Social Science and Public Policy

Richard Freeman

backpublications - journal papers

Reciprocal instrumentalism: Scotland, WHO Europe, and mental health
Smith-Merry, J, Freeman, R and Sturdy, S

This paper explores the relationship between the World Health Organization’s Regional Office for Europe (WHO Europe) and Scotland in the context of mental health. Since devolution Scotland has gained autonomy as a constituent country of the United Kingdom and has developed a reputation for progressive mental health policy. Scotland has also become increasingly involved in WHO, notably in the development of the Mental Health Declaration for Europe. In this paper we examine the interactions that regulate the relationship between these two actors in order to determine how and why the relationship was built. Our analysis draws on interviews with individuals involved in the development of the Declaration and its accompanying Action Plan alongside an analysis of related texts. We observe that the relationship between Scotland and WHO was created and perpetuated through personal communication, meetings and the joint production of documents, in a way that mutually validated the policy aims and agenda of both actors.

Publication Type: journal paper      Source: International Journal of Public Policy 9 (4/5/6) 260–276
Date: 2013       Link:

Making knowledge for international policy: WHO Europe and mental health policy, 1970-2008
Sturdy, S, Freeman, R and Smith-Merry, J

It is widely agreed that the effectiveness of the World Health Organization (WHO) as a policy body derives chiefly from its reputation as a source of authoritative knowledge. However, little has been done to show just how WHO mobilises knowledge for policy purposes. Rather, commentators tend simply to assume that the WHO is a technocratic organisation, which uses technical expertise to define normative, universally-applicable standards on which to base policy. This paper tells a rather more complex story. Looking in detail at the efforts of the WHO European Regional Office, since the 1970s, to reform mental health policy across the region, it shows that the organisation’s main policy successes in this field were achieved, not by circulating standardised data or policies, but by creating opportunities to share holistic, experience-based and context-sensitive knowledge of instances of best practice. We go on to analyse our findings in light of ideas about 'epistemic communities', and show how an appreciation of the nature and constitution of epistemic communities can illuminate the different ways that knowledge may inform international policy.

Publication Type: journal paper      Source: Social History of Medicine, forthcoming
Date: 2013

For a (self-)critical comparison
Freeman, R and Mangez, E

This paper reflects on the design and organization of cross-national comparative research in social and public policy, based in our own experience of leading and taking part in projects of this kind. We acknowledge recent criticism of comparison conceived as the measurement of similarity and difference between discrete national units, and note the political as well as methodological difficulties such work entails. We describe our attempts to overcome them, calling for both (1) a critical theory of comparison and (2) a critical practice of comparison. We outline ways of working based on the collective interrogation of case studies, and conclude by formalising an approach to comparison conceived not as cross-national experiment but as international encounter.

Publication Type: journal paper      Source: Critical Policy Studies 7 (2) 198-206
Date: 2013       Link:

Reverb: policy making in wave form

When we think of policy as mobile, what is it we think is moving? Asking after the mobility of policy is important not least for the ontological questions it raises: what is policy such that it moves? Ordinarily, we might think of policy as existing in time and space while, given certain conditions, some policies move from one time and/or space to another. This paper, by contrast, begins by describing policy as resulting from movement, setting out a model or heuristic which takes its mobility as prior to its existence. For policy is made in communicative interaction, both oral (in meetings) and textual (in documents). We might think of it in wave form, which helps to explain both its mobility and its mutability. The paper illustrates this conception in a study of WHO activity in respect of mental health in Europe, exploring aspects of translation - understood as the generation of messages in interaction - and of iteration, as those messages are reformulated and repeated in different contexts. The policy concept reverberates, and it is in this way that collective sense is consolidated and reproduced.

