Think tanks and health policy in the United Kingdom: The role of the King’s Fund

Abstract

The King’s Fund is a long-established health policy think tank involved in work on evidence-based policy in the United Kingdom. There have been few accounts of how think tanks operate. This essay seeks to partially fill that gap by reviewing the work of the Fund between 2010 and 2018, when the author was its chief executive. The essay outlines the history and status of the Fund, its funding and staffing, and the range of activities undertaken. Examples of policy areas in which the Fund was active and its impact on both policymakers in central government and leaders working in the National Health Service are discussed.

Introduction

A recent review summarised the literature on think tanks in relation to the various forms they take, their contribution to evidence-based policy making, and their prospects at a time of questioning of the role of experts in government. ¹ There is a long tradition of using research and science in government, and think tanks have been increasingly prominent alongside advocacy groups, research institutes, special advisors and public bodies like the Office of Budgetary Responsibility – an independent agency set up to carry our analyses of the United Kingdom’s public finances.

The literature review found that most scholars agree that policy expertise is the main output of think tanks, that they seek to influence policy makers and the wider public, and that they do so via informal and formal channels using their position in policy networks. It also noted the symbiotic relationship between the media and think tanks with some think tanks in a privileged position with regard to media access and others struggling to cross the media threshold. This essay draws on the work of the King’s Fund to explore these issues.

The primary users of evidence are politicians, civil servants and public officials, with the media also having a role as an intermediary between the generators and users of evidence. Generators and users share an interest in policy making but often have distinctive languages, cultures and incentives. They also often operate on different timescales. Experience in Canada of using ‘linkage and exchange’ to move research into policy is one example of efforts to bridge the work of generators and users and in so doing increase the relevance and application of research on health services. ²

In the United Kingdom, three think tanks have a specific focus on health policy: the Health Foundation, the King’s Fund and the Nuffield Trust. The role of these think tanks has been analysed through the lens of linguistic ethnography, including the role of language and social interaction in their work. ³ But there has been no detailed descriptive account of how think tanks operate that might help inform those seeking to learn from their experience.

This paper is a partial attempt to fill that gap. It focuses on the work of the King’s Fund where the author served as chief executive between 2010 and 2018. The author’s experience of working as a health services researcher in universities and a temporary senior civil servant in the Department of Health played an important part in shaping how he undertook this role.

A brief history

The origins of the King’s Fund can be traced back to 1897 when it was established as the Prince Edward’s Hospital Fund for London to raise money to support voluntary hospitals in London. ⁴ When Prince Edward was elevated to the throne, its name was changed and shortened to the King’s Fund. Over time its role evolved from fund raising to developing managers, supporting innovations, sharing best practices, and, from the mid-1980s, acting as a think tank.

Leadership is provided by an appointed board of trustees who serve in a voluntary capacity and the Fund operates as a charity under a Royal Charter. A member of the royal family serves as the Fund’s president. This role is largely symbolic with the president relying on the trustees to ensure sound governance.

The work of the Fund is carried out by around 130 staff under the leadership of a senior management team. The annual budget at the time under review was around £15 m, sourced in part from an endowment of investments, which provided around third of the budget. This was supplemented by income generated though activities such as conferences, externally commissioned research, hiring out the Fund’s central London buildings and leadership development programmes undertaken for the National Health Service (NHS).

The core values of the Fund include a commitment to independence, interpreted as not being aligned to particular political or sectional interests, and ensuring that research and evidence are used to ‘speak truth to power’, to channel Aaron Wildavsky. ⁵ The work programme aspired to make a difference through a combination of research and publications, the development of health care leaders, and support in implementing ideas advocated by the Fund.

Policy analysis and research

A team of 20 staff were responsible for policy analysis and research. They brought experience from universities, the civil service, the health sector, local government and voluntary sector organizations. Each year they produced a range of publications including research reports, briefings, blogs and ‘explainers’ that provided factual analysis of current issues.

