# Policy Involvement among Executive Leaders: Cancer Control in England and France, 1997-2007

François Briatte

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François Briatte. Policy Involvement among Executive Leaders: Cancer Control in England and France, 1997-2007. Political Studies Association (PSA) Northern Postgraduate Conference, Jun 2008, Edinburgh, United Kingdom. halshs-00287431

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# Policy Involvement among Executive Leaders:
Cancer Control in England and France, 1997-2007*

François Briatte

f.briatte@ed.ac.uk

## Introduction

This paper addresses the involvement of top officials from the executive branch of government in health policy. Specifically, it examines the involvement of English and French political leaders in national cancer control programmes over the past decade, and offers a common theoretical framework to explain several empirical cases of high-level politicians interfering with the making of cancer control policy.

The topic deserves some attention insofar as there is no straightforward functional explanation for it. Politicians engage with issues that they consider either as part of the normal attributions of their office, or as part of the exceptionally critical events that emerge in everyday life and that seem to require action to be taken from them, aside from the administrative routines of public service. In the latter case, however, several intermediate offices exist between public affairs and high-level executive leaders, as shown in Table 1.

<table><caption>Table 1. Key offices at the higher end of the English and French executive branches.</caption><thead><tr><th>Level of power</th><th>England</th><th>France</th></tr></thead><tbody><tr><td>1 Prime executive leadership</td><td>Prime Minister</td><td>Presidency of the Republic<br>Prime Minister</td></tr><tr><td>2 Senior ministerial appointees</td><td>Secretaries of State</td><td>Ministres d'État, Ministres</td></tr><tr><td>3 Junior ministerial appointees</td><td>Ministers of State</td><td>Secrétaires d'État</td></tr><tr><td>4 Higher civil servants</td><td>Department leaders</td><td>General directors</td></tr></tbody></table>

Other factors should therefore be taken into consideration to explain the involvement of high-level officials from levels (1) and (2) into cancer control, which cannot be explained by constitutional arrangements or by the absence of responsible officials at levels (3) and (4). A first background assumption in this paper is then that high-level officials have the possibility to interfere in the making of a wide gamut of policies, and that their political preferences, in association perhaps to personal motives, will incite them to do so. The paper first offers a theoretical framework for the former, and then attempts to interpret four particular empirical cases through its lens.<fnref n="1" />

<footnote>* For presentation at the PSA Postgraduate Northern Conference, Edinburgh, 4 June 2008.</footnote>

<footnote n="1">¹ Personal motives, which frequently explain the involvement of individuals in the cancer third sector, are left aside in this paper, until some evidence can be collected through interviews.</footnote>
# 1. A theoretical logic of policy involvement

## 1.1. Environmental constraints

Richard Rose's description of ministerial policy involvement in Britain fits the general hypothesis that this paper formulates for executive leaders in both politics:

> The multitude of time-consuming and difficult tasks that confront a Cabinet minister gives him some freedom of choice in what he does. Because there are not enough hours in a week to do everything that could be done, a minister must, consciously or unthinkingly, give priority to some roles rather than others. It could be argued that the most important decision a Cabinet minister makes is how to allocate his time as between competing roles. (Rose 1971, p. 404-5)

Rose then details three different roles for ministers: departmental representative, chief executive, and 'key issues' minister. The first role will convey a minister 'to speak on behalf of his Department in the [lower House of Parliament], both to advance departmental causes and to defend the department against criticism... The minister can also present and publicize the department in the press and television'<fnref n="2" /> (Rose 1971, p. 404). The second role describes his leadership of a large administrative organization. The third and last role is presented as follows:

> [A minister] concentrates what discretionary time exists upon a few key issues for which his department has primary responsibility. The key issue may be forced upon a minister by its crisis character... or it may be chosen by a minister on other grounds. [...] A corollary of the key issues role is that the individual minister ignores as much as possible many other issues for which his department is responsible. In some instances, he may have capable junior ministers to whom some tasks can be delegated. Alternatively, civil servants can sort the files, recommend courses of action and present him with documents designed to facilitate choice or formal approval (Rose 1971, p. 405).

The first logic of policy involvement that emerges from this descriptive account is conditioned by the narrow temporal boundaries of political activity (time constraints). The role of civil servants in providing their directors with concise data about current affairs affects furthermore the capacity of executive leaders to engage in decision-making (informational constraints).

