Christina: This is not an opinion piece about the current states of politics—nor is it a defense of the European Union. But it is hard to ignore a sense that many people feel remote from decisions that affect their lives. This made me reflect on some basic guiding principles of EU decision making, and how they influence who governs what.
EU policy and legislative making are firmly grounded in the Treaties of the European Union. The Treaties describe policy areas where the EU can act directly and those where Member States are sovereign (such as healthcare and public health).
The Treaties also set out principles of EU policy making. While some may wish to argue that the EU imposes its rules on the people, formally (and legally) the EU operates according to the principles of “Subsidiarity” and “Proportionality”.
Without dusting off the dictionary, or looking up the Lisbon Treaty itself, I think of these words as synonyms for power sharing, partnership, and, maybe most importantly, joint responsibility:
- Subsidiarity means that decisions affecting citizens should be taken as close to the citizen as possible. It is a presumption in favor of local (in the European case, this means national!) action. The legal definition refers to various levels of power, by defining the aim of subsidiarity as being to ‘guarantee a degree of independence for a lower authority in relation to a higher body or for a local authority in relation to central government’; and
- Proportionality sets boundaries around what the EU does. It aims to ensure that any EU action remains within its remit and in line with the objectives of the broader EU Treaties. Prior to finalizing EU action, one should therefore ask: is this action limited to reaching the objective it sets out to achieve?
I don’t claim that law or decision making at the EU level is easy, nor do I think that the EU always gets it right. I do, however, believe these basic principles help strike a balance between top-down decisions and local policy making.
Fraser: But what about acting in the absence of ‘hard’, formal powers? What is the EU experience there?
Christina: The area of public health at the EU level is a dense, intertwined forest of policies and decision-making. It is defined in Article 168 of the Treaty on the Functioning of the European Union as a ‘shared competence’. This means that Member States define and deliver their own national health and medical services; the EU’s role is to guide countries to improve public health, promote initiatives that work well (i.e. improve population health) and share knowledge among various stakeholders. Practically, this might mean studies, exchanges of people and information, benchmarking, mutual learning, and exploration.
While this may sound messy—and perhaps even raise a ‘cooks and policy broth’ problem—it has significant merits. Having organized multiple capacity building efforts for local and national health decision makers, most organizations I know want the EU to do more (soft) policy in public health. There is an appetite for knowing what works in different countries, for sharing knowledge and undertaking joint activities that provide EU added value to an area under intense strain and pressure—almost regardless of the Member State.
Fundamentally, this mode of policy making rests on an assumption that common problems are best addressed through mutual collaboration and exploration–not top-down prescription.
Fraser: What might this mean for the NHS? Taken seriously and in combination, it seems to me that these approaches could lead to a radically different—and far more localized—system.
My initial thoughts are that the principles of subsidiarity and proportionality would:
- Reverse one of the main operating assumptions of the current system. Instead of starting with a presumption in favor of national (top-down) action, subsidiarity would start with a (bottom up) focus on the capabilities of citizens, their families, networks, voluntary associations and neighborhoods;
- Instead of thinking that accountability always ‘goes up’, it would see accountability running in multiple directions, mainly at the local level and always back to the citizen. It would probably also see mutualism (where parties in the system would treat their relationships as symbiotic and two-way) as a more fruitful concept than simple (one-way) accountability; and,
- National policy making would be focused and used very sparingly, maximizing the latitude for locally-determined approaches. National programs would also be very different in nature; they would be more focused on facilitate, mutual learning between local areas – rather than the performance managed implementation of nationally-designed models.
Even this short list shows the potentially radical power of these principles. The list further shows that the gap between the current system and a ‘subsidiarity-friendly’ NHS is wide.
Finally, it is also not clear that a much more localized system would in fact be desirable, while it is abundantly clear that the practical, political and cultural hurdles would be significant. Much more work is needed to flesh this early thinking out!
Conversely, lessons from the EU on the use of ‘soft power’ instruments strike me as obvious. A more curious and networked system would be more able to create opportunities for disciplined experimentation, innovation, learning and adaption.
Doing this in a supported fashion, outside the influence of regulatory or performance management systems, would leave local systems more able to define their own problems, create their own solutions and improve their own outcomes. Here we should declare an interest, given that this is exactly the kind of work we find fruitful and stimulating.
It seems like an irony to be asking what the NHS can learn from the EU as Brexit proceeds, but the above suggests a value in that irony. We should keep learning from the EU experience, just as we would for any system trying to manage a central-local tension.
Let us know what you think by using #NHSEU and tagging @ICFHealth and @Strategy_Unit.