of old patients, reduce the healthcare expenditure by using the telehealth and telecare technology.
Telecare is “Telecare is electronic equipment, sensors and aids used in a person’s home to support independent living” (DH, 2013). Where is Telehealth is “the use of electronic equipment to monitor a patient’s vital signs such as blood pressure, pulse, and respiration. The equipment transmits the readings for observation by monitoring centre. And telemedicine is giving medical advice remotely by telecommunicating with clinician. The policy document reflects the reasons behind this decision are, increased population with long term conditions in England, high expenditure of 70% of healthcare is on long term conditions, and based on the evidence of the positive impact of telehealth. (DH, 2013)
Model 1: Kingdon Model of Agenda Setting:
(Kingdon, 1984 cited in Buse, et al, 2005) argued that policy matters arrive to the government policy agenda by entrepreneurs’, who can be outside or inside the government employment of opportunities, which Kingdon refers to them as policy windows. Policy entrepreneurs can be outside or inside the government. And policy windows open and close based on the mixture of interaction of characteristics, conditions, political institutions and policy solutions. According to Kingdon, the crossing of three currents called streams transfer the policy to the agenda. These streams are problem stream, politics stream and policy stream. Problem stream includes the governmental interventions to public problems; these governmental solutions are affected by historical actions taken to solve and intervene with the problems. In this stream, interest and pressure groups, crises events, reports transmit the issue to the governments. On the other hand, policy stream includes the assessment and examination of problems and their provided solutions. From the perspectives of this stream, policy actions to solve problems should be consistent with the societal values and norms, practical and applicable to be attractive and able to reach the high agenda. According to (Shibuya, 1996), due to the subjectivity of agenda setting, the definition of an issue is of high importance. Moreover, public perception and judgment of the impact of proposed change is highly important. The third stream is the politics stream, this current covers the events and changes on national level. Examples of these events are, interest groups campaigns, and changes in the government. Although these streams work independently, their intersection is influenced by certain factors to open or close the window of opportunity. Influential factors can be explicit such as the media influences and minister electorate. Implicit factors are the participation of actors with expertise like researchers and consultants (Kingdon cited in Buse, et al,2005). Kingdon explain the policy as non-linear process, each stream function independently and once intersection occurs the window opens. Moreover, issue get redefined over time and although randomization can be noticed during the process agenda setting, but according to Kingdon it can be influenced by feasibility of proposed solutions and the role of actors and interest groups (Kingdon cited in Stout & Stevens, 2000).
Policy Analysis using Kingdon’s Model:
Problem Stream:
In this stream the author will start by looking at the evidence behind the problem and the historical intervention in DH published policies and documents. The issue behind this policy can be addressed by increasing older population and long-term and conditions and increased health expenditure on
these problems. the prevalence of chronic diseases such as diabetes worldwide is expected to increase from 285 million adults in 2010 in 91 countries including UK to 439 million individual in 2030 (Shaw, et al., 2010). In a report by (DH, 2004), it is estimated that 60% of adult individuals in England has chronic disease, including Asthma, arthritis, diabetes, COPD, mental health problem, and other chronic illnesses. In England according to (Holman, et al, 2011) study the number diabetic adults is expected to reach 4.6 million by 2030. Chronic disease can lead to more chronic health issues that make patients conditions more complex and reduce the quality of their lives including their social lives (DH, 2004). People with chronic disease are prone to have longer
hospitalization and have more frequent admissions (DH, 2004).
NHS has been keen to address the problem of increasing chronic illness and their burden on individuals’ life and on healthcare cost. The initial initiatives by the NHS started from the National Service Frameworks (NSFs) by the late 1990s, the frameworks addressed the standards of managing chronic diseases such as diabetes and COPD. NSFs were applied separately for each condition.
Later integration of services has been recognized, especially that some patients have more than one chronic illness (Dixon, A., et al, 2007).