Publication Type: journal paper      Source: Environment and Planning A 44 13-20
Date: 2012       Link:

Stakeholder consultation and social mobilization: framing Scottish mental health policy
Sturdy, S, Smith-Merry, J and Freeman, R

Public and stakeholder consultation is increasingly important in the policy process, both in the UK and elsewhere. Social scientists have considered consultation primarily in terms of how it relates to decision-making – either as a means of involving a wider constituency of actors in the decision-making process, or as a means of legitimizing the decisions taken by policymakers. This article shows that consultation can also serve a rather different role in relation to policy: as, in effect, the first stage in policy implementation. Based on direct observation of a stakeholder consultation on Scottish mental health policy that took place during late 2007 and early 2008, it draws on elements of social movement theory to show how that consultation served as a means of enrolling, orienting and mobilizing stakeholders to implement a largely pre-existing set of policy aims.

Publication Type: journal paper      Source: Social Policy and Administration 46 (7) 823-844
Date: 2012       Link:

The practice of policy making
Freeman, R, Griggs, S and Boaz, A

Editorial introduction to the special issue of Evidence and Policy 7 (2) The Practice of Policy Making.

Publication Type: journal paper      Source: Evidence and Policy 7 (2) 125-133
Date: 2011       Link:

Documents, practices and policy
Freeman, R and Maybin, J

What are the practices of policy making? In this paper, we seek to identify and understand them by attending to one of the principal artifacts - the document - through which they are organized. We review the different ways researchers have understood documents and their function in public policy, endorsing a focus on content but noting that the processes by which documents are produced and used have been left largely unexamined. We specify our understanding of the document as an artifact, exploring aspects of its materiality in both paper and electronic forms. The key characteristic of the policy document, we suggest, is the way it is produced and used collectively, in groups.

Publication Type: journal paper      Source: Evidence and Policy 7 (2) 155-170
Date: 2011       Link:

Implementing recovery: an analysis of the key technologies in Scotland
Smith-Merry, J, Freeman, R and Sturdy, S

Background: Over the past ten years the promotion of recovery has become a stated aim of mental health policies within a number of English speaking countries, including Scotland. Implementation of a recovery approach involves a significant reorientation of mental health services and practices, which often poses significant challenges for reformers. This article examines how four key technologies of recovery have assisted in the move towards the creation of a recovery-oriented mental health system in Scotland. Methods: Drawing on documentary analysis and a series of interviews we examine the construction and implementation of four key recovery 'technologies' as they have been put to use in Scotland: recovery narratives, the Scottish Recovery Indicator (SRI), Wellness Recovery Action Planning (WRAP) and peer support. Results: Our findings illuminate how each of these technologies works to instantiate, exemplify and disseminate a 'recovery orientation' at different sites within the mental health system in order to bring about a 'recovery oriented' mental health system. They also enable us to identify some of the factors that facilitate or hinder the effectiveness of those technologies in bringing about a change in how mental health services are delivered in Scotland. These finding provide a basis for some general reflections on the utility of 'recovery technologies' to implement a shift towards recovery in mental health services in Scotland and elsewhere. Conclusions: Our analysis of this process within the Scottish context will be valuable for policy makers and service coordinators wishing to implement recovery values within their own national mental health systems.

Publication Type: journal paper      Source: International Journal of Mental Health Systems 5:11
Date: 2011       Link:

Analysing policy transfer: perspectives for operational research
Bissell, K, Lee, K and Freeman, R

Policy transfer occurs regularly. In essence, a strategy developed elsewhere is taken up and applied in another policy context. Yet what precisely is policy transfer and, more importantly, under what conditions does it occur? This paper describes policy transfer and addresses three main questions, exploring what perspectives of policy transfer might contribute to operational research (OR) efforts. First, what facilitates the transfer of OR results into policy and practice? Second, what facilitates effective lesson-drawing about OR results and processes between and within countries? And third, what would increase the amount of OR being carried out by low- and middle-income countries and used to inform policy and practice at local and global levels? Mexico’s adoption and adaptation of the DOTS strategy is used here as an example of policy transfer. Policy transfer is relevant to all countries, levels and arenas of people, institutions and organisations involved in health. With a more systematic analysis of learning and policy processes, OR policy and practice outcomes could be improved at all levels, from local to global. Policy transfer offers theory and concepts for analysing OR from a new perspective. The present paper proposes a model of the policy transfer process for qualitative research use. Comprehensive policy transfer research, given its length, complexity and need for qualitative researchers, should not be envisaged for all OR projects. All OR projects could, however, incorporate some concepts and practical tools inspired from this model. This should help to plan, evaluate and improve OR processes and the resulting changes in policy and practice.