Both constraints are either accentuated or attenuated by the formal arrangements that mediate them in a given polity. Time, for instance, 'is further constrained by particular institutional features of British elections, with their attendant consequences for new governments and new Cabinets' (Rose 1971, p. 406). Executive leaders are also heavily dependent on the 'vast bureaucratic resources dedicated to providing data on optimal policy choice' (Canes-Wrone et al. 2001, p. 532). The underlying properties of political-administrative relations also shape the capacity of governments to engage into policy

<footnote n="2">² In England, the permanent secretary often acts as the Department spokesperson, a position which French ministères have no functional equivalent of.</footnote>
innovation. In that respect, Peter Hall's account of state structure in France and Britain emphasises the role of ministerial *cabinets* in the former polity (Hall 1983), which have no real equivalent in the 'policy bureaucracy' of the latter one (Page and Jenkins 2005).

Rose finally underlines the critical nature of issues which executive leaders decide to address, often under coercive constraints such as media attention, interests expressed by the selectorate<fnref n="3" /> or by pressure groups, although that is not necessarily the case. In some instances, the sheer willingness of politicians has produced a sufficient impetus for then to engage into policy-making:

> Policy shifts that confer benefits on groups insufficiently powerful to have effectively demanded them are not common occurrences, but they do happen from time to time, and, when they do, they can have momentous consequences and are therefore worth trying to understand. Since these policy outcomes could not have been predicted on the basis of known preexisting forces, that is, classes or interest groups, observers posited the existence of some other force to account for them... social scientists inferred the existence of an autonomous force located in the state, even though they could not directly observe it. This new force seemed to depend on state resources and to be guided by the preferences of political leaders. (Geddes 1994, p. 4)

The next sub-Sections deal in more detail with the substance of such preferences.

## 1.2. Material and symbolic survival in politics

The second logic of involvement that allows to investigate more deeply into political preferences is summarised in the notion of political survival, hypothetically reduced to office-keeping for political leaders and office-seeking for their challengers:

> ... no sensible understanding of what liberal democratic governments should do, have done, or will do is possible without attention to the realities of office seeking and office keeping, and how those realities are perceived by those involved. This theme— stunningly obvious in one sense—is nonetheless all too frequently ignored... our contribution is to insist that whatever technical improvements are possible—in polling accuracy, in economic modeling, the simulation of policy options, and so on—it remains essential to emphasize the centrality of the most basic features of governmental policy making in democratic polities. These, we have suggest[ed], include the need to maintain regime legitimacy, the competitive struggle to achieve (and keep) office, and the search for a balanced policy portfolio. (Klein and Marmor 2006, p. 906)

Political survival, however, reaches beyond election or re-election.<fnref n="4" /> In addition to their strive for high approval rates among the selectorate, incumbents equally protect the symbolic prestige of their office among three other audiences:

<footnote n="3">³ Bueno de Mesquita *et al.* (2003) define the selectorate (crediting Susan Shirk for the term) as ‘the set of people with a say in choosing leaders and with a prospect of gaining access to special privileges doled out by leaders’ (p. xi).</footnote>

<footnote n="4">⁴ This paper focuses on office-keepers, i.e. incumbents. The political dynamics of office-seeking relate to different activities, such as party politics, financing and electoral campaigns, etc.</footnote>
1. First, while in office, ministers aim at ideological approval and professional trustworthiness among civil servants in order to facilitate implementation and avoid antagonising professions that might initiate costly sectoral conflicts which could damage their reputation as a competent departmental leader.

2. Second, they also seek support from their governmental peers in order to preserve inter-departmental collaboration. Preserving the esteem and sympathy of both civil servants and colleagues reduces the risk for ministerial appointees to lose the patronage of the head of government.

3. Third, politicians are conscious that their legacy to political history will be surveyed, analysed and investigated by future generations of politicians, voters and citizens. In that sense, they share a behavioural trait with monarchs and other powerful characters that are conscious of their ability to 'make history.'

In parallel to *material* office-keeping, elected or appointed officials pursue strategies of *symbolic* office-keeping, which seek to improve their testimonial to political life. How these strategies translate in practice is surveyed below.

**1.3. Practices of office-keeping**

As an alternative to utilitarian models where decision-making is guided by the maximization of net constituency benefits, Kent Weaver notes that the existence of a negativity bias among constituencies encourages *blame-avoiding* (the minimization of concentrated losses, even when it means sacrificing greater benefits) over *good policy-making* (the maximization of net benefits to society, determined by cultural norms and political ideology) and *credit-claiming* (the maximization of surplus of concentrated – claimable – constituency benefits over losses; Weaver 1986, p. 375).