Chronic illnesses care integration strategies have been adopted based on international evidence from United states and Canada (Ashton, et al., 2003;Jha, et al., 2003; & Ham, et al.,2003 cited in DH,2004), which included strategies such as support of self-care, by provider and patient education and
support of network, and reminders; second, and specific disease management. In addition, the (DH,2004) report two other care models adopted from US are chronic care model (Wagner, et al., 2001cited in DH,2004) and risk pyramid model have influenced the birth of case management in the
NHS policy(Dixon, A., et al,2007). In 2005 the DH published a policy (supporting people with long term conditions) that address the
support of self-care, case management and disease specific management integrating the care between primary care and specialized physician and appointing 3000 community nurses as case managers (DH,2005). However, evaluating the progress revealed that expected result of 50% reduction in hospital emergency admission of chronic diseases was not met, based on the study by (Gravelle, et al., 2007) that assessed that impact of care management approach of elderly people and found no correlation with reduced hospital admission (Dixon, A., et al,2007). In 2006, DH published “Our health, our care, our say: a new direction for community services” policy to invest more and increase the number of expert patient program courses to 100 000 patients by 2012, investing 18 million bounds to enhance self-management for chronic diseases. However, per (Griffiths, et al., 2007) the evidence of the impact of the expert patient program was not clear and positive results on self-efficacy were limited and small. Moreover, there was no change on the use of healthcare. In (Darxi,2008) the next stage review the chronic disease have been cited as a one of challenges in 21st century to the NHS due to ineffective choices and utilization of prevention of opportunities. (Newbold, 2013) in his blog (how can we deliver the fundamental changes to meet the challenges the future) has highlighted the need of setting up the needed health services for chronic diseases and measure the impact of care provided. Moreover, In a recent
publication by the department of health (DH), a new vision for district nursing practice that included a support for aging population and the use of telehealth technologies to assist patient with their conditions from home(DH,2013). In conclusion, the problem stream shows important historical actions by DH and relevant studies that examined the impact of the problem and other studied evaluated action taken to address the problem.
Policy Stream
Several studies have been conducted to examine the impact of telehealth on disease management.
Telehealth is found to reduce hospital admission for patient with diabetes (Jia, H., et al, 2009) and reducing blood glucose level (McMahon, G. T., et al, 2005). The (DH, 2011) has conducted a large complex study project called a whole system demonstrator (WSD) program, which was started in May 2008 to have a robust evidence of the impact of telehealth, as a feasibility study for taking the
decision to apply telehealth. The study included 6191 patients with almost 50% of them with chronic conditions of (Diabetes DM, hypertension HTN, and Chronic obstructive pulmonary disease COPD). The study result indicated that the proper application of Telehealth technology can reduce the following measures: 14% of emergency admission, 14% of patient stay days, 8% in tariff
cost, and 45% in mortality rates. The report estimated that telehealth and telecare can benefit three million individual with chronic health condition in England. However, (Car, Huckvale & Hermens,2012) argued that evidence of the initial findings has been criticised for uncertainty, because of the results of other recent studies by (Chaudhry, et al., 2010 and Koehler, et al., 2011 cited in (Car,Huckvale & Hermens, 2012) indicated that there are no benefits of telehealth for patients with heartfailure. Therefore, according to them such mixed evidence does not justify the decision to invest and that successful implementation of telehealth depends on complex factors such as severity and
type of disease. Moreover, (Goodwin, N.,2012) has considered the evidenced on the impact of telehealth is varied in term of robustness, due to complexity of the measures such as mortality, and variety of technologies and diseases. Moreover, he cited the uncertainty in cost effectiveness as telehealth can increase the cost. According to (Steventon, 2012) the WSD should produce better results to ensure cost saving. In conclusion, Analysing the policy from policy stream reveals the importance of evidence to decision making, but on the other side of the coin criticism of the evidence, other contradicting evidence and potentiality for cost inflation were not considered.
Political Stream
The initiative to introduce telehealth and telecare has been started by the 3 million lives initiatives campaign by Minister of State for Care Services Paul Burstow MP (Na, 2012). Moreover, one of the key governmental changes in the NHS is Clinical Commissioning Groups, CCGs in which decisions about purchasing healthcare will be taken by clinicians (DH, 2010). In addition, efficiency savings of £15 billion and £20 billion, between 2011 and 2014 required by the NHS in the time of resources scarcity (Nicholson, 2009 cited in Abbelby, et al., 2010). Addressed some improvement strategies to enhance the productivity of the NHS, these strategies included enhancement of self-
care and the integration of care between pharmacists and GP to reduce load on GPs by enhancing pharmacists role in chronic disease management (Abbelby, et al., 2010). The author thinks that political stream was not very dominant in setting the agenda. However, the cost savings and high expenditure might be the explicit intersecting factor for the three streams. Applying Kindon’s model to analyse the agenda setting has proven that the most prominent stream is the problem stream, which agrees with (Shibuya, 1996) argument that the problem stream is the most visible stream and the least systematic stream. But the author thinks that problem stream is the most systematic stream.