Publication Type: journal paper      Source: International Journal of Tuberculosis and Lung Disease 15 (9) 1140-1148
Date: 2011       Link:


Les transformations du système de santé mentale: l'exemple de l'Ecosse
Smith-Merry, J, Freeman, R and Sturdy, S

System transformation in mental health is of immediate concern across countries throughout Europe and beyond. In this paper we describe a paradigm shift in Scottish policy from the control of psychiatric disorder to mental health governance and explore the means by which it has been supported and sustained. No longer characterised by outdated legislation, poor communication and a very limited policy framework, mental health policy in Scotland is held up as exemplary by the World Health Organization, the European Commission and other international actors. We identify four key factors in this structural transformation: 1) a renewed institutional mandate for mental health at the moment of devolution; 2) a commitment to consultation and communication both among mental health actors and agencies and with a wider public; 3) the use of information in performance management and, 4) the degree of reflexivity fostered by engagement in international networks. [In French: English version available as draft paper]

Publication Type: journal paper      Source: Revue Sociologie Santé 34 143-164
Date: 2011

Health care systems and the problem of classification
Freeman, R and Frisina, L

Classification is integral to comparison. The aim of this paper is to reflect on the nature, purpose and limits of classification in comparative health policy. We begin by describing the role of classification in comparative research design, discussing Weber’s concept of the ‘‘ideal type’’ and drawing on the sociology of scientific knowledge to reflect on classification as an essentially social and uncertain process. In the sections which follow, we present an outline history of the classification of health systems, identifying a 'normal science' of comparative studies of health policy and exploring a number of theoretical, conceptual and methodological issues which arise from it.

Publication Type: journal paper      Source: Journal of Comparative Policy Analysis 12 (1) 163-178
Date: 2010       Link:

What is translation?

What is ‘translation’, and how might it help us think differently about knowledge transfer and exchange? The purpose of this article is to set out, for policy makers and practitioners, the theoretical and conceptual resources that translation holds and seems to represent. It begins by recasting research, policy and practice themselves as instances of translation. It explores understandings of translation in literature and linguistics and in the sociology of science and technology, developing them in respect of a brief case study of the seminal women’s health text, Our bodies, ourselves. In concluding, it picks up key themes of uncertainty, practice and complexity.

Publication Type: journal paper      Source: Evidence and Policy 5 (4) 429-447
Date: 2009       Link:

A National Health Service, by comparison

The National Health Service (NHS) has always been compared to other things, to other organizations and systems both at home and abroad. This paper explores those comparisons, beginning with the origins of national public health care in Lloyd George’s study of German social insurance, and ending with Gordon Brown’s claims for the NHS as ‘the best insurance policy in the world’. It considers the comparisons and contrasts made for and with the NHS at the time of its foundation and the comparison of state and market around 1990, before reviewing the contemporary function of comparison as form and basis of health governance. The paper presents three related patterns of thought: one prompted by encounter with the other, one sustained by metaphor and one developed in more formal, analytic comparison. It concludes by discussing why comparison itself is such a dangerous and contested thing.

