It’s the economy, stupid! When economics and politics override health policy goals – the case of tax reliefs to build private hospitals in Ireland in the early 2000s

Irish economic, political and health policy context

Economic and political context. Between 1995 and 2005, Ireland experienced exceptional economic growth with annual growth rates between 5% and 10%% (Whelan, 2009). Between 1995 and 2000, real GDP growth averaged 10% a year, way beyond growth rates in other European countries (Honohan, 2002).

This expansion, which was subsequently found to be unsustainable, was driven by a pro-cyclical economic policy, largely dependent on Foreign Direct Investment; and a property boom fuelled by government tax-reliefs and over-generous, unsound lending practices by banks. These factors, combined with low interest rates, which were predetermined by Ireland’s Eurozone membership, fed ‘an orgy of borrowing and consumption’ (Kirby, 2010 : 4).

Irish economic growth came to a sudden end in 2007/8, at the onset of the global financial crisis (Bergin et al., 2011). By 2010, borrowing rates were unsustainable and Ireland entered an EU/IMF/ECB (European Central Bank) bailout (Department of Finance, 2010).

Two national political parties, Fianna Fáil and the Progressive Democrats (PDs), were in power continually from 1997 to 2007 (Murphy, 2008). Fianna Fáil, which was self-styled as the ‘republican party’, was the largest, oldest, dominant party in Ireland. ‘At its most basic level, Fianna Fáil is nationalist – culturally, politically, and economically P 50 (Puirséil, 2017). However, Fianna Fáil’s ideology has always been ‘ambiguous’ with the party showing itself to have ‘chameleon-like qualities in coalition’ moving to the left while in coalition with the Labour party in the early 1990s and towards the PD’s between the late 1990s and early 2000s P 67 (Puirséil, 2017) (O’Malley & McGraw, 2017).

Popularly known as the PDs, the Progressive Democrats party, which was formed in the late 1980s by a group that split from Fianna Fáil, pursued economically liberal policies with a strong low-tax, pro-business and pro-market focus (Collins, 2005). Although the minority party in government for ten years from 1997, they had considerable influence over government policy, especially economic policy (Leahy, 2009). Their leader, Mary Harney, was Tánaiste (deputy prime minister) and from 2004 until 2010 she was the Minister for Health. In government, the PDs held considerable influence over health policy even before occupying the health ministry (Wren, 2003).

The Minister for Finance from 1997 to 2004, Charlie McCreevy, was a senior Fianna Fáil member closely allied with the PDs and their leader. Fianna Fáil adopted the PD’s position on many issues in the late 1990s and early 2000s, with ‘little obvious difference in ideology between the two. This owed much to the personality of the Minister for Finance, who was a PD in all but name,… increasingly Fianna Fail became associated with the finance industry and developers’ (Puirséil, 2017: 67). Together, the PDs and the Charlie McCreevy had significant influence over Government policy (Collins, 2005; Leahy, 2009). (Puirséil, 2017)

Health policy context

In 2001, a new health strategy ‘Quality and Fairness’ was published, which outlined 121 actions in a seven year reform programme (Department of Health, 2001). The Strategy proposed many measures, of which few were achieved, as most reform efforts went into restructuring the health system from eleven old health boards into one Health Service Executive in 2005 (Burke, 2009; Smith & Normand, 2011).

During the 1990 and early 2000s, public hospitals were under increasing pressure to treat more public patients, to reduce waiting times as well as meet the demand for those with private health insurance (Department of Health, 2001). In 2000, there were limited numbers of beds in standalone, private for-profit hospital beds with some parts of the country without any private hospitals (Wren, 2003). Research published in 2018 found that in the year 2000, there were 6,920 beds in 37 public hospitals, 6,116 beds in 34 private not-for-profit hospitals and 335 beds in four private for-profit hospitals (Mercille, 2018).

As public finances expanded significantly, the Irish public health budget quadrupled between 1997 and 2007, rising from €4 billion to €16 billion (Department of Health, 2010). This rise reflected the economic growth and increased expenditure across spending departments, especially on wages. Analysis on the differences in health expenditure across 30 OCED countries in the early 2000s found that 90% related to GDP per capita (Department of Health, 2010). Analysis of this period of increased spending, undertaken by an Irish government commissioned expert group on resource allocation and financing, stated:

Research on the determinants of health expenditure has shown that there are three main factors which drive increases: 1) national income; 2) population age structure; and 3) institutional features of the health-care system (Propper, 2001). The expert group which reported in 2010 found that these factors were applicable to Ireland at that time. Examination of trends in Irish public health expenditure, national income, population size and composition and prices reveals that the same associations are largely supported by Irish experience over the period 2000–2009 (Department of Health, 2010).