Moreover, policy actors of researchers and interest groups have contributed by evidence and commentaries to all the streams. Therefore, the author consider them the implicit intersecting factor,
Table 1: Summary of analysis using Kingdon Model:
Stream Application to Improving quality of life for people with long term conditions policy (DH, 2013
Problem
stream – Increasing prevalence of chronic illnesses.
– Increasing healthcare expenditure with large portion spent on chronic illnesses.
– Impact of chronic illnesses of individual health and social life.
– Influence of evidence and interest group of researchers who conducted studies
about the impact of the problem of chronic illness and the effectiveness of previous interventions of expert patient program and case management.
NHS previous attempts to solve the problems of chronic diseases:
– Late 1990s National Service Frameworks (NSFs) for chronic conditions. Eachcondition has its separate framework.
– Later integration has been introduced.
– 2004: Influence of International care models:
– 2005: DH published a policy (supporting people with long term conditions)
addressing the support of self-care, case management, disease specific management integrating the care, & appointment of case managers.
– 2006, DH published “Our health, our care, our say: a new direction for community services” to invest in expert patients program.
– 2008: DH published “the next stage review” policy, which cited chronic disease.
– 2013: a new vision for district nursing practice to support telehealth and telecare.
Policy stream Whole system demonstrator (WSD) program project by DH & other research bodies.
Pollical stream 3 million lives initiatives campaign.
– Change in the NHS is Commissioning structure; CCGs will be responsible for purchasing services instead of patient care trusts PCTs.
– Required cost saving from NHS.
– NHS has moved from target based measurements to outcome based measurements.
Model 2: The Hall Model: legitimacy, feasibility and support:
(Hall et al, 1975 cited in Buse, et al, 2005) argued that three important characteristics of an issue should be available to take the policy into the agenda. These are legitimacy, feasibility and support.
Legitimacy refers to the appropriateness of issues from governmental perspectives to be acted on.
Example of legitimate issues is the national law to protect the country from war. Another example is providing equal healthcare. Feasibility refers to the practicality of solutions in terms of the availability of resources, skills, knowledge and necessary fundamental structures. And support, by the public and important interest groups to a policy issue is important for successful
implementation.
Table 2: Policy Analysis using Hall Model:
Stream Application to Improving quality of life for people with long term conditions policy (DH, 2013)
Legitimacy (Goodwin, N.,2012) reported that speakers in the King’s Fund international conference of telehealth argued that providing telehealth care is moral in addition to the cost benefits.
More importantly, the (DH,2012) mandates that significantly influence the commissioning board includes a special section for enhancing the quality of life for people with long term
conditions that includes the support for the use of technology, patients access to their online records.
Feasibility The WSD program has examined befits, cost and feasibility to invest in telehealth and telecare. (please see Kingdon’s Policy stream analysis)
Support The use of telehealth and telecare is obviously supported by the department of health, and this was evident in the review of relevant policies in this essay. However, interest groups that include researchers and organizations such King’s fund and Nuffield trust found the evidence to invest in telehealth and telecare is not sufficient. Therefore, the author thinks that
support of the policy is not high, due to lack of robust sufficient evidence.
Model 3: Advocacy Coalition Framework ACF Approach (Sabatier and Jenkins-Smith):
Sabatier and Jenkins-Smith explain the policy change as on-going process in the policy subsystems and influenced by big external episodes. A clarification example of ACs is the healthcare is a system in UK, a subsystem will be for example: GP (general physicians) practices, community nursing and mental healthcare. In subsystem, actors function as producers, disseminators and evaluators of policy. These actors in the subsystem form Advocacy coalition groups, each collation share similar ideas and beliefs. Advocacy coalition is “a group distinguished by a distinct set of norms, beliefs and resources, and can include politicians, civil servants, members of civil society organization, researchers, journalists and others” (Buse, et al, 2005)P.132. The collation actors believe rarely changes and these changes occur due to major events; this is what is meant by external episodes. Whereas, incremental changes small changes in collation attitude toward a policy occur because of learning. Another Important element of this model is the policy brokers, who are actors working to find feasible solutions between coalitions. Moreover, in this model public are not considered to play any role per (Sabatier & Jenkins-Smith, 1993 cited in Buse, et al, 2005).
Other important concepts of the model indicate that policy change and learning happen during a long period a decade or more. Actors interaction, and subsystems are interrelated with government, in which actor are from various governmental levels and policies are implicitly theorized as a believe systems in terms of achieving their goals (Jenkins-Smith & Sabatier, 1994).
