Like most works of social science, this book began with a puzzle. About fifteen years ago, I became interested in the Dutch health reforms under way at the time and realized that the slow transformation that they represented could be not explained by either of the two models of transformative change then prominent in the literature. The Dutch reforms were brought about neither by a “big bang” during a window of opportunity nor by the gradual accumulation of disjointed incremental changes. Pursuing that puzzle led me to an exploration of the dynamics of the scale and pace of policy change that has culminated in this book. That exploration led me to study past episodes of health care reform in a new light, and gave me the tools to examine contemporary episodes – notably the “Obamacare” reforms in the United States and the Coalition government’s reforms in England – as they unfolded.

I believe the framework that has resulted can illuminate the dynamics of policy change not only in health care, but also in other areas central to the agenda of governments.

The focus of the book is on explaining bursts of policy change, in a way that avoids both the overly simple dichotomy of big-bang vs incremental change and the tautology of inferring a “window of opportunity” from the fact that a burst of change occurred. First we need to understand when conditions are ripe for policy change – what opens “windows of opportunity.” But then we need to appreciate that different strategies of scale and pace are possible in those moments – change may be big, or fast, or both, or neither. Understanding why one strategy is chosen and not another takes us into the “assumptive worlds” of political decision-makers, as they assess their ability to overcome vetoes in the present and over time. In ten cases across four countries and seven decades in which conditions were propitious for policy change, we can observe these dynamics at work.

Let me also be clear about the type of policy change with which I am concerned. The “scale” of change to which the title refers relates to fundamental elements of power and governance: the balance of interest among key interests, the mix of instruments of control and the legitimating principles regarding the function of the state and the entitlements and obligations of citizenship. Who decides on the allocation of resources throughout the system? What sanctions do they wield in enforcing their decisions? And what organizing principles constrain their actions? This definition might jar with the way in which specialists define the scale of change within their respective policy arenas. For example, a substantial increase or reduction in public spending – that is, the relaxation or tightening of budget constraints – might be seen as major change. But if the flow of funds is simply augmented (or reduced) without empowering (or disempowering) key actors or changing the sanctions available to them and the expectations they face, those new (or reduced) resources will flow along established channels towards established ends.

Readers of my previous Accidental Logics will find some similarities but substantial differences of focus here. Like Remaking Policy, Accidental Logics focused on the distinctive policy logics that characterized the policy frameworks of different national health care systems (US, British, and Canadian). It likewise argued that these frameworks were, from the perspective of the health care arena, essentially accidents of history: they were adopted during windows of opportunity that were opened, not by the dynamics of the health care arena itself, but by broader political forces. But while dealing in some detail with these episodes of major change, Accidental Logics nonetheless focused on how policy logics played out between windows of opportunity, mediating the impact of policy change and shaping the landscape onto which subsequent windows of opportunity would open.

This book reverses the emphasis. Here I am concerned primarily with what happens around and within windows of opportunity – the factors that create these episodes and the strategic decisions about the scale and pace of change that are made at those times. Policy change that impacts on fundamental elements of power, governance and citizen understandings in areas as central to the responsibilities of contemporary governments as health care is a political minefield. Decisions about when and how to embark on such change is therefore a matter for political leaders at the highest level. My focus here is accordingly less on the politics of the health care arena itself than on the “high politics” at the centre of government that drive these decisions. I believe the framework I present – which deals with the “strategic domains” within which politicians assess their current and future ability to overcome vetoes – therefore has explanatory power well beyond the field of health care policy.

Nonetheless, for those interested in the long periods between episodic bursts of change, I offer two new theoretical perspectives, also demonstrated by the cases. The first is a theory of policy cycling in these long interstices, as positive and negative feedback to the prevailing framework drives an oscillation or spiraling among the options available in the established repertoire: centralization/decentralization; integration/specialization; regulation/deregulation; largesse/austerity, etc. The second is an approach to understanding “institutional entrepreneurs” as actors who find platforms within the new policy frameworks to combine resources across institutional and sectoral (public/private) boundaries to create new institutional forms, with consequences unintended by policy-makers.

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