Policy outputs combined responses to government plans and proactive work that sought to influence what government does in areas identified as priorities by the Fund. In the mid-2010s, four priority areas accounted for most policy outputs: finance and performance, prevention and population health, new care models and leadership and cultures in health care organizations.

These priorities emerged from discussions among staff and with the board of trustees and reflected an assessment of the policy environment and the expertise in the Fund. They were also shaped by the many interactions and dialogues between the Fund’s staff, policymakers, practitioners and university researchers working on health policy.

Most policy outputs were based on secondary analysis of existing research and routine NHS data. Staff also undertook original data gathering through fieldwork designed to understand the impact of government policies and local innovations in care. These outputs were usually initiated by the Fund but in some cases were the result of external commissions in the four priority areas in the work programme. Occasionally, international fieldwork was undertaken, as in case studies of exemplars of integrated care. ⁶

Evidence took different forms. It encompassed research generated by the scientific community, surveys that reported on public attitudes, and the experience of people affected by policy. The interpretation of evidence required judgement on the weight to be attached to data of different types and strengths. This was especially the case when evidence was incomplete and its interpretation contested – for example, in relation to the impact of market-based reforms in the NHS.

Policy work was supported by the communications team which also comprised around 20 staff. Its role was to undertake editing and production of publications, develop and maintain the website, and communicate the work of the Fund through social media. It arranged for policy staff to speak to the media and helped ensure the Fund’s work was reported in specialist health policy journals as well as broadcast and print media.

Collaboration between the policy and communications teams led to innovations in the Fund’s outputs. These included animations to explain integrated care and the shifting landscape of the NHS, podcasts and filmed interviews with conference speakers posted on the website.

Policy outputs sought to combine analysis of policy with analysis for policy. ⁷ Analysis of policy focused on assessing the strengths and weaknesses of government plans while analysis for policy aimed to offer a view on what should be done to deliver improvements in health and care. This included criticizing, and in some cases rejecting, government plans and highlighting issues that required more attention by policymakers.

An example of the latter was work where the Fund set out in a series of publications the case for new models of integrated care. When this case was accepted by government, staff worked to support implementation by offering advice to areas of the country seeking to integrate care through a combination of expert knowledge and facilitation of the staff doing the work locally.

A related example was the work of the Barker Commission, established by the Fund to outline a new settlement for health and social care in which entitlements to social care would be aligned with those in health care. ⁸ The Commission’s report was ignored by policymakers in an area of public policy seemingly stuck in the doldrums.

In this case, the Fund sought to maintain the visibility of the commission’s proposals in the hope, if not expectation, that a future government would show interest in its findings. A willingness to persist in advocating policy changes is an essential requirement when the ‘policy windows’ ⁹ that enable reform appear to be closed.

Working with policymakers

Shaw and colleagues make a distinction between think tanks working ‘frontstage’ and ‘backstage’. ³ ‘Frontstage’ means calibrating how policy outputs are written and communicated, with a view to influencing policymakers. In the Fund, this entailed the chief executive and senior colleagues being closely involved in quality assurance of policy outputs and ensuring consistency with the position taken by the Fund. It also entailed working with the authors of policy outputs in crafting recommendations for action.

The position taken by the Fund on health policy emerged from discussions among staff and on some occasions with the board of trustees. These positions were underpinned by a view on the role of the NHS, and how it needed to evolve. As far as possible, each position was based on an assessment of available evidence and was agreed after debate and challenge both internally and in discussion with outside experts.

‘Backstage’ means meeting policymakers to discuss issues of common concern using the formal and informal channels available to think tanks. Many of these meetings were with civil servants and public officials in national NHS bodies, on some occasions they extended to politicians. Of particular importance were meetings with health ministers, as well as contacts with politicians in opposition parties and parliamentarians specializing in health policy.

