Explaining Variations in Municipal Hospital Provision in the 1930s: a study of Councils in the far South West

Abstract

Recent work has sought to explain the striking variations in municipal hospital provision in the 1930s by quantitative analysis. Such work has not so far provided a hypothesis which satisfactorily explains the range of variations found. This study, grounded in an analysis based on the Advocacy Coalition Framework and the results of three case studies of events in the county boroughs of Plymouth and Exeter and in Devon County Council, uses a qualitative methodology developed by iteration between a deductive approach drawing on recent work and an inductive approach using a computer-assisted analysis of primary source material and proposes a new hypothesis. The hypothesis developed is that where a local authority inherited a Poor Law workhouse as a result of the Local Government Act (1929) development would be more likely to occur in places where councillors exhibited strong progressive beliefs in accountability to the wider community and in their social responsibility towards that community; where they had successful experience of direct hospital provision in other fields; and when they had available a committed entrepreneur able to marshal support for change within the council. In addition to its empirical findings the study contributes to the development of public policy theory by suggesting improvements to the Advocacy Coalition Framework. Such improvements comprise recognition of the importance of ‘deep core’ as well as ‘policy core’ beliefs to policy change, consideration of path dependency as a significant method of policy learning, and of the roles of entrepreneurs and policy brokers. Finally the study draws attention to the relevance of the study to current practice in the implementation of public policy and proposes specifically that local NHS agencies should give greater prominence to identifying and supporting individuals with the skills of policy entrepreneurs.