Fellow travellers in transformative times: a reflection on 21 years membership of the European Health Policy Group

1. Introduction

It must have been early 2000, around the start of the new Millennium. I was working as a junior lecturer/researcher at the then Institute for Health Care Policy and Management at Erasmus University in Rotterdam, the Netherlands. Still barely familiar with Dutch health care as a policy system, let alone with European health care policy systems I decided that it would be a good idea to attend a seminar of the recently established European Health Policy Group. I had heard good stories about this new multidisciplinary group, founded by Elias Mossialos and Adam Oliver. My PhD thesis supervisor, Tom van der Grinten, also went there, as did some of my colleagues from the Department of Health Economics and Health Insurance, people like Erik Schut and Wynand van de Ven for example. They were close colleagues of me, although our respective disciplines from which we studied health care policy were different.

The seminars were held at the famous London School of Economics (and Political Science). That alone instilled some awe in me as a young researcher. My nervosity was somewhat compounded because my supervisor had seriously advised me to purchase a nice (yet expensive) suit for this seminar at the LSE. So, I did, after all, who am I to ignore the advice of my supervisor! At Schiphol Airport, I met my colleague Erik Schut and since he was also wearing a tie for the first time in his life, I could not help but conclude that he had received the same sound advice. We set off for London, curious to see what awaited us. Well dressed and with a mix of curiosity and nervosity we entered the seminar room in the LSE Old building around noon, lunch was being served.

A quick glance at the attendees in the seminar room soon led us to conclude that we were completely overdressed. We immediately went to the bathroom and stripped ourselves of all the unnecessary, pretentious, clothes. Since then, I have never worn a tie, let alone a suit, when gone to the EHPG. This was not just another bunch of pretentious academics, I realised when I went home on Friday afternoon after two intensive days in London. These were, or would become, fellow travellers. It turned out that they became a very pleasant company of fellow travellers!

I have been an active member of the EHPG for more than 20 years. Two seminars each year. Same schedule every year. Each seminar would last 24 hours, from noon to noon, interrupted by a dinner on Thursday evening and a long evening at the pub. We would meet every year in September in London and soon decided to have Spring meetings in other European cities, hosted by the institute of one of our fellow travellers. Most often these where South European cities as we somehow preferred Mediterranean locations in Spring. And we became friends, with a preference for comfort.

From the very beginning, the group was a mix of health scientists, health economists, health lawyers, political scientists, and a dentist. Most of us worked in academics but we also had fellows from think tanks such as Nuffield Trust and Kings Fund or other national and European institutes, such as the European observatory on health systems and policy. Our fellow travellers came from the UK, Scandinavia, France, Germany, the Netherlands (with Rotterdam being an important Hub), Portugal, Italy of course, and I probably forget some countries since we also have had seminars in Krakow and Budapest. And there were some North-Americans with an interest in European health care policy attending the seminar, scholars like Joseph White, Richard Saltman, Ted Marmor, Carolyn Hughes Tuohy, Colleen Flood. We started our seminars at LSE but when Adam stepped down, we organised our Fall meetings at Kings Fund and some years later at the London School of Hygiene & Tropical Medicine, hosted by Nick Mays and Stefanie Ettelt. It very much depended on who the local organisers were in London. When Adam stepped down, Gwyn Bevan, Stefanie Ettelt and Anna Dixon took over. Accompanied by European continental co-organisers such as Zeynep Or and myself.

We were the so-called steering group of committee, although there was not so much to steer with this group. We always ended the seminar with a ‘business’ meeting in which we discussed new directions and destinations. The privilege of being one of the coordinators was that you had a pre-vote on the next location and the next theme. We certainly had a preference for nice locations, nice companions and not too many formalities. Illustrative, for example, is that we never managed to keep our own website up and running, despite some brave attempts of our dentist, Paul Batchelor. There was not much discipline in the group nor a thirst for formality. At Kings Fund, the Thursday evening dinners were organised with a table setting, but this did not work quite well for the group that we were. In fact, what brought and kept us together was a genuine interest in each other's health care systems and disciplines. So, we wrote and discussed papers and we more or less became the purveyor of Health Economics, Policy and Law (HEPL), a Cambridge University Press journal established by Adam Oliver in 2006.

During each seminar, we discussed up to six papers. Each paper session lasted at least an hour, usually an hour and a half. The paper was presented by the discussant, not the author. There was not much room for ego in the group. In later years, we also organised thematic sessions with a keynote or presentation by a national or local expert on that topic. And we started to think about, and work on, special issues and thematic sessions. We were fellow travellers in transformative times. Trying to make sense of how our health policy systems work, or did not work, and how they were being reformed during times of austerity, and later also because of Brexit and the Covid-19 pandemic.

