This paper is part of the proceedings of the 2nd

Annual

conference on Qualitative Research for Policy

Making, 26 & 27 May 2011, Belfast

History and Policy

A Typology of Approaches and Its Uses

Ellen van Reuler

1

Centre for the History of Science, Technology and Medicine

The University of Manchester

United Kingdom

Abstract

The relevance of historical studies for policy is a topic that has become increasingly

debated over the past few years. In this paper, I develop a typology of modes of policy

relevant history that helps us classify and apply historical scholarship in the policy

environment.

This typology is based on distinctions along two dimensions. The first dimension is

the concept of history applied, because history can be ‘the past’ or a method to study

developments over time. The second dimension is the primary aim of the study, which

can be either problem-oriented or understanding-oriented. These two dimensions are

combined into a typology of four modes of history for policy. Central to this model is that

each of the four modes requires specific ‘translational devices’ if we want to transfer the

results of the historical analyses to the policy process. Several elements of this typology

are illustrated drawing from my research on the contemporary history of cancer care and

palliative care in England and the Netherlands.

1. Introduction

Why should the policy community pay attention to history? The following two quotes

provide suggestions. The first is from a noted historian of medicine, the second from a

physician who was the English Chief Medical Officer from 1998 to 2010.

Policy is always history. Events in the past define the possible and the desirable, set

tasks, and define rewards, viable choices, and thus the range of possible outcomes. As we

move through time those choices reconfigure themselves and trends may establish

1 I would like to thank John Pickstone from the Centre for the History of Science, Technology and

Medicine in Manchester for the stimulating discussions that shaped the typology presented in this paper.

The research reported in this paper is funded by a Wellcome Trust Doctoral Studentship.

themselves - but at any given point the ‘actionable’ options are highly structured. It is the

historian’s disciplinary task to define those likelihoods. Most important, what history can

and should contribute to the world of policy and politics is its fundamental sense of

context and complexity, of the determined and the negotiated. Rosenberg (2006, p.28)

I never ever heard a discussion during my twelve years in post - although I tried many

times to raise it - where people would sit down and say: Now, have we ever done

anything like this before? What tools did we use? What worked well? What didn’t work

well and how are we going to take that learning into the change programme that we are

now going to introduce?’ People reached for the tools almost absent-mindedly. Say,

we’ve got to have a few regional road shows, we’ve got to do some legislation, we’ve got

to do this, we’ve got to do that, but not thinking fundamentally about change the way that

I believe is done in many of the most innovative organisations in other sectors.

Donaldson (2011, 37:43 - 38:30).

Rosenberg and Donaldson both maintain that history can be useful for policy, but their

concepts of history and their aims for the use of history differ. These differences and their

consequences for the transfer of insights from historical studies to policy making are

discussed in this paper.2

2. Literature review

Although not a main focus in social sciences, history-conscious approaches are certainly

not unknown. But most of the effort relates history to fields like sociology and

anthropology, rather than to ‘applied’ social sciences such as policy studies (for example,

Hodgson, 2001; Mahoney & Rueschemeyer, 2003; McDonald, 1996; Monkkonen, 1994).

Nevertheless, the case for the use of historical evidence to inform policy making has been

made convincingly (Berridge, 2008; The British Academy, 2008). Examples of

arguments for the value of historical perspectives for policy are:

1. Long-term perspective allows for a sense of chronology and the identification of

continuity as well as change;

2. Diachronic attitude supports the identification of slowly developing and temporally

distant causes of current problems;

3. Historical analyses allow for combinations of various types of source material, levels

of interpretation, and theoretical perspectives;

4. Contextualisation of issues under investigation provides insight into a wide range of

influences lying behind the immediate issue (See Berridge & Strong, 1991; Berridge,

1994, 2000, 2001, 2008, 2010; Hacker, 2005; Pollitt, 2008; Stevens, Rosenberg &

Burns, 2006; Tilly, 2006; Zelizer, 2000).

2 An important distinction can be made between policy history and histories that are of use for policy. On

the one hand, accounts of the first type describe and analyse, for instance, the decisions that led to a

particular policy document or governmental intervention. This does not imply that that these histories

are always relevant for current policy. On the other hand, policy relevant histories need not be

concerned with policy as such, but provide insights of use to policy makers. This paper deals with these

policy relevant histories.