Much of this increased investment was making up for decades of under-spending, when Ireland spent well below the OECD average on health (Wren, 2003). Ireland’s average health spending per capita between 1995 and 2008 came seventeenth of 25 OECD countries (McDonnell & McCarthy, 2010).

Capital spending in Ireland between 1997 and 2002 was above the EU per capita average, however this ‘should be seen against a backdrop of the twenty-seven preceding years from 1970 to 1996 in which Irish (capital) investment averaged only 66% of the EU average’ (Wren, 2004: 2). Between 1990 and 2002, Ireland’s spending on its public capital health infrastructure varied between 0.22% and 0.49% of GDP (OECD, 2017).

While public current spending on health increased in the 1990s, there were few attempts to reform the financing or inequitable structure of the Irish health system (Department of Health, 2010). Ireland’s inequitable and inefficient public private mix of healthcare is well documented, characterised particularly by the absence of a universal primary care system and inequality in access to the public hospital system, in that those who can afford to pay privately get preferential (quicker) access to public, as well as private, hospital beds (Burke, 2009; Department of Health, 2010; Tussing & Wren, 2005; Wren, 2003).

Documentary analysis

The following databases were searched for relevant documents:

However, very few Irish specific documents were found; therefore snowballing methods were used to source relevant documents referenced in government reports and grey literature. A novel feature of this academic research was to use Freedom of Information requests to obtain documents not in the public domain, as well as asking each interviewee for documents relevant to the research. This yielded dozens of documents, so only those directly relevant to the changes to finance acts were included.

Thirty-six primary and secondary documents were analysed in order to trace relevant policy developments. These are listed in Supplementary File 2. The primary documents related directly to the Finance Acts while the secondary documents provided background for political, health and economic policy developments.

Interviews

Twenty one in-depth interviews were carried out with policy elites involved in the policy processes by the lead author during 2010 and 2011. Questions asked are in Supplementary File 1. The lead author had at that time over a decade of experience of interviewing people for health policy/services research.

Elite interviews are with ‘individuals considered influential, prominent, and well informed’ (Marshall & Rossman, 2011). Everyone interviewed for this research was ‘elite’, in that they were senior ministers, political advisors, senior departmental and health services officials; owners or chief executives of private hospitals; senior medical personnel or representatives of private hospitals. Snowball and purposive sampling were used to identify and recruit the interviewees (Marshall & Rossman, 2011). The research protocol and instruments were approved by Trinity College Dublin, School of Medicine’s Ethics Committee in 2009. The participant information leaflet and informed consent form are in Supplementary File 3 and Supplementary File 4.

Interviewees were guaranteed anonymity and confidentiality. Given the small size of Ireland and the policy making community, interviewees (IVs) are referred to by numbers, as saying they are a departmental official or a minister or an advisor could make them identifiable. One interviewee is identified in the text as he published a memoir subsequent to the interview where he retold what he had told in the interview and it is now in the public domain (Sheehan, 2013).

Two key interviewees turned down the request for interview. In order to mitigate against bias, i.e. there is a probability that those who gave interviews were more favourable to the research, in instances where just one person or a small minority of people made a point, this is made clear in the analysis. Also triangulation of findings from the documents was used to support and verify points made by interviewees. In particular, documents obtained through FOI were used as these often stated the actual position rather than the official public or political position at the time. These were used as prompts in the interviews to validate or challenge points being made.

The strengths of the methods are the in-depth analysis of the policy making process, which allows not only a description of what happened, but also allows for an analysis of what explains what happened. The limitations of the case is that it is just one case that may be atypical of policy making processes.

Policy characteristics

Variable 1 – the severity of the problem. Public policy literature details the importance of clarity on the extent and the nature of the policy ‘problem’ and the extent of consensus on it in relation to the policy process and in particular agenda setting. Specifically, Kingdon, Walt and Gilson and Shiffman et al. highlight how this variable plays a crucial role in a ‘problem’ moving up the political agenda becoming a policy choice or decision.