2. Legacies and latitude: a rough guide

We travelled through transformative times. David Cutler (2002) distinguished three successive reform-waves in the history of health care. During the first wave, from the beginning of the twentieth century until the end the 1960s, governments were mainly concerned with promoting equal access based on equal needs. The issue of universal coverage and the enactment of national health insurance have led to long during conflicts between medical practitioners, insurers, employers, employees, and the government (Immergut, 1992; Blake and Adolino, 2001). Once these conflicts had been largely settled – by the second half of the twentieth century – two dominant health care systems could be discerned; a tax-funded National Health Service (Beveridge-system) and a Bismarckian social insurance system, often complemented with private health insurance (Saltman et al., 2004). Against the background of the economic crises of the 1970s, a second wave of reforms reached the beaches of Europe. Governments became more and more concerned with cost containment by means of rationing health care services and controlling access to health care (Mossialos and Le Grand, 1999).

While governments were indeed able to limit the growth of their health care budgets, by the 1980s, scepticism was increasing about the effectiveness of supply-side regulation in health care. The ageing of the population, technological progress, and economic growth continued to raise public expectations and, consequently, public expenditure on health care, while cuts in health care spending by means of expenditure caps and supply-side and demand-side rationing were provoking strong opposition. What is more, the tools being used – expenditure caps and supply rationing policies (price control of services and drugs, as well as their volume) were adversely affecting the efficient allocations of resources in health care provisions.

This, in turn, created a window of opportunity for a third wave of health care reforms in which some countries looked for market-oriented solutions to contain overall health care expenditure while at the same time enhancing the efficiency in health care delivery (Cutler, 2002). Incorporating Alan Enthoven's (1978) ideas about ‘managed competition’, competition in health care was being introduced in the purchasing and provision of medical care (the so-called purchaser/provider split) as an alternative to regulatory limits on health care costs and implicit or explicit rationing policies.

We, the fellow travellers, were surfing on this third wave of health care reforms. There is this quote that I found in an early article written by Albert O. Hirschman and Charles S. Lindblom, notably an economist and a political scientist who had discovered that they were using similar arguments in their attempts to understand the political economies of their times. They wrote: ‘Detailed descriptions of types of incremental meandering would also be interesting; perhaps this would more clearly differentiate between a sequence that led to reform and another that leads to revolution.’ (Hirschman and Lindblom, 1962: 221). This quote tells exactly what drove us in those early years of the EHPG. We tried to get a grip on the waves, the current and the tide of these reforms.

Given the causal interference of social, political, and economic factors, health care has always stimulated the development of multidisciplinary approaches, all concerned with what Hirschman (1994) calls the on-and-off connections between political and economic progress. For sociologists, health care is a critical case for the study of the transformation of social stratification patterns and cleavage-structures in Western societies. For economists, health care is one of the most ambitious and contentious projects of capitalist industrial democracies; aimed at the trade-off between the maximisation of economic wealth and the efficient and just allocation of scarce resources. For political scientists, finally, there is no area in which the efficiency and legitimacy of state intervention vis-à-vis the market has been debated as much as in relation to the welfare state. Equal access to reflect the equal needs of all citizens is still a key value in modern health care systems. Health care ought not only to be distributed according to need, but also subsidised according to the ability to pay (Wagstaff and Van Doorslaer, 1993). From this perspective, the widespread scepticism about the feasibility of market-oriented reforms in health care was understandable. But such scepticism was also fostered by arguments that question the instrumental, technical, and institutional suitability of the market as a governance arrangement in health care. And, fair enough, we were equally sceptical about hierarchical bureaucratic solutions for health care governance.