Weaver's theory retreats in a costs-benefits analysis of public policy that is not necessarily suited for the study of agenda-setting where the split is less between costs and benefits than decision and non-decision. With this limitation in mind, his categorization of blame-avoiding strategies is directly relevant to the framework of this paper, in particular the 'jump on the bandwagon' strategy, which he describes as defecting blame 'by supporting popular alternative' (Weaver 1986, p. 385).

Blame avoidance and credit claiming apply to both material and symbolic office-keeping (Figure 1), although some strategies tend to prevail over others depending on the timing of mandates. Material blame avoidance, for instance, dominate pre-electoral periods, whereas symbolic credit-claiming should become more apparent in the last years of office of longstanding politicians who do not seek re-election.
<figure><img src="image_2.png" /><figcaption>Figure 1. Articulation of political preferences.</figcaption></figure>

Table 2 lists the determinants of policy involvement as discussed in Section 1. Section 2 provides four short case studies taken from the contemporary history of English and French national cancer control policy-making.

<table><caption>Table 2. Summary of explanatory factors for policy involvement.</caption><thead><tr><th>Type of constraint</th><th></th><th>Paper section</th></tr></thead><tbody><tr><td>Structural constraints</td><td>Time<br>Information</td><td rowspan="2">1.1</td></tr><tr><td>Institutional constraints</td><td>Political-administrative nexus<br>Elections</td></tr><tr><td rowspan="3">Political preferences</td><td>Type</td><td>Office-keeping (incumbents)<br>Office-seeking (challengers)</td><td rowspan="2">1.2</td></tr><tr><td>Nature</td><td>Material (elections, appointment)<br>Symbolic (testimonial)</td></tr><tr><td>Strategies</td><td>Blame avoidance<br>Credit claiming<br>Good policy-making</td><td>1.3</td></tr><tr><td>Ideational constraints</td><td>Cultural norms<br>Political ideology</td><td></td></tr></tbody></table>

## 2. Case studies in cancer control

### 2.1. Three cases of bandwagoning

Within the four national cancer control programmes under scrutiny (Figure 2), the first French plan (2000) and the second English plan (2007) seem to conform to what may be termed as 'jumping on the patient bandwagon.' In both cases, the ascendancy
of policy-making – which involved high-level executives – can be traced at least partly to the demands of cancer patients, mediated by representative groups.

<figure><img src="image_3.png" /><figcaption>Figure 2. Main cancer control policy initiatives in England and France, 1995-2007.</figcaption></figure>

In France, the *États Généraux des malades atteints du cancer* (Cancer Patients Forum) organised by the *Ligue Nationale contre le cancer* in November 1998 proved to be extremely effective in gaining momentum for cancer care. The event successfully conveyed the idea that some aspects of cancer care were eminently problematic, and that urgent action had to be taken for the sake of all cancer patients in France. In this respect, the ‘cancer patient’s view’ provided a problem stream that was to be later used to justify governmental action. At the time, Secretary of State Bernard Kouchner was particularly keen on following such a patient-led agenda insofar as it resonated with his own legislative agenda, which revolved around patients’ rights; the preface he wrote for the *White Paper* book published after the Forum illustrates this conjunction of interests, which might explain why the French Department of Health easily jumped on the patient bandwagon and published a cancer plan in February 2000 (Table 3).

<table><caption>Table 3. Chronology for French national cancer policy initiatives, 1998-2000.</caption><thead><tr><th>Timeline</th><th></th><th>Health Minister</th></tr></thead><tbody><tr><td>1998 Nov</td><td>General Cancer Patients Forum.</td><td>Bernard Kouchner</td></tr><tr><td>1999 Apr</td><td>White Paper published by the National Cancer League.</td><td></td></tr><tr><td>2000 Feb</td><td>National Cancer Programme announced.</td><td>Dominique Gillot</td></tr></tbody></table>

Identically, in England, the ‘patient’s view’ was at the heart of the 2007 Cancer Reform Strategy, which originated in the efforts of several third sector organizations involved in cancer care. Cancer Research UK was particularly effective in mobilizing support for a ‘Cancer Plan 2’ by gathering 250,000+ signatories of the ‘Cancer 2020’ petition and by ordering a King's Fund report that came out sympathetic to a revision of current cancer services. In parallel, several cancer associations temporarily coalesced in the Cancer Campaigning Group, which was instrumental in attracting media attention. Again, jumping on the bandwagon concurred with the departmental agenda, due to
structural evolutions within the NHS that required some adjustment in cancer policy. The Reform Strategy itself was announced by Health Secretary Patricia Hewitt at the All-Party Parliamentary Group on Cancer annual conference in 2006 (Table 4).