Access was facilitated by the experience and networks of senior staff and shared membership with policymakers of the health policy community. This included staff having worked with policymakers in previous roles, which helped avoid there being ‘two worlds’ that were difficult to bridge. The nature of dialogue with politicians varied depending on the individuals involved, rather than the political parties they represented. Some were more willing and interested to engage openly than others.

Between frontstage and backstage were activities that are best described as examples of the ‘convening role’ of the Fund. This entailed bringing people together from different organizations, and providing a safe forum for the discussion of policy issues and choices. Activities included public events, such as conferences and seminars, together with private meetings, breakfast events and working dinners in which issues were debated under the Chatham House rule.

The Fund drew widely on international expertise, including the appointment of a number of international visiting fellows who contributed to the work programme and policy outputs. The Fund also used its networks in the United Kingdom to engage health policy analysts in universities and other settings, thereby helping them to gain access to policymakers. In enacting the convening role, the Fund fulfilled the function of a translator and knowledge broker between the generators and users of evidence.

In all of this work, a judgement had to be made about how to maintain access to policymakers and decision makers while preserving the independence that lay at the heart of the Fund’s work. This could be challenging when governments adopted policies at odds with those advocated by the Fund. In this context, speaking truth to power meant expressing concerns and criticisms firmly on the basis of evidence, and setting out alternatives that should be pursued.

An ever-present risk for the Fund was being seen to ‘sit on the fence’ by not articulating its views forcefully – for example, in the debate about the reforms to the NHS devised by Andrew Lansley under the Conservative and Liberal Democrat Coalition Government in 2010. In this case and others, the evidence used by the Fund included the experience of its staff and those working in health care – what Klein, drawing on Aristotle, refers to as ‘phronesis’. ¹⁰

The Fund’s position on the organization of the NHS was critical of centralised approaches to improving performance and supportive of work designed to reform the NHS ‘from within’. ¹¹ This included valuing the role of managers within the NHS, including those from clinical backgrounds, and advocating the adoption of quality-improvement methods. ¹² The role of organizational cultures in shaping the experience of staff and patients featured prominently in the work programme.

Work on prevention and population health became more salient over time. As a result, the Fund engaged more closely with local authorities and voluntary and community sector organizations. This included drawing on international examples of population health as well as the growing interest in asset-based community development in the United Kingdom. Innovations in the private health care sector were explored where they offered learning for the NHS.

Influencing policy

Heclo’s seminal work argued that policymaking is both an intellectual activity and a political process. ¹³ By this he meant that it is an arena in which interests compete for influence and where policy makers puzzle about the course of action to take. This draws attention to the role of ideas and information in shaping policy alongside the role of pressure groups and others who lobby for specific outcomes.

A well-known framework in the literature on the policy process suggests that policy agendas are forged through the interaction of problems, policies and participants in a ‘policy primeval soup’. The policy process is complex and messy and not amenable to simple explanations. ⁹ Think tanks function as ‘policy entrepreneurs’ in advocating policy solutions alongside others seeking to influence policy.

Policy change tends to happen as a consequence of work developed over time rather than resulting from a single report designed to produce a specific output. The precise timing of change is often unknowable and certainly beyond the control of think tanks and others seeking to exert influence. Persistence, as well as timeliness, was therefore important in using ideas to influence policy.

This was illustrated by the example of integrated care which seemed a distant prospect when the Coalition government proposed an extension of competition within the NHS in 2010. Concern about the government’s plans led to a pause in the passage of legislation and an opportunity for the case for integrated care to be heard, successfully, in the listening exercise that was then undertaken. The Fund was one of a number of organizations making this case.

One way in which think tanks can exert influence is by shaping how issues are defined and debated, sometimes described as problem framing. An illustration was the Fund’s work on NHS finance and performance, which from 2011 onwards included quarterly reports based on the views of a panel of NHS finance directors and analysis of routine data. These reports tracked the steady decline in performance during the 2010s and underpinned arguments that the NHS required additional funding and staff to deliver national standards of care.