At a time in which publications in public policy ‘remain present and future oriented,

and history-lite’, historical studies emphasise aspects that differ from mainstream policy

analyses (Pollitt, 2008, p.13; also Raadschelders, 1998; Zelizer, 2000)..

Given the development of the British History & Policy website from 2002 onwards

and the publication of books and articles, such as, Pierson (2004; 2005), Pollitt (2008),

Stevens et al. (2006), and Zelizer (2005), it might seem that the value of history for

policy is an issue that has emerged only recently.3 However, concepts like dynamics of

policy and inheritance in policy appeared in earlier studies (Rose, 1976; Rose & Davies,

1994). Worth mentioning are also the books on the uses of history by decision makers

and social history and social policy by May (1973), Neustadt & May (1986), and

Rothman & Wheeler (1981).

Some of these authors, most notably Rothman and Wheeler, mention that the

translation of historical studies for policy audiences is a complex endeavour. Insight into

the different modes of history for policy and the strategies that can be used to maximise

their potential to inform policy is crucial, but this is an issue hardly addressed in the

literature.

3. Research Method

The primary aim of this paper is to present a simple typology of forms of historical

analysis which are useful for policy and the strategies for translation of these analyses to

a useful input for policy making. In subsection 4.1, I sketch the typology, while the

subsequent subsection discusses the relationship between the modes of history and policy

issues. Subsection 4.3 contains a note on the presentation of the outcomes of historical

studies for policy. I give some examples to illustrate the typology and the ‘translational

devices’ that can be used to transfer the results of the historical analysis to the policy

process in subsections 4.4 and 4.5. These examples are based on my ongoing research on

the histories of palliative care4 and cancer care in England and the Netherlands during the

3 See http://www.historyandpolicy.org.

4 Notions of palliative care have changed over time and several closely related terms, such as hospice

care, palliative medicine and terminal care, are in use. The term currently dominating English

governmental policy is end of life care (see Department of Health, 2008). A well-known definition of

palliative care is provided by the World Health Organisation:

‘Palliative care improves the quality of life of patients and families who face life-threatening illness, by

providing pain and symptom relief, spiritual and psychosocial support from diagnosis to the end of life

and bereavement. Palliative care:

- provides relief from pain and other distressing symptoms;

- affirms life and regards dying as a normal process;

- intends neither to hasten or postpone death;

- integrates the psychological and spiritual aspects of patient care;

- offers a support system to help patients live as actively as possible until death;

- offers a support system to help the family cope during the patients illness and in their own

bereavement;

- uses a team approach to address the needs of patients and their families, including bereavement

counselling, if indicated;

- will enhance quality of life, and may also positively influence the course of illness;

post war era. These histories are grounded in a variety of primary and secondary written

sources, such as policy reports and parliamentary proceedings, as well as (oral history)

interviews.5

4. Discussion

4.1 A typology of modes of policy relevant history

The quotes in the introduction stress the importance of history for policy, but they present

dissimilar modes of history. It is helpful to conceptualise these differences by

distinguishing the approaches on two dimensions:

A. The concept of history applied:

a. History as ‘the past’;

b. History as a method to study the social world and its development over time.

B. The focus of the study:

a. Problem-oriented studies, which start with a particular problem in mind and aim

to contribute to a solution for this issue;

b. Understanding-oriented studies, which increase our comprehension of policy

and its contexts.

Illustration 1 shows the typology of modes of history for policy that emerges if we

combine the two dimensions discussed in the previous paragraph. In this typology,

investigations following Donaldson’s suggestions would result in a mode 1 analysis,

while Rosenberg’s ideas match with mode 4 histories for policy.

- is applicable early in the course of illness, in conjunction with other therapies that are intended to

prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to

better understand and manage distressing clinical complications’ (World Health Organisation,

2006). 5 For reasons of readability, I decided to exclude references from these examples to avoid densely

referenced accounts. Further references are available from the author upon request. For a discussion of

the debates about the regional concentration of cancer care, see also Van Reuler (2008). For a brief

analysis of the position of hospices in the health care system in England and the Netherlands, see Van

Reuler (2010).