We, as a multidisciplinary group of health policy analysts, found each other in our fascination for the complexity of health care and we accepted that this complexity has consequences for health care governance in the sense that we will always end up with ‘second best’ solutions (Arrow, 1963). In Wealth of Nations, Adam Smith already had argued for the necessity of professional self-regulation by physicians as an alternative to the ‘invisible hand’ of the market because of the asymmetric distribution of medical knowledge (Smith, 1776). Kenneth Arrow's seminal article about uncertainty and information-asymmetry in the medical care market served as a sort of core paradigm in health economics in the sense that it became an undeniable truth that any medical market would not only be inequitable, but highly inefficient as well (Arrow, 1963). According to the sociologist Donald W. Light, the appeal to competition in health care was mainly politically and ideologically informed, not supported by any scientific evidence, and therefore potentially devastating in its consequences. ‘The myth of efficiency, productivity, and accountability trumps the myth of trustworthy expertise applied altruistically to the needs of patient … client, I mean customers. It is the master myth of society.’ (Light, 2000: 971). In ‘Speaking Truth to Power’, finally, the American political scientist Aaron Wildavsky once argued that the ‘pathology’ of health care policy is that the past successes of medicine are likely to lead to future failures in health care policy. For, as life expectancy increases, only partly as the result of medicine, a nation's health care system is faced with an older population whose ailments are more difficult to treat, sending the costs of treatment ever higher while each improvement in health and medicine becomes more expensive than the last. It is the ‘doing better but feeling worse’ syndrome of the late modern welfare state which, in the end, will also undermine solidarity, since: ‘the rich don't like waiting, the poor don't like high prices, and those in the middle tend to complain about both.’ (Wildavsky, 1979: 285). One could also argue, as Robert G. Evans for example did in his reflections on a special issue that we did for the Journal of Health Politics, Policy and Law about the legacies and latitude in European Health Policy, that sustaining solidarity in a market-like environment requires such strong and sophisticated regulation that ‘it resembles riding north on a southbound horse.’ (Evans, 2005: 286).

This special issue in the Journal of Health Politics, Policy and Law was one of the first fruits of our attempt to get a grip on changing health care systems. Adam Oliver and Elias Mossialos had taken the lead as guest-editors and together we produced eleven country-specific papers about the Legacies and Latitude of European Health Policy reforms. In his editorial note, Mark Schlesinger wrote:

The European Health Policy Group, through embracing a common conceptual framework for this study, nonetheless brings together authors with diverse scholarly interests and disciplinary training […] As a result, the authors of different case studies were sensitive to different aspects of health-policy making. This makes it harder to compare their conclusions in a sensible manner. But it also makes for a richer and more nuanced portrayal of the trajectories and juncture points in health care reform. (Schlesinger, 2005: 3)

The special issue can be read as a detailed guide of transformative health care systems. According to Mark Schlesinger, we had every reason to be proud of this collaborative achievement. And so, we were! We were Fellow Travellers on contested paths with a Lonely Planet in the pocket, and we were keen to continue our journey.

3. Travelling across issues, countries, and time

Adam Oliver took the initiative to start a new Journal on Health Economics, Policy and Law. The first issue was published in 2006 and HEPL would become our Rough Guide of European health policy systems. Now that we had proven to be able to work together, we could think of more sophisticated combinations of authors and disciplines. We looked for topical themes that we discussed during a series of seminars. In 2010, we published a special issue in HEPL on cross-country issues in health care: about choice, equity, efficiency and cost (Bevan et al., 2010). In 2012, Anna Dixon and Emmi Poteliakhoff (2012) were the guest-editors of another special issue on 10 years of European health reforms. A special issue with observations from Richard Saltman, Adam Oliver, Theodore Marmor and Carolyn Hughes Tuohy and several comparative papers on specific issues. In 2015, we did a special issue on the global financial crisis and its effects on health and health care (Appleby et al., 2015).

Brexit was one of these themes that concerned us deeply, also because it potentially undermined the prospects of our European group and it immediately caused for uncertainty for our non-British colleagues working in the UK. Tamara Hervey did a great job in explaining to us the ins and outs of Brexit in relation to the British NHS and to British politics in general. And, finally, in January 2022 a special issue was published on the country responses to the Covid-19 pandemic.

The Covid-19 pandemic also meant a temporary break from a long series of noon-to-noon seminars in London or in other European cities. Of course, we tried to organise the EHPG seminars online. But for this bunch of fellow travellers, the online option simply did not work. I decided to hand over my coordinating role to others. It is fair to say that I had also found other fields of interests in my academic life and that my Vice Deanship took much more time and effort than expected (and on occasion also required me to wear a suit). Others have taken over and the European Health Policy Group is alive and kicking. It is how life goes, I guess. But it also meant a sad farewell to friends. So, when we were allowed to return to London in June 2022, for the celebration of the 21st anniversary of the group, I immediately decided to catch the Ferry and to make the crossing to good old England. The reception was on the roof terrace of the Marshall building of the LSE, symbolising a journey that started at the Old building and now had arrived at the newest building of the LSE. There we stood, fellow travellers as fiddlers on the roof in times of turbulence and change.