These arguments involved collaboration with the Health Foundation and the Nuffield Trust on a number of reports linked to government spending reviews. Leaders of the three tank tanks agreed to work together to offer a common assessment of the state of funding in the NHS and the scale of resources required to ensure a sustainable position. Their judgement was that the case for additional funding would be greater if they spoke with one voice rather than separately.

Collaboration was facilitated by relationships cultivated over a number of years and movement of staff between the three organizations. Joint work was also undertaken on social care and the NHS workforce where there was common ground. On other issues, relationships were sometimes competitive as each organization sought to make its voice heard and demonstrate its ability to make an impact.

A key priority for the Fund was to influence practice as well as policy. This meant writing reports with the needs of local NHS leaders in mind (described internally as aiming at Wolverhampton and Wigan as well as Westminster and Whitehall) and having the capability to work with these leaders and their partners in other agencies in carrying ideas into action.

Assessing the fund’s impact

Assessing the impact of think tanks is an inexact science and the methods used evolved over time. They included regular surveys through independent agencies to seek the views of stakeholders about the Fund’s work.

Stakeholders included members of parliament, civil servants and public officials, leaders in the NHS, local government and the voluntary sector, and researchers in universities and other settings. Respondents were asked for their opinions on the work of the Fund and its standing vis-a-vis sister organizations. Survey findings invariably confirmed the direction taken rather than requiring major changes in the Fund’s work.

The Fund also assessed impact by defining the changes it wished to see in each priority area of work and bringing together evidence from different sources on whether these changes were happening. The results were interpreted cautiously in view of the difficulty of isolating the influence of the Fund from that of others advocating change.

Data on media coverage of the Fund, use of its website and references in parliament to its work were also used to assess impact. The results were presented regularly to the board of trustees in the process of holding the chief executive and senior management team accountable.

Challenges

The Fund faced several challenges. On finances, the board challenged staff on the use of resources, given a commitment to maintain the value of the Fund’s endowment over the medium term. The requirement to raise two-thirds of its annual income (about £10 m) from sources other than the endowment was pursued in ways that did not compromise the Fund’s independence and were aligned with its charitable objectives.

An organization of around 130 staff is always faced with a challenge of retention as staff left to take on roles elsewhere. These roles included setting up new organizations including the Point of Care Foundation and the International Foundation for Integrated Care, which were incubated within the Fund. Staff also moved to more senior roles in related organizations such as the Nuffield Trust, NHS England and the Centre for Ageing Better.

Another challenge was the Fund attenuating its impact by undertaking too many functions. To avoid this, a decision was taken to close down the work of a team specializing in issues related to service improvement, and redirect resources to the policy team and other functions. Recognition that other organizations were better placed to undertake service improvement work informed this decision.

Policy outputs were identified as the work of named authors but were usually reported as presenting the position of the Fund. This could have caused tension if there was divergence between the views of individuals and that of the Fund, but the collegial working environment – as shown in regular staff surveys – meant that this rarely occurred.

The other side of the coin was the risk of group think. Recruitment of staff from varied backgrounds and a culture that encouraged internal debate and challenge were safeguards against this happening. The use of a range of stakeholders to advise on work as it evolved, including a panel of people with living and lived experience in the work of the Barker Commission, was another means of bringing in wider perspectives.

Finally, there was the challenge of social media. Guidelines were put in place on the use of social media, to avoid staff commenting on issues in a way that brought the Fund’s independence into question, however unwittingly.

Conclusion

In his review of the literature on think tanks, Pautz notes growing questioning in some quarters of the role of ‘experts’ in government. ¹ What then does the future hold for health policy think tanks like the Fund?

It is plausible to suggest that they will continue to exert influence if their work is of a high standard and seen to be independent of partisan or ideological bias. This work is beneficial in offering challenges to the policies proposed by political parties and suggesting practical alternatives. Transparency in how think tanks operate, for example, on sources of funding, is essential to maintain their legitimacy at a time when they face increasing scrutiny.