Illustration 1 - Typology of history for policy modes

As shown in Illustration 1, each of the modes of history for policy is characterised by a

specific set of questions. Histories of the ‘problem-oriented - past type’ (mode 1), for

instance, show whether a similar problem occurred before and how it was dealt with at

that time. This knowledge informs current decision making, because the strategies that

were successful can be repeated and past failures give an indication of avoidable courses

of action.

Mode two histories focus on the position of the problem under investigation in

time. Questions are asked about the emergence of the issue, distant causes and causes

that developed slowly over time. Also issues of path dependency play a role in mode 2

analyses.

In mode 3 histories, history is conceptualised as past, while the focus of the study

is understanding-oriented. The inclusion of multiple cases allows us to compare the

content and the context of the instances. Moreover, the similarities and differences of the

causes of the problem are researched. This analysis helps us to understand how similar

the current problem is to past situations. Another possible outcome is that we can

identify which of the previous instances shows most resemblance to the current issue.

Mode 4 histories, which are understanding-oriented and apply historical thinking

as a method, analyse additional issues. In these studies, a problem is seen as a dynamic

construct with causes that developed over time according to various trajectories.

Moreover, the relation to earlier instances of comparable issues and the changes that

occurred are relevant. These histories may also show to what extent past developments

were actually shaped by policy and which other forces were of influence.

Illustration 1 also shows possible moves from mode 1 studies to more complex

modes of policy relevant history. If we want to progress vertically from problem-oriented

to understanding-oriented studies, we multiply the number of cases analysed and we

contextualise them. By contrast, the horizontal move from history as past to history as

method entails a temporalisation of the phenomenon under investigation. In other words,

we move from a static view of the subject to a dynamic conceptualisation of the issue and

its causes.

The arrows in Illustration 1 do not imply that every history for policy study has to

start with a mode 1 analysis and add layers of complexity to move to mode 4. It is

possible to develop a mode 2, 3 or 4 historical analysis immediately. Moving from mode

1 or mode 2 to mode 4 has the benefit that the problem around which the questions in

mode 1 and 2 studies are centred remains present in understanding-oriented modes of

history for policy. This implies that a link to a current policy debate will exist. By

contrast, many historians start their studies for other reasons than its direct policy

relevance and will carry out a mode 4 analysis. Nevertheless, these analyses may hold

lessons that can inform current or future policy making. The moves from the four modes

of history to policy are elaborated on in the following subsection.

4.2 Translational devices

The intellectual projects of historians and policy makers do not align naturally. Policy

makers focus on knowledge to inform actions, whereas historians develop their analyses

mainly as knowledge for understanding. Therefore, we need strategies, which I call

‘translational devices’, to ensure that the insights from policy relevant histories are

framed in a way that enables their transfer to the policy process.

Illustration 2 shows the same typology as Illustration 1, but now the policy issue

for which the histories are relevant is placed in the centre. We can see that the policy

issue is closer related to the problem-oriented modes of history than to the understanding-

oriented modes. Each of the four modes of history for policy sketched in the previous

subsection has its own specificities. Consequentially, the transfer from insights from each

of the modes of history to inform policy has its own characteristics. These relationships

are indicated with the arrows A to D in Illustration 2. I sketch the ‘translational devices’

that can help us to maximise the potential of each of the modes of history to inform

policy in the following paragraphs.

Illustration 2 - The modes of policy relevant history and their relation to policy issues

Mode 1 histories are closely linked to Donaldson’s suggestion to consider whether we did

something comparable in the past and to what extent the outcomes were favourable

before opting for a policy tool. The reasoning strategy behind the identification of these

‘good guides from the past’ for current practice is based on the analogy. The answers to

the questions for this mode of history for policy often result in clear suggestions for

policy makers (See Rose, 2005, p.42-47 for a discussion of learning policy lessons from

analogies).

In mode 2 history for policy analyses we place an issue in the flow of time and then

come back to the specific issue. Which insights for the policy process can we gain from

this work? Examples are an understanding of sequences of developments, insight in the

duration of episodes, identification of temporally distant causes and influences

developing gradually over time, and knowledge of differences in the pace of various

developments. Some of these outcomes of mode 2 histories for policy analyses, transfer

to policy relatively easily. Temporally distant causes, for instance, can be treated

similarly to causes that developed recently in the sense that policy makers can try to

develop strategies to deal with them to reduce the problem. An understanding of the

sequence of developments provides insight into cause and effect relationships beyond the

level of statistical correlation. Duration and pace of developments are particularly

relevant for policy makers to develop a feeling for the time scale that might be needed to

implement a solution to the problem.