Policy Analysis using Advocacy Coalition Framework:
In an attempt to apply the ACF to the chosen policy the author has chosen three distinct professional bodies in the UK and conducted a search in their websites for telecare, telehealth, telemedicine and chronic illness/disease. Starting with the Royal College of General Practitioners (RCGP) is the professional membership body for general PR actioners in UK. It is committed to improve the delivery of healthcare by the involvement in healthcare political issues and decision making (RCGP,nd). The author has searched RCGP website, but no relevant documents were found to the policy of choice. Same search done on the British Medical Association & British Nursing Association website and no relevant information has been obtained. However, organization such as King’sfund and Nuffield Trust has provided extensive information about the cost effectiveness and debate about investment in telecare as explained in Kingdon’s model. This reveals the limited applicability of ACF model to address the agenda of chosen policy, which agrees with (Buse, et al.2005) argument that ACF model is applicable in analysing the policy change in open and decentralized system such as the United States. But, it is not feasible for policy analysis in United Kingdom, in which there is less coalition’s interactions. However, policy brokers’ role might be evident in the role of researchers and other interest groups.
Discussion and Conclusion:
Kingdon’s model has proven to be applicable in the public sector in many countries such as Canada, and United Kingdom, this credits the model from transferability among nations (Exworthy, et al.,2002; Howlett, 1998 & Stout & Stevens, 2000). Although Kindon’s model does not explicitly emphasis the role of evidence, it is found the evidence plays an essential role in all three streams specifically the problem and policy stream, which leads the author to conclude that evidence and interest groups of researchers plays a key role in intersecting the streams and opening of a widow.
The application of Kingdon model in analysing the policy agenda of using telehealth and telemedicine has proven it comprehensiveness and holistic approach. The chronic illness issue has been tackled by policy makers since long time, and gone through developmental stages from specific frameworks, care models, integration of care, expert patient program and currently the use medical technology. However, they political stream has not provided prominent influences except in terms of cost savings and commission changes (evidence against). Hall and Kingdon models are similar in the feasibility perspectives, which are technically addressed in the policy stream of Kingdon model and in the feasibility of Hall. However, the writer believes that Hall model is logical, but over simplistic, in which it lacks addressing the problem itself, governmental previous actions, interest groups and evidence. On the other hand ACF has been found inapplicable from the limited attempt here by the author to analyse the policy agenda using ACF, researchers and interest groups of King’s fund and Nuffield trust were the most prominent key players. Based on the application of the three models to analyse the agenda setting of chosen policy, the author reconfirms that Kigdon’s model best is the best in explaining the agenda of chosen policy.
Appendix1:
Model 4: Issue Attention Cycle (Down):
(Down, 1972) argues that public attention toward policy issues is influenced by a systematic “issue
attention cycle”. In his model, he explains that a policy issue that caught the public attention does
not stay under the spot of attention for a long time as it incrementally disappears. He theorizes this
cycle into five stages.
Table 3: Issue Attention Cycle (Down):
Stage Description
1 Pre-problem stage: At this stage the issue or problem has not caught the attention by
the public. Although, it might be addressed by interest groups and
researchers. Problems at this stage are at their worst status.
2 Alarm discovery and
euphoric enthusiasm:
Major events such as crises stimulate the public attention to
problems and to find interventions for them.
3 Realizing the cost of
significant progress:
This is the stage of problem solving cost recognition.
4 Gradual Decline of
Intense Public Interest:
The public interest decrease after recognizing the cost and
difficulties in solving the problem.
5 The post-problem stage: At this stage the problem loses the public attention and becomes
forgotten and replaced by another problem. However, the actions by
the government to solve the problem so still continue.
Page 15 of 18
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The marks
58/100
The feedback:
Theory, concepts and use of evidence:
Some good points, especially on parts of Kingdon (problem stream), but other streams and models received less attention.
Analysis and originality:
Good analysis/details in places, but thin and brief elsewhere. Some points on p. 8 not clear. Too much use of ‘the author thinks’ – any evidence?
Connection between theory and practice:
Good attempt to apply models, but more needed on criteria of ‘best’.
Structure and Presentation:
Broadly well structured, but attention needed to language, referencing (inappropriate use of brackets)
and mixing of referencing systems (alphabetical and numbers in bibliography). Extensive bibliography.
Key strengths of this assignment:
Clear evidence of research and thought.