<table><caption>Table 4. Chronology for English national cancer policy initiatives, 1997-2007.</caption><thead><tr><th>Timeline</th><th></th><th>Health Secretary</th></tr></thead><tbody><tr><td>1997</td><td>May</td><td>Labour government elected.</td><td>Frank Dobson</td></tr><tr><td>1998</td><td>Dec</td><td>EUROCARE 2 comparative survival data published.</td><td></td></tr><tr><td>1999</td><td>May</td><td>Number 10 cancer summit.</td><td></td></tr><tr><td>2000</td><td>Sep</td><td>NHS Cancer Plan published.</td><td>Alan Milburn</td></tr><tr><td>2001</td><td></td><td>Labour government re-elected.</td><td></td></tr><tr><td>2005</td><td></td><td>Labour government re-elected.</td><td>Patricia Hewitt</td></tr><tr><td>2006</td><td>Aug</td><td>Pressure from the third sector to enact a second cancer plan.<br/>King's Fund recommends updating the NHS Cancer Plan.</td><td></td></tr><tr><td></td><td>Nov</td><td>Cancer Reform Strategy launched by Patricia Hewitt at<br/>Britain Against Cancer Conference.</td><td></td></tr><tr><td>2007</td><td>Dec</td><td>Cancer Reform Strategy published.</td><td>Alan Johnson</td></tr></tbody></table>

The national cancer control programme updated through the Reform Strategy (the *NHS Cancer Plan*) was itself a case of bandwagoning, although to a different source. Instead of patient pressure, the critical factor in initiating policy-making was created by the EUROCARE epidemiological study launched in 1989 with the support of the European Commission. By providing comparative cancer survival data for over 20 Member States, the second wave of EUROCARE results (Coebergh et al. 1998) clearly indicated that Britain was not performing on a par with Western states in terms of survival for several types of cancer, including some of the most common. The results of EUROCARE produced a latent 'policy trigger' effect (Weaver 1989), resulting in the organisation of a cancer summit at 10 Downing Street, under the patronage of the Prime Minister who later appointed the National Clinical Director for cancer, Mike Richards (McIntyre 2004).

### 2.2. One possible case of credit-claiming

Jacques Chirac's initiative to launch a cancer plan in his Bastille Day interview of 14 July 2002 (Table 5) was launched in the absence of any compelling study or significant patient pressure. Moreover, the French health care system enjoys a national reputation for excellence and is subject to a different type of expenditure politics that underline over-spending – instead of under-spending in the NHS – as its key issue (Palier 2008). Finally, Chirac announced his initiative *after* his re-election and most probably with no intention of running for a third mandate, which rules out explanations based on office-seeking. Even though his motivations certainly went beyond posterity, symbolic credit could be claimed for making cancer a national priority, along with road safety and help
for disabled people.<fnref n="5" /> Chirac's 'grands chantiers,' as he called them, somewhat echoed Mitterrand's 'grands travaux,' by which he is still remembered. His priorities presented the other advantage of being impossible to counter: It is indeed hard to imagine what kind of political opposition could have stemmed from a programmatic line that emphasized helping people stricken with a 'dread disease,' avoiding the death of mainly young people in road traffic accidents, and paying attention to disabled people. The three priorities resonated with the necessity for politicians to respond to public manifestations of suffering (Jennings 1999). The need for politically consensual policies was emphasized by the context set by the 2002 presidential election: Chirac's election did not follow a clear victory over the Left in the second round, and his mandate came from the cumulated vote of 82% of the voters from all positions but the extreme-right on the political spectrum. The success of Chirac's credit-claiming strategy is now open to interpretation, but a sign of social learning has been the similar Alzheimer's Disease Plan launched by Nicolas Sarkozy with explicit reference to the Cancer Plan.

<table><caption>Table 5. Chronology for French national cancer policy initiatives, 2002-2003.</caption><thead><tr><td>Timeline</td><td></td><td>Health Minister</td></tr></thead><tbody><tr><td>2002</td><td>May</td><td>Right-wing presidency and parliament elected.</td></tr><tr><td>2002</td><td>Jul</td><td>Jacques Chirac announces Cancer Plan.</td></tr><tr><td>2003</td><td>Mar</td><td>Cancer Plan published and announced by Jacques Chirac.</td></tr></tbody></table>

### 3. Summary

Statesmen operate under administrative arrangements and physical time constraints that imply high volumes of delegation. This paper argues that involvement into policy-making at higher end of the executive branch is partly explainable through interwoven logics of material and symbolic office-keeping, which translate into blame-avoiding as well as credit-claiming strategies while in office.

<footnote n="5">⁵ Chirac had already been involved with a cancer-related issue in 1996 when he announced, again in a highly symbolic Bastille Day press conference, that the buildings of the Jussieu campus would be evacuated for asbestos removal. According to a journalist interviewed by Henry (2000, p. 718-719), his announcement was a total surprise to the minister of education, and was motivated by the wish not to be criticised in the future for letting people intoxicate themselves with asbestos fibres—a case of blame avoidance.</footnote>
Cases of policy involvement into cancer control from executive leaders in England and France do not answer to a single type of explanatory factor.<fnref n="6" /> However, segments of their explanatory narrative can be elucidated along the theoretical lines described in Section 1, which offers a wider set of explanatory factors than previous theoretical attempts to characterise why high-level politicians participate in policy. This set might be used to generate hypotheses suitable for subsequent empirical verification.<fnref n="7" />

## References

Bueno de Mesquita, B., Smith, A., Siverson, R. and Morrow, J. (2003) *The Logic of Political Survival*. Cambridge: MIT Press.

Canes-Wrone, B., Herron, M. and Shotts, K. (2001) ‘Leadership and Pandering: A Theory of Executive Policymaking’, *American Journal of Political Science* 45(3): 532–550.

Coebergh, J., Sant, M., Berrino, F., and Verdecchia, A. (1998) ‘Survival of adult cancer patients in Europe diagnosed from 1978-1989: the Eurocare II study’, *European Journal of Cancer* 34(14): 2137–2278.

Geddes, B. (1994). *Politician's Dilemma. Building State Capacity in Latin America*. Berkeley: University of California Press.

Hall, P. (1983) ‘Policy Innovation and the Structure of the State: The Politics-Administration Nexus in France and Britain,’ *Annals of the American Academy of Political and Social Science* 466: 43–59.

Henry, E. (2000) *Un scandale improbable. Amiante : d'une maladie professionnelle à une “crise de santé publique.”* Doctoral dissertation, University of Compiègne.

Jennings, M. K. (1999) ‘Political Responses to Pain and Loss’, *American Political Science Review* 93(1): 1–13.

Klein, R. and Marmor, T. (2006) ‘Reflections on Policy Analysis: Putting it Together Again,’ in Moran, M., Rein, M. and Goodin, R. E. (eds), *The Oxford Handbook of Public Policy*, Oxford University Press, pp. 890–910.

McIntyre, P. (2004) ‘Britain’s Cancer Czar’, *Cancer World* 2:59-64.

<footnote n="6">⁶ For example, the *NHS Cancer Plan* was launched at a time when New Labour had promised to close the gap between Britain and average European health expenditure; as shown in another paper, policy learning between the cancer sector and the system-level NHS reforms also carries some explanatory weight (‘The principles and politics of cancer care,’ for presentation at the ESPANET Annual Conference, Helsinki, 18-20 September 2008; draft available).</footnote>

<footnote n="7">⁷ An apposite remark to this matter comes from an informal discussion with Daniel Clegg: any attempt to verify the argument developed in this paper implies testing its counterfactual—why high-level executives *do not* get involved in cancer control. Section 1.1 hints at explanations reflecting lack of time, weak interest, and delegation to lower officials.</footnote>
Page, E. and Jenkins, B. (2005) *Policy Bureaucracy: Government with a Cast of Thousands*. Oxford: Oxford University Press.

Palier, B. (2008) *La réforme des systèmes de santé en Europe*, 3<sup>rd</sup> edition. Paris: Presses Universitaires de France.

Rose, R. (1971) ‘The Making of Cabinet Ministers,’ *British Journal of Political Science* 1(4): 393-414.

Weaver, K. (1986) ‘The Politics of Blame Avoidance’, *Journal of Public Policy* 6(4): 371-398.

Weaver, K. (1989) ‘Setting and Firing Policy Triggers’, *Journal of Public Policy* 9(3): 307-336.