Variable 2 – ideas for intervention. There is a large body of policy literature identifying where the ‘solution’ comes from, the idea for intervention, its origin and if and when potential alternatives emerge. The selection of this variable was influenced by Kingdon’s notion of the primeval soup from where policy ideas emerge, the importance of policy content and characteristics as identified by Grindle and Thomas, Walt et al. and Shiffman & Smith This literature draws attention to the importance of available alternatives during the policy process where new solutions can emerge as the alternative and become the policy choice.

Actor power

Variable 3 – guiding institutions. The key role played by institutions and actors in particular gained greater precedence through Walt and Gilson’s policy triangle. David Wilsford’s work on path dependency specifies how institutions can be central to maintain the status quo rather than bringing about change. Kingdon notes the need to pay attention to policy communities who have a key role to play in influencing the policy process. Grindle and Thomas identify how institutions play a key role during non-crisis, ‘politics as usual’ situations of policy change. ‘Institutions’ have a key influence on the extent to which an issue gains traction, becomes a priority and is actually addressed in public policy measures.

Variable 4 – the role of policy entrepreneurs. Kingdon’s classic work on why policy issues rise onto and fall off governments’ agendas, identified the problem, policy and political streams that come together at a certain moment in time to form a policy window, and this window is often opened by a policy entrepreneur (Kingdon, 1995). Kingdon defines ‘policy entrepreneurs’ as ‘advocates who are willing to invest their resources – time, energy, reputation, money – to promote a position, in return for future gain’ (Kingdon, 1995: 179). Kingdon identifies how policy entrepreneurs are ‘not only responsible for prompting important people to pay attention, but also for coupling both problems and solutions to politics’ (Kingdon, 1995: 18). Kingdon also points out how there is no single formal or informal position for policy entrepreneurs, they can be a cabinet secretary, lobbyist, civil servant or academic.

While Walt and Gilson did not use the specific term policy entrepreneur, by putting actors at the centre of the policy triangle they are drawing attention to the role of individuals and the organisations in which they work, play in the policy process. Grindle and Thomas outlined the importance of the perception and behaviour of policy elites and ‘how their actions can be understood as manoeuvring within constraints and opportunities created by context, circumstance and policy characteristics’ (Grindle & Thomas, 1991: 188).

Variable 5 – private sector interests. While there has always been a focus on the role of government and public institutions in what and how policy gets made, Shiffman & Smith, Grindle and Thomas and Walt et al. each highlight the need to pay equal attention to the role of private sector interests in the formulation of health and public policy.

Political contexts

Variable 6 – political ideology. This variable encompasses the importance of historical, economic and political context as well as the political institutions that influence the policy choice. Touhy highlighted the importance of political context in policy change. Kingdon devised a specific political stream to represent the importance of politics in the policy process. Walt and Gilson included the political and economic context as key to ‘context’ as one of the variables in their policy triangle. Grindle and Thomas and Shiffman & Smith each specify the need to take into account the political concerns and ‘interests’ of decision makers, the political ideology and the political decision process, while David Wilsford links path dependency to existing institutions as detailed below:

Variable 7 – policy process/window of opportunity. Policy literature is as much concerned with the policy process that led to a particular policy’s development and or its implementation as much or more than the actual policy content (Grindle and Thomas, Walt and Gilson). When Kingdon’s three streams (problem, policy and political) come together, he describes this as the window of opportunity which creates a possibility for change. These do not come along too often as much policy change is incremental, but occasionally, often due to the political context as identified by Touhy and Wilsford, critical change can occur in ‘windows of opportunity’ or ‘exceptional opportunity’. Grindle and Thomas focus on windows which occur often after a significant crisis or seismic event which often open these ‘exceptional windows’.

Interdependency of the variables. While the three themes and seven variable emerging from the policy literature are independent in the conceptual framework, there is an explicit recognition that they are interrelated and often overlap. For example, actors and policy entrepreneurs are influenced by what policy is deemed a political priority and the economic, social and political context that they are operating within.

The conceptual framework developed for this research was devised by merging and combining aspects of the work referenced. All interviews were transcribed, coded, recoded and distilled using NVivo 9 under themes and variables identified in a conceptual framework specifically. NVivo allows the researcher to organise and classify data, to work through the data systematically so as to ensure a rigorous justification for the findings and an audit trial of analysis and findings (Bazeley, 2011). All material was then analysed using this conceptual framework as outlined in Table 1. Table 1 includes the original literature from where the variables were derived.