Arrow C represents the move from mode 3 histories to policy. As mentioned

before, the lessons from understanding-oriented histories for policy are harder to

determine. In this case, we have to make an adaptation for the differences in context of

the instances studied. A possible outcome can be that we can say that the contexts of two

situations are relatively comparable, while differences with the third and the fourth case

are substantial. In drawing lessons from mode 3 histories for a policy issue, it is

important to assess the consequences - either favourable or unfavourable - of differences

in context. However, significant contextual differences need not imply that the past

instance has nothing to offer to the current policy issue. Even if the context differs, a past

instance may, for example, help policy makers to generate alternative solutions.

Mode 4 histories have to be adapted for time as well as context if the outcomes are

to feed into policy (Arrow D in Illustration 2). Since these two operations enabled the

move from mode 2 and 3 histories to policy, most ideas presented in the previous

paragraphs can be of use to mode 4 histories. However, the combination of characteristics

in mode 4 histories lends itself to three further uses in a policy context.

- Reasoning about continuity and change in contexts: This translational device

combines an analogy with a force field analysis (see Lewin, 1951; Daft, 2003). The

application of this ‘extended analogy’ means that you search for historical

antecedents of current problem. For each of the instances, you plot the major factors

stimulating and restraining change in a force field diagram. A comparison of these

force fields provides an indication of the feasibility of the implementation of a

proposal and will hold clues about the main barriers for change.

- Policy evaluation: Mode 4 histories are particularly suitable for the evaluation of

policies with a focus on context, long time spans, and unintended consequences. The

average evaluation of policy interventions by mainstream policy analysts takes place

within a few years after implementation. Consequentially, long-term influences

cannot be taken into account. Another strength of history is contextualisation. For

long-term policy evaluation this means that external factors that interfered with the

implementation of the policy and the outcomes that were achieved can be identified.

- Search light: Offering mode 4 histories to policy makers can help them to

incorporate a feeling for developments over time and context in their future problem

solving.

In addition to the Arrows A to D, Illustration 2 also includes four dotted arrows.

They indicate that relatively complex histories can be reduced to simpler, policy relevant

histories by stripping away layers of complexity. Is it worth the effort to develop complex

modes of history if we might want to reduce them to simpler forms to increase their

potential to inform policy making? My answer would be affirmative. Mode 1 studies, for

example, can be enriched if a mode 3 study is carried out, because this allows you to

select not just a case in the past, but the ‘best case’ - i.e. the case with the most similar

context.

4.3 A note on presentation

In addition to the dissimilarities of the intellectual projects of policy makers and

historians, the standards for presenting research differ as well. Historians generally prefer

detailed narratives, whereas policy makers favour a list with recommendations for action.

Therefore, historians who want to present their work to the policy community, should

think carefully about the language and format they use. The further one moves away from

mode 1 histories, the more pressing this issue becomes.

Historians might not want to position themselves as advisors who advocate a certain

action. In that case, the transfer of mode 2, 3 and 4 histories to policy making can be

supported by reducing the histories to a summary of the main changes, stabilities, causes,

trajectories and contextual influences. An overview of these issues is likely to be a more

usable input for policy than a (long) historical narrative.

Not only the presentation of the research results, but also the way in which they are

framed matters. For mode 2, 3 and 4 studies, it can be useful to frame the histories in

concepts and theories policy makers are familiar with. This approach helps to make the

outcomes of historical studies more accessible to policy makers. Moreover, these models,

such as Kingdon’s model of policy streams, can help historians to articulate clearer

whether actual practice converged on or diverged from what policy makers would have

expected on the basis of these models (Kingdon, 1984).6

4.4 Example 1: The regional organisation of Dutch cancer care In this subsection, I illustrate the typology using the case of the current debates on the

regional organisation of cancer care in the Netherlands. I will first give an overview of

the current Dutch health care system to provide the context for this debate. Since the

example in subsection 4.5 relates to developments in English health care, I now describe

the two health care systems briefly from a comparative perspective.

Four main areas of differences between the English and the Dutch health care

system can be identified.

1. Funding arrangements. The English National Health Service (NHS) is funded by the

government from tax revenues. In the Netherlands, however, inhabitants are obliged

to insure themselves against health care costs.

2. Ownership. Whereas the British state is - in the end - responsible for NHS premises,

the Dutch health care infrastructure is owned privately. Most health care providers

in the Netherlands operate on a not-for-profit basis.

3. Governmental influence. In comparison to the situation in the Netherlands, the

influence of the British government on the NHS is relatively direct and far-reaching.

4. Reform and stability. Many observers perceive the English NHS to be in a

continuous flux since the reforms of the early 1990s. The Dutch health care system

is comparatively stable and changes are implemented more gradually (for example,

Boot & Knapen, 2005; Ham, 2004; Rivett, 1997; Schäfer, Kroneman, Boerma, van

6 In this way, histories for policy can not only influence policy making, but they might also have an

impact on the academic study of policy.

den Berg, Westert, Devillé & van Ginneken, 2010; Schrijvers & Droyan Kodner,

1997).

One of the workshops during the concluding conference of the Dutch National Cancer

Control Programme (NCCP)7 in November 2010 focussed on the regional coordination of

oncological care. The attendees agreed that the implementation of a structure in which

specific cancer treatments are concentrated in a limited number of hospitals would be

desirable for reasons related to the quality and efficiency of care.

A typical mode 1 history for policy question would be whether a regional structure

for cancer care was implemented in the Dutch health care system before. The short

answer is that this has not been the case. A somewhat longer response is that the

governmental planning of centres for radiotherapy on the basis of the law on specialised

medical interventions (WBMV)8 from the 1980s onwards was an earlier instance of the

centralisation of cancer care. The implementation of this law was successful from the

perspective of the central government. If we apply an analogy without giving the

situation much further thought, we could say that the introduction of a law on the regional

organisation of cancer care would be an option. However, the inclusion of radiotherapy in

the WBMV is a topic on the political agenda, because the government wants to increase

competition in the health care system and the central control of the availability of medical

equipment does not fit this context. The general trend in health care policy is toward

delegation of power from the government to health insurers. Therefore, legal codification

of the regional concentration of cancer care is unlikely to be a feasible option. These

reasons show that a simple analogy is not always the best lesson history has to offer to

policy. The following paragraphs illustrate what mode 2, 3 and 4 histories might add.

A mode 2 history for policy analysis would stress how the current problem

developed over time. Among the drivers for the recent emergence of the debate on the

centralisation of cancer care are the increased availability of data on hospital performance

and the fact that the breast cancer patients association in cooperation with the consumers

association published a ranking of the best hospitals for breast surgery in 2005. In

addition, insurers obtained the power to contract with hospitals on the basis of quality and

price for a governmentally defined segment of medical treatments during the recent

health reforms. The first publicly known instance in which a health insurer used this

power to influence the place of treatment of their customers occurred in October 2010.

More indirect causes for the debate on the regional structure of cancer care that a

historian would identify are, for instance, the increasing complexity of cancer treatments

and the availability of international, comparative statistics on cancer survival rates.

A limited form of a mode 3 historical analysis took place when one of the attendees

of the NCCP conference mentioned that the regional organisation of cancer care had been

discussed during the mid 1990s and 2000s. Her fairly short conclusion was that ‘the time

was not yet ripe for it’ in those days, but that the proverb ‘three times lucky’ would hold

this time. A historian could contextualise these developments further as part as a mode 3

analysis. In that case, we would come across influences like changes in the health care

system and treatments available for cancer. A likely conclusion of a comparison of the

7 In Dutch this programme is known as the ´Nationaal Programma Kanker (NPK 2005-2010)´.

8 In Dutch: ´Wet Bijzondere Medische Verrichtingen

´.

three instances of attempts to concentrate oncological care would be that the context of

this issue had indeed changed substantially. To a historian, however, the implications of

this finding for the feasibility of the introduction of concentrated cancer care would not

be as obvious as for the workshop participant.