Publication Type: journal paper      Source: Social History of Medicine 21 (3) 503–520
Date: 2008       Link:

Global health and the problem of governance

Publication Type: journal paper      Source: Harvard Health Policy Review 9 (1) 26-34
Date: 2008       Link:

Learning by meeting

It has become something of a truism that organisational and political environments are internationalised, and that policy making is informed at least in part by increased understanding of what takes place in parallel domains and jurisdictions. Leaders and policy makers learn about, from and with their counterparts elsewhere. By the same token, the international meeting, workshop or seminar has become a more prominent part of professional, organisational and political routines. This paper asks simply: what do we learn by meeting? While both learning and meeting can be readily dismissed as operations of a crude construction of power, the paper is interested in what might remain. It is notable, for example, that international encounters are often highly valued by participants, albeit in ways they find difficult to express. What do participants experience in meeting, and what do they know differently as a result? Drawing on seminal work by Margeret Mead and others, and using ethnographic and documentary methods, the paper describes processes of introduction, presentation, recognition, confusion, socialisation, communication and reporting. Conceived as a microstudy of purportedly macrolevel activity, it is meant both as an exercise in analytic interpretation and as a resource for participants and practitioners.

Publication Type: journal paper      Source: Critical Policy Analysis 2 (1) 1-24
Date: 2008       Link:

Organizing mental health in Scotland
Smith-Merry, J, Freeman, R and Sturdy, S

This paper reports the first phase of a research project on mental health policy in Scotland that investigates the way knowledge is mobilised in the policy process. In this first phase of the project, the authors’ concern has been to map the organisational domain of mental health policy in Scotland, paying attention to the form and structure of agencies and organisations as well as to the relationships between them. The paper describes a set of organisations in which central government is dominant but notes also a range of organisational forms and functions, and a diversity of sources of knowledge, expertise and information on which they draw. A dense network of linkages between agencies is identified.

Publication Type: journal paper      Source: Mental Health Review Journal 13 (4) 16-26
Date: 2008       Link:

Epistemological bricolage: how practitioners make sense of learning

How do policy makers come to know what they know? How do they think of learning? And how does that inform what they do? In this qualitative, empirical study, public health officials variously display scientific, institutional, and more socially situated epistemological strategies or rationalities. In turn, the study reveals that a key element of what they do is "piecing together," assembling and literally making sense of different bits of information and experience, often creating something new from what they have acquired secondhand. It shows how much policy making is knowledge work, and how learning might be thought of as a process of epistemological bricolage.

Publication Type: journal paper      Source: Administration and Society 39 (4) 476-496
Date: 2007       Link:

The work the document does. Research, policy and equity in health

At the center of the politics of health equity, in many countries and circumstances, stands a signal report of research. This article is concerned with what might be described as the architecture of such documents, including how they are produced and organized and the relationships they demonstrate with others that parallel, precede, and succeed them. The article examines how scientific and political authority is established and comments on the evidence of cross-national learning that these documents reveal. It discusses differences in how the problem of health equity is constructed in different countries and how research findings are converted into policy recommendations. It begins to trace a process of implementation by noting how these documents are referred to and written about. The argument is that the politics of health equity are expressed or realized in the documents and reports, which are its principal vehicle. This is not to claim that there is no world beyond the text or that the world somehow is a text, but that to fully understand that world we must understand the text and the work it does.

Publication Type: journal paper      Source: Journal of Health Politics, Policy and Law 31 (1) 51-70
Date: 2006       Link: http://www.

Comparative perspectives and policy learning in the world of health care
Marmor, T R, Freeman, R and Okma, K

The main point of this article is to explore the methodological questions raised by weaknesses in international comparative work in the field of health policy. The core question is how competent learning from one nation to another can take place. The article argues that there is a considerable gap between the promise and the actual performance of comparative policy studies. Misdescription and superficiality are all too common. Unwarranted inferences, rhetorical distortion, and caricatures, all show up too regularly in comparative health policy scholarship and debates. The article first describes the context of the health and welfare state reform debates during the past three decades. In almost all industrialized democracies, rising medical expenditures exacerbated fiscal concerns about the affordability of the mature welfare state. In reaction to pressure for policy change in health care, policy makers looked abroad for promising solutions to domestic problems. The following section takes up the topic of cross-national policy learning. Then, it critically reviews recent debates about health care reforms and addresses the purposes, promises and pitfalls of comparative study in health policy. The next section categorizes existing comparative health policy literature to highlight the character, possibilities and limits of such work. The concluding section returns to the basic theme: the real promise of comparative scholarship and the quite mixed performance to date.