Policy characteristic

Severity of problem. By 2000, there was widespread agreement inside and outside the health system that the shortage of public hospital beds and the associated long waits for public patients in emergency departments and for hospital admission for elective treatment was one of the major challenges facing the Irish health system (Department of Health, 2001).

Simultaneously, there were increasing numbers with private health insurance without much choice in private hospital options. By 2001, over 47% of the population had private health insurance, which facilitated faster access to care in public as well as private hospitals (HIA, 2013). Private health insurance contributed towards less than 7% of overall health expenditure in the early 2000s (OECD, 2004).

While there was agreement about the shortage of public beds and long waiting times experienced by public patients, there was significant disagreement as to the causes. Government decisions had closed large numbers of public hospital beds in Ireland during the 1980s economic crisis (Wren, 2003). By 2000, in line with international trends, there was an expectation of a falling need for hospital beds facilitated by advances in medical technology, shorter lengths of hospital stays and increased numbers of day cases.

Since the 1990s, government policy stipulated that a maximum of 20% of patients treated in public hospitals can be private patients (Wren, 2003). In 2002, after this policy was restated in Quality and Fairness, 25% of public hospital discharges were found to be private and in some hospitals up to 40–50% of patients were private (Comptroller and Auditor General, 2003). This high demand for private treatment in public hospitals, combined with incentives, encouraged doctors and hospitals to prioritise private patients over public patients and exacerbated two-tier access to hospital care (Burke, 2009).

The main explanation given by interviewees for the shortage of public hospital beds was the failure to invest in the capital public health budget.

As specified earlier, Ireland’s capital spending was higher than EU average between 1997 and 2002 but that was making up for 25 years of underspending on capital health infrastructure (Wren, 2004). Interview data revealed the perception that if the public system was not going to invest sufficiently in building public hospital beds then tax breaks were a good way to incentives the private sector to do so.

As detailed earlier in this article, there were very few private for-profit hospitals and beds in 2000 when compared to the proportion of the population with private health insurance (Mercille, 2018).

Ideas for intervention. The long waits for public patients needing admission to public hospitals emerged as a central issue in the 2001 national health strategy (Department of Health, 2001). Arguments for and against whether private hospital capacity would assist in alleviating public hospital capacity was evident in both the documents analysed and the interviews. What emerged were two totally separate policy processes – one in the Department of Health where the majority of expansion was envisaged through investment in and expansion of the public system (Department of Health, 2010). The other in the Department of Finance, where the idea of incentivising private sector capacity through tax reliefs for developers was facilitated by the Minister of Finance.

‘Quality and Fairness’, which was published in 2001, included a key proposal to increase the numbers of hospital beds by 3,000, 650 of which were due to come on stream in year one, 450 of which would be publicly provided (Department of Health, 2001). The strategy specifically stated under action 78 –

   Additional acute hospital beds will be provided for public patients:

Quality and Fairness was published in December 2001 but was developed during 2000 and 2001. While there was a large public consultation process and parallel policy development process involving national and international stakeholders for Quality and Fairness, many of the key decisions were made in meetings not in the public domain (Department of Health and Children, 2001; Wren, 2003).

In parallel, in 2000, the Department of Finance was developing the annual Finance Act, which is the primary legislation that brings the provision for the national budget into effect. The development of the Finance Act takes place behind closed doors. In the national budgets in the years up to 2001, there had been a proliferation of tax-reliefs, which gave tax breaks to developers to build hotels, houses, apartments, car parks, and shopping centres (Commission on Taxation, 2009).

Tax-reliefs were a central instrument of government policy, which fuelled the economy and a construction industry boom, which in turn generated huge tax revenues for successive governments. Tax-reliefs allow individuals or companies to pay less tax due to ‘reliefs’ (Department of Finance, 2011). Ireland had 245 tax-reliefs in the 2000s, a far higher number than any other OECD country (Commission on Taxation, 2009). There was unanimity among interviewees in this study that the changes to the Finance Act in 2001 and 2002 that gave tax-reliefs to build private hospitals were an extension to healthcare of the model used in other sectors. While there was consensus on the problem of the shortage of public hospital beds, there was little consensus on the solution. Some interviewees spoke about how tax reliefs to incentivise private hospital development were seen as a politically acceptable alternative to public sector investment.