As became clear from the discussion of history for policy in Subsection 4.1, mode

4 analyses are the most complex form of the four. This means that a mode 4 historical

analysis of the regional structure of cancer care would incorporate most of the issues

elaborated on for the modes 1, 2 and 3. On top of that, attention would be paid to the

trajectories followed by the variables influencing the concentration of oncological care.

The dynamic context of the three attempts to organise Dutch cancer care at a regional

level would also be studied. These investigations indicate, among others, that the

implementation of the first advisory report that suggested to centralise cancer care was

hampered by the interests of hospitals and medical specialists who were afraid to loose

part of their work.9 Moreover, this analysis would include the fact that the centralisation

of oncological care dropped from the political agenda during the second half of the

1990s, because parliament had to deal with more pressing issues in health care. One of

the conclusions about the second debate on centralisation of cancer care, which took

place in 2004, could be that the role of the only independent, specialist cancer hospital in

the Netherlands did not contribute to building support for this idea. Although the debate

first emerged in the context of the start of the NCCP, the publications on the

centralisation of cancer care by the directors of the cancer hospital that appeared shortly

afterwards polarised the debate.

The main question for the current debate on the concentration of oncological care

is: Would a renewed attempt to implement it succeed? In my view, an extended analogy

is a particularly suitable translational device to help us answer this question. The force

field analyses show that the situation remained relatively stable between the first and the

second attempt to centralise cancer care, but that the changes between the second attempt

and the current situation are significant. The shifts of the balance in the governance

structure of health care, with an increasingly central position for the health insurers,

makes successful implementation of centralisation in the current circumstances more

plausible than in the past. Additionally, an extended analogy holds information that

health insurers who aim to concentrate oncological care could interpret as the main

factors constraining change. For example, the enumeration structure for medical

specialists has not changed significantly and hospitals would still be afraid of loosing

work and income.

9 Under the health care payment system in place at that time, loosing work meant a reduction of income

for hospitals and for consultants who worked in hospitals that were not part of a university.

4.5 Example 2: The comparative histories of English and Dutch voluntary

palliative care As described in the methods section of this paper, my project focuses on comparative

histories of palliative and cancer care. In this section, I will briefly explain the reasons for

comparative histories for policy and then related this to the typology presented in this

paper.

What is to be won by including a geographical comparison in policy relevant

histories? Comparative histories can be used to develop extra analogies or compare

trajectories of similar developments at different places. More extensive use of

understanding-oriented modes of history for policy can be made if the issue under

investigation is explicitly framed comparatively. These questions can relate, for instance,

to the reasons why a phenomenon is present in one country, but absent at another place.

Another example of a comparative history for policy question is why the first hospice that

was similar to the English hospices was established in the Netherlands nearly 25 years

after St. Christopher’s hospice was founded in London in 1967.

In the following paragraphs, I explore a comparative historical question of which the

answer can be of use to policy making. I will present the backgrounds to voluntary

palliative care by developing a mode 2 history for policy analysis.

In a report published by the think-tank Demos in Autumn 2010, it was argued that

the establishment of voluntary palliative care, especially in the form of home care

services, in Britain would be desirable (Leadbeater & Garber, 2010). A related,

interesting comparative question is how England developed a relatively medically

oriented system of palliative care provision, whereas a differentiated structure, including

medically oriented palliative care as well as voluntary palliative care by home care teams

and in low-care hospices, evolved in the Netherlands.

A mode 2 analysis indicates that the changing balance between voluntary and NHS

driven provision of palliative care is an important theme in the history of palliative care

in England. Cicely Saunders wrote about the decision to establish St. Christopher’s

Hospice, the first modern hospice in England and indeed in the world, outside the NHS:

‘We want to be independent because we need freedom of thought and action; we want to

be an interdenominational but a religious foundation, and we want freedom to develop

and expand as we are led to do so’ (quoted in du Boulay & Rankin, 2007, p.64).

An arrangement with the Regional Hospital Board was, however, negotiated for St.

Christopher’s. Moreover, the NHS participated in the foundation of hospices during the

mid 1970s. The governmental influence on providers of palliative care increased by the

late 1980s, because the government expected District Health Authorities to cooperate

with the voluntary sector to ensure that the needs of their population were met. These

requirements were soon accompanied by ring-fenced funds for hospices. By the mid

1990s, NHS managed hospices accounted for circa a quarter of the total number of

hospices. Other hospices relied on the NHS for at least a substantial part of their income.