Publication Type: journal paper      Source: Journal of Comparative Policy Analysis 7 (4) 331-348
Date: 2005       Link:

Making sense of health politics through cross-national comparison: Odin Anderson's seminal essay
Freeman, R and Marmor, T R

Publication Type: journal paper      Source: Journal of Health Services Research and Policy 8 (3) 180-182
Date: 2003       Link:

The health care state in the information age

The computerization of the medical record has important implications for the governance of health care, and the importance of health care means that changes wrought there are indicative of changes in government as a whole. This paper draws on work in public policy, medical sociology and studies of science and technology, as well as on cross–national empirical research in Britain and France. It describes the recent development of information policy in health care as an exercise in state–building, realized specifically in the governance of the health professions. The paper concludes with a discussion of what is both new and not so new in the form and extent of state power which emerges.

Publication Type: journal paper      Source: Public Administration 80 (4) 751-767
Date: 2002       Link:

Learning from devolution: UK policy since 1999
Freeman, R and Woods, K

Publication Type: journal paper      Source: British Journal of Health Care Management 8 (12) 462-466
Date: 2002       Link:


Reforming health care in Europe
Freeman, R and Moran, M

Publication Type: journal paper      Source: West European Politics 23 (2) 35-58
Date: 2000       Link:

Recursive politics: prevention, modernity and social systems

The aim of this paper is to connect the recent interest in prevention to recent developments in social theory. It begins by recovering some of prevention's essential features from the realm of common sense, showing that what is taken to be the common sense of prevention is emblematic of modernity. For prevention is built on scientific understandings of cause and effect and the possibility of prediction; on a capacity for controlled intervention by government in social life; on a universal value base; on the authority of professional expertise; on rational, calculating, individual social subjects. As this order develops and changes, many of its constituent elements begin to be threatened by social processes which it has itself set in train. Prevention is affected by (and implicated in) these changes, too. But far from being eclipsed by them it becomes more prominent. Drawing on systems theory, the paper argues that prevention meets the essential purpose of boundary maintenance by which the functioning of social systems is sustained. For reasons both external and internal to welfare agencies, including an increased burden of social risk and increasing organisational complexity, this need to mark and maintain system boundaries is ever more pressing. At the same time, at least part of the problem of the fragility of boundaries is attributable to attempts to maintain them. It is for this reason that preventive policy making can be described as recursive, or self-propelling.

Publication Type: journal paper      Source: Children and Society 13 (4) 232-241
Date: 1999       Link:

Competition in context: the politics of health care reform in Europe

The purpose of this paper is to provide a basis for exploring the relationship between competition and quality in health care by delineating the different institutional economic and political contexts in which pro-competitive reform was conceived and carried out in different European countries. It begins by distinguishing between national health services and social insurance systems, suggesting that different kinds of system generate different kinds of problem. Different patterns of reform in Italy, Sweden and the UK, and in France and Germany are then reviewed in turn. The paper shows how, since the end of the long boom, health systems in Europe have been exposed to a set of economic, political and ideological pressures. The way these were brought to bear meant that governments in those countries with national health services were much more disposed to radical, pro-competitive reform than others. For them, competition represented a way of managing resource constraint in an increasingly complex and demanding political environment; ideas about quality were marginal to their purpose. The paper then explores the application of competition in different contexts, first among providers and then among purchasers, for which the UK and Germany serve as examples in turn. In each case, competition is only made effective by new forms of managerial direction. Across systems, competition appears less clearly associated with quality than with political control.