The tax breaks when proposed were seen as a potential solution amongst the interviewees with hindsight but at the time were vehemently opposed by officials in the Departments of Health and Finance evident in the section below.

Actor power

Guiding institutions. The guiding institutions in this policy’s development were the government departments of finance and health. Documents obtained show that officials from both departments opposed the changes to the Finance Acts in 2001 and 2002, which gave tax breaks to build private hospitals. Differences between the ministers of Finance and Health are also detailed, showing the health ministers opposition to the proposal.

In one communication between the Department of Finance and the Department of Health, a Finance official said:

In response, a Department of Health official said:

These findings were reinforced by the interview data

These show that senior civil servants in both government departments and the Minister for Health’s were opposed to the introduction of tax reliefs.

The role of policy entrepreneurs. Two policy entrepreneurs emerge clearly from the documents. In the first year that health institutions were included for tax-reliefs, James Sheehan, a surgeon and co-owner of Ireland’s first stand-alone private hospital, lobbied finance minister McCreevy seeking tax reliefs for ‘charitable’ i.e. not-for-profit hospitals. Sheehan was at the time in the process of looking for investors in a private hospital he wanted to build in Galway. This was originally planned as not for profit but became a for-profit hospital in order to secure investment to get the Galway Clinic up and running (Sheehan, 2013).

In November 2000, Sheehan wrote to the Finance Minister:

Communication between the finance and health departments at the time reflect this.

This finding was verified by interview data:

A response from the Department of Finance specified ‘the Minister is inclined to extend the tax-relief sought by Sheehan’ (Department of Finance, 2000).

The 2001 Finance Act included stipulations that gave tax breaks to developers to build private hospitals with stipulations that hospitals would have more than 100 beds and be of charitable status (Department of Finance, 2001).

In 2002, a representative of private hospitals, Michael Heavey, lobbied the government for the tax-reliefs to be extended to for-profit hospitals.

Some of the interviewees spoke about how this was a direct result of lobbying the Minister of Finance by private sector interests, specifying Michael Heavey who them represented the private hospitals.

The Finance Act 2002 was amended to include the provision of tax free finance for the development of for-profit hospitals and the number of beds required was reduced to 70 (Department of Finance, 2002).

This is verified by FOI material which includes a letter from Michael Heavey, who was representing private hospitals to the health minister Michael Martin, making the case for smaller hospitals and those which were not charities to be included (Heavey, 2000).

'Why should these hospital [for- profit and under 100-bed hospitals] not qualify for relief?' (Heavey, 2000).

Private sector interests. The extent of private sector influence is evident from the fact that the two policy entrepreneurs that directly influenced the changes to the Finance Act over the two years were from private hospitals. In one communication between the Departments of Finance and Health during this time, a hand-written note from a senior finance official stating that the Minister was under pressure from private sector interests - Jimmy Sheehan – the owner of a private hospital to introduce tax reliefs (Department of Finance, 2000a).

One interviewee stated:

Every interviewee was asked about the extent of lobbying. All of the public sector interviewees acknowledged that lobbying took place at a political level. Politicians and/or political advisors interviewed concurred and in two instances specified times and dates that they lobbied which were verifiable through the documents obtained under Freedom of Information,

Political contexts

Political ideology/institutions. The senior partner in successive coalition governments, Fianna Fáil, was in power continuously from 1997 to 2011. Fianna Fáil, traditionally had a strong working class base; however, during its time in office, it shifted to the right as government economic policy was driven by the PDs (Leahy, 2009; Puirséil, 2017). Recent political science analysis has found that Fianna Fáil were ideologically ambiguous, more pragmatic than ideological,

Although the Minister for Finance, McCreevy, was a long standing Fianna Fáil member, his political ideology and economic policy was considered closer to the PDs’ policies (Leahy, 2009). McCreevy was a close ally of PD leader Mary Harney, and their influence was referred to, both in the media and in interviews for this study, as the ‘McCreevy/Harney’ axis (Leahy, 2009) (Puirséil, 2017). This Harney/McCreevy axis shared an ideology and belief in tax-reliefs as an efficient tool for capital investment and the achievement of public policy goals.

The role of the private sector emerged as a strong theme in the interviews.

Another finding emerging from the interviews was that the existing mix of public and private healthcare allowed for increasing private provision without any real public or political scrutiny of the development.

One of the clearest findings of this research is the political nature of the policy making process. In the case of the introduction of tax-reliefs to health, it was policy making outside of the health domain, which led to a large increase in the numbers of beds in private, for-profit hospitals.

These changes to the finance Acts in 2001 and 2002 resulted in a disproportionate increase in the numbers of private hospital beds. Figures published in 2018 show a threefold increase in the numbers of inpatient beds in private for-profit hospitals between 2002 and 2010, while the numbers of beds in public and voluntary hospitals declined during this time (Mercille, 2018).

Policy process/window. Two separate policy processes were in train while tax-reliefs to build private hospitals were introduced. The first was the public process of developing a new national health strategy, which started in autumn 2000 (Department of Health, 2001). The other was the annual budget development process, which ran throughout the autumn in the run up to the December 2000 budget and culminated with the publication of the Finance Act in March 2001.

Interviewees confirm what the documents show: that the tax breaks were driven by the Minister of Finance, McCreevy, and that health officials and the health minister had little success in their opposition.

Some of the interviewees explained how the development of the Finance Act worked to the exclusion of other government departments, even if it related to them.

Sheehan, when interviewed, claimed that he drafted the wording that appeared in the legislation.

This is verified in two FOI document used in this research. One health official stated ‘the Minister is under pressure from Jimmy Sheehan to concede tax incentives for his project’ (Department of Finance, 2000a). Days later a finance official in the Department of Finance wrote to the Department of Health stating ‘The Minister is inclined to extend the tax relief sought by Sheehan’ (Department of Finance, 2000). Sheehan has subsequently written publicly about this matter ((Sheehan, 2013)). This scenario was put to and corroborated by other interviewees.

The subsequent changes made the next year were directly influenced by the representative of the private hospitals lobbying the finance minister. This too was corroborated by the documents and interviews. The 2001 and 2002 tax breaks for private hospitals resulted from lobbying, behind closed doors, with no public or political debate about their possible impact on access to public hospital care and the quality of care. In 2018, private hospitals are not regulated and are not included under the remit for quality appraisal by state regulator HIQA (the Health Information and Quality Authority).

Reflections on the conceptual framework and methods

The conceptual framework devised for this research drew on key health and public policy texts. While three themes and seven separate variables were identified, central to the framework was the interrelatedness of the variables. The findings from the documents and the interviews were then coded, recoded, distilled and analysed through the framework.

In some places, data were double or treble coded e.g. the justification for using the private sector to address the long waiting times for public patients was coded in ‘ideas for intervention’, ‘political ideology’ and ‘private sector interests’. If unsure where best to code/recode/distil them, this was discussed by the lead author with the co-authors and a judgement was made as to where best to use the data. The coding, recoding and distilling of the rich data gathered allowed not just for a description of the policy process but an in-depth analysis as to why this policy choice was made and who and what influenced the policy process under the seven variables.

The inclusion of the ‘policy window’ in my conceptual framework allowed the authors to gain more insight and to utilise the interview content to explore the policy process. Examination of the policy window revealed unknown or unreported aspects of this policy making process. It found that the Minister for Finance, who was lobbied by a private hospital developer, then invited him into the department to assist with drafting the relevant sections of the act, which gave tax reliefs to build private not for-profit hospitals. The following year, after more lobbying the Act was changed to reduce the hospital size and include for-profit hospitals.

The ‘policy windows/process’ variable reinforces the importance of examination of the interaction of interests, ideas and institutions, an analytical paradigm that integrates political, processes and power as originally proposed by Walt & Gilson (1994) and later developed (Gilson & Raphaely, 2008). The findings also support the literature which advocates the study of policy should be as much about what was not done as much as what is done (Gilson et al., 2011; John, 2012; Walt et al., 2008), as well as identifying the perverse and unintended consequences of policy decisions.

The conceptual framework devised for this research provided a useful tool through which to organise and analyse the material garnered from the interviews and the documents. This research reiterates recent calls for rigorous research into and analysis of health policy making (Gilson et al., 2011; Walt et al., 2008). With clear methods and a firm theoretical grounding, there is much scope for further theoretical and empirical work.

The use of documentary analysis and key informant elite interviews was appropriate for this type of research, producing large volumes of rich data. The use of Freedom of Information requests added greatly to the data gathered as they revealed what was going on behind the scenes in the Department of Health and the Department of Finance, which was not evident in the publicly available documentation. This documentation allowed the researcher to verify or challenge findings in the interviews.