Under New Labour, governmental control of palliative care continued to increase. While

levels of public funding rose, the same was true for control measures, such as the

application of targets. The most recent major policy document on palliative care in

England is the End of Life Strategy that was published in 2008. My evaluation of this

plan is that the implementation would result in a further integration of palliative care into

the NHS. Thus we can see that, the introduction of voluntary palliative care would imply

a significant move away from the past trends in England.

The first initiatives to establish palliative care in the Netherlands were volunteer

led. These services support people dying at home and their relatives. Additionally, these

volunteers created a form of palliative care, which appears to be unique for the

Netherlands. In these so-called low-care hospices, volunteers provide care for a few

terminally ill persons at a time.

In terms of governmental policy for palliative care in the Netherlands, it is

noteworthy that the Secretary of State for Health decided in the mid 1990s that palliative

care had to be integrated into the health care system as a whole. Therefore, she stimulated

care homes and nursing homes to establish palliative care units, while low-care hospices

would not be reimbursed for their housing costs. This policy was an impetus for the

creation of palliative care units in care and nursing homes, but the proliferation of low-

care hospices continued. Though hardly formally debated, a new chapter in palliative care

policy seems to have started in 2007. The Minister of State for health received a report

which stated that low-care hospices experienced problems with funding their housing

costs. Her response was to grant them additional resources. Currently, around 80% of the

costs of the low-care hospices are on average covered by public funds. Most of the people

in charge of low-care hospices are keen to continue to rely on private funds for the

remainder of their income, because this gives them the freedom to run their low-care

hospice as they want. Currently, the extent to which the voluntary sector palliative care

providers can and should be accountable for the public money they receive is being

debated.

Applying the translational device of the identification of developments over time,

these mode 2 accounts show, among others, that the current structure of the provision of

palliative care in both countries is firmly rooted in its development over time. Therefore,

it is questionable whether the implementation of voluntary palliative care will be

successful in England. It is, for instance, unsure whether potential English volunteers will

perceive a deficiency in the provision of care for the dying that they want to create a

service for. Moreover, it can be expected that tensions will emerge between the current

providers of palliative care and the new entrants. The comparative dimension of this

example reveals that voluntary palliative care has also disadvantages from a

governmental perspective. The Dutch experiences indicate, for example, that it is hard to

ensure that sufficient levels of voluntary palliative care are available around the country.

Additionally, quality criteria and output targets are difficult to impose on voluntary

providers of palliative care.

5. Conclusion

In this paper, I sketched a typology of four modes of history for policy based on the

distinctions between 1) history as past and as method and 2) the focus of the study, which

is either problem-oriented or understanding-oriented. Moreover, several translational

devices to move from histories to policy were discussed. Mode 4 and mode 2

translational devices were illustrated by discussions of the debates on the regional

organisation of cancer care in the Netherlands and the suggestion to introduce voluntary

palliative care services in England.

The typology of modes of history for policy is a stylised model. It is certainly

possible to imagine investigations that combine aspects of two or more modes of history

for policy. Moreover, additional translational devices to move from history to policy can

be developed. Nevertheless, the examples presented in this paper show that the typology

is a useful tool to think through the various modes of policy relevant history and the

translational devices that are needed to derive a lesson from these histories that is of

practical use to the policy community.

If history attracts interest from a policy perspective, history is often conceptualised

as the past. So, a legitimate question is: ‘Why should we move beyond these relatively

simple accounts that might hold clear lessons and apply history as method approaches?’

A short answer is that the temporalisation of an issue has several benefits. A multilayered

account of the emergence of a problem enables us to identify, for example, temporally

distant causes or developments that unroll slowly over time. Additionally, mode 4

histories for policy allow us to look at a fairly complex picture of how a topic evolved

and how it compares to earlier developments. As illustrated in the example about the

regional organisation of cancer care in the Netherlands (Subsection 4.4), this enhances

our understanding of the present options open to various stakeholders. Not all issues

require these extensive analyses and it is the task of the historian to judge which mode

and translational device are most suitable and feasible in a particular situation.

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