Publication Type: journal paper      Source: International Journal for Quality in Health Care 10 (5) 395-401
Date: 1998       Link:

Prevention and government: health policy making in the United Kingdom and Germany

The gap between rhetoric and reality in health policy making for disease prevention services is well recognized. I do not try once more to close the gap, but rather argue that the rhetoric of prevention is politically significant. Beginning with an account of prevailing explanations of prevention in policy making, I explore the idea that prevention has a pervasive legitimacy in health politics. This affords opportunities for instrumental policy making by government. To this end, I concentrate on the relationship between disease prevention and health care delivery, discussing in detail the association between prevention and health care reform. My arguments are based on case studies of policy making in Germany and the United Kingdom. I discuss implications for understanding the core interests of government, physicians, and users with respect to prevention in health policy making. The concluding section offers comparative commentary on the role of disease prevention in health sector restructuring.

Publication Type: journal paper      Source: Journal of Health Politics, Policy and Law 20 (3) 745-765
Date: 1995       Link:

Pathways through care: the experience of psychiatric patients
Spicker, P, Anderson, I, Freeman, R and McGilp, R

The aim of this project was to identify the pathway through psychiatric care beyond the point of first admission. This was carried out from the point of view of users, considering the pathway as a set of subjective experiences. Fifty interviews were conducted with people undergoing psychiatric care in a range of service settings, using a semi-structured interview schedule. Although the research was initially conceptualised in terms of pathways, the routes followed by patients proved to be too diffuse to be charted. Some patient careers were both prolonged and erratic. Patients do not follow a definite pathway; rather, they move through a set of complex stages which are often unclear. If respondents lack a subjective sense of a pathway, they feel, at least in part, that it is because they do not know what is happening.

Publication Type: journal paper      Source: Health and Social Care in the Community 3 (6) 343-352
Date: 1995       Link:


User perspectives on psychiatric services: a report of a qualitative survey
Spicker, P, Anderson, I, Freeman, R and McGilp, R

Publication Type: journal paper      Source: Journal of the Association for Quality in Health Care 3 (2) 65-72
Date: 1995


Discharged into the community: the experience of psychiatric patients
Spicker, P, Anderson, I, Freeman, R and McGilp, R

Publication Type: journal paper      Source: Social Services Research 1995 (1) 27-35
Date: 1995       Link: into the community: the experience of psychiatric patients


Prevention in health policy in the Federal Republic of Germany

The comparative study of what tend to be regarded as marginal questions of health policy, such as prevention, is developing slowly. This case study covers important developments in preventive policy making in the Federal Republic of Germany in the period 1968-1990. The paper is intended both as a descriptive summary of institutional arrangements for prevention in health and as a preliminary analytical essay. It considers the evolving positional interests of federal and state governments, the public health service, the sickness insurance funds and the medical profession. It looks in detail at constitutional conflict over prevention at the end of the 1960s, at the progressivism of health policy conceptions of the early 1970s, at the liberal conservatism which characterised the 1980s and at the place of prevention in health care reform legislation. It refers to responses to HIV and AIDS and comments on the extent to which the circumstances of preventive policy making in health have changed with unification. The paper concludes by discussing the importance of the German case in developing ideas about the role played by prevention in health politics.

Publication Type: journal paper      Source: Policy and Politics 22 (1) 3-16
Date: 1994       Link:


Governing the voluntary sector response to AIDS: a comparative study of the UK and Germany

The impact of AIDS on Western polities serves as a useful indicator both of social values and of political and organisational relationships. At the same time, community-based nonprofit organisations have been at the forefront of AIDS policy-making and service development. Taking Britain and Germany as case studies, this paper discusses similarities and differences in the functions accorded to the voluntary sector in the pattern of responses to HIV and AIDS. Typical problems confronted by emergent voluntary sector welfare agencies are noted and particular features of AIDS service organisations described. Separate accounts are then given of the development of a federated network of AIDS service organisations (ASOs) in Germany and of contrasting experience in the UK. While governments have shared a concern to confine the activity of ASOs to serving the needs of those groups directly affected by AIDS, other significant differences in policy development may be attributed to differences in the organisational structure of the health sector.

Publication Type: journal paper      Source: Voluntas 3 (1) 29-47
Date: 1992       Link: