This chapter looks empirically at the field of health technology assessment (HTA) and argues that it is possible to identify the ‘defence’ style of hyper-active governance posited in the previous chapter. HTA is the crucial expert policy area, involving deciding which drugs and other medical treatments are safe and cost-effective to be prescribed by a local doctor or hospital. HTA has been described by international organisations promoting its use as ‘the systematic evaluation of the properties and effects of a health technology, addressing the direct and intended effects of this technology, as well as its indirect and unintended consequences, and aimed mainly at informing decision making regarding health technologies’ (www.inahta.org). It is a process for making delicate decisions about whether a country will fund a medicine, often based on variants of cost–benefit analysis. In this sense, HTA is a classic arena of expert governance: it is the attempt to turn highly emotive decisions about life and death – about who gets access to new potentially life saving drugs and medical treatments – into rational, evidence-based questions of medical science.

In October 2016, The Guardian published a story about what it called ‘The Cult of the Expert’, which had dominated the first decade of the twenty-first century (Mallaby, 2016). Following the global financial crisis, the chair of the US Federal Bank, Ben Bernanke, was asked by a congressional committee whether he had $85 billion to inject into the economy. ‘I have $800 billion’, he replied. ‘Somehow’, the Guardian noted, ‘America’s famous apparatus of democratic checks and balances did not apply to the monetary priesthood. Their authority derived from technocratic virtuosity’. Scholars have noted since the 1990s how political issues have tended to be put in the hands of so-called experts; scientists, lawyers, clinicians, economists and the like (Fischer, 1990; Barker and Peters, 1993; Hoppe, 1999; Maasen and Weingart, 2006). As political scientist Alasdair Roberts argued in his evocative 2011 book The Logic of Discipline, ‘the pervading sense was that liberal democracies lacked the capacity to make hard choices and that mechanisms were necessary to force those choices or empower technocrat-guardians who would make them on society’s behalf’ (Roberts, 2011, p. 144). Following the fall of the Soviet Union and the rise of Francis Fukuyama’s famously flawed ‘End of History’ thesis, ‘by the turn of the 21st century, a new elite consensus had emerged: democracy had to be managed’ (Mallaby, 2016).

This book has shown that experts widely assumed to have been given much autonomy over governance over the past three decades are in fact intimately linked to the state. Governments defend them from public attack (see Chapter 3), empower them with more resources to fight crises (Chapter 4) and include a wider range of ‘experts’ in their working (Chapter 5). Successful areas of public policy widely claimed to be the domain of experts – monetary policy and electoral administration specifically – are designed to be closely connected with, and steered by, public authorities. This chapter turns to the theoretical implications of this argument and, in particular, delves deeper into explaining the ‘pathological’ aspects of the case studies, noted in Chapters 3–5.

This chapter looks empirically at the field of health technology assessment (HTA) and argues that it is possible to identify the ‘defence’ style of hyper-active governance posited in the previous chapter. HTA is the crucial expert policy area, involving deciding which drugs and other medical treatments are safe and cost-effective to be prescribed by a local doctor or hospital. HTA has been described by international organisations promoting its use as ‘the systematic evaluation of the properties and effects of a health technology, addressing the direct and intended effects of this technology, as well as its indirect and unintended consequences, and aimed mainly at informing decision making regarding health technologies’ (www.inahta.org). It is a process for making delicate decisions about whether a country will fund a medicine, often based on variants of cost–benefit analysis. In this sense, HTA is a classic arena of expert governance: it is the attempt to turn highly emotive decisions about life and death – about who gets access to new potentially life saving drugs and medical treatments – into rational, evidence-based questions of medical science.

This book is about how politicians govern the experts they put in charge of public decisions. It aims to challenge some common assumptions scholars of governance often make about how experts come to be given power in liberal democratic states, and how subsequently they retain that power. There is a large and sprawling theoretical and conceptual literature on ‘the politics of expertise’ in governance and public policy that demands attention and informs what Andrew Gamble (1990) calls a conceptual ‘map’, which this book uses to frame the empirical case studies. This map does not involve the deduction of hypotheses and their empirical testing; it is a way of framing, in an encompassing manner, the empirical dynamics the book identifies in the following chapters. This map is what the book terms the expert–politics nexus, which refers to diverse political relationships between elected governments and civil servants, and ‘arm’s length’ expert-led agencies. To do so, the book offers a new approach to combining and linking previously disparate approaches to ‘expertise’ in governance research.

Hyper-active governance is about more than just government resisting public demands that they intervene in expert-led agencies. Often intervention is required to protect the status quo. Emergencies are a good example of this. In the event of a terrorist attack, a bush fire or a fire in a nightclub, politicians are expected to be in control of the situation. However, this does not mean that they rely any less on experts and expertise. In fact, during emergencies experts are arguably even more important. Ministers need information on the ground, expert assessments of whether things are going to get better or worse, how the situation is expected to progress and what might be done to alleviate human suffering in a highly contingent and dynamic context. They hence create emergency technocratic agencies staffed with scientists and experts in all aspects of emergency prevention, response and recovery.

This book has been about the relationship between politicians and experts, and how governments manage the inevitable consequences of giving experts more power over important political decisions. Governments manage the ‘expert–politics nexus’ by defending the experts from public attack, resourcing them to tackle emergencies and making them include alternative conceptions of ‘expertise’. Principals and agents interact closely to deal with substantive challenges whilst simultaneously handling inevitable public criticism.

The previous chapters have sought to map and explain dynamics of contemporary governance in which governments have relied upon experts to govern complex policy problems but have taken a ‘hands-on’ rather than ‘hands-off’ approach – ‘hyper-active governance’. The dynamics were summarised through the terms ‘defence’ and ‘empowerment’. This chapter focuses on a third style, which is termed ‘inclusion’. This style of governance refers to how governments may rally popular opposition to a policy explicitly designed to be made by experts. Expert-driven decisions are not politically uncontentious, and the fallout of expert-led policy processes can be a societal backlash if they are seen as unnecessarily biased or unfair. Governments sometimes side with society in the backlash and demand that experts revise their decisions to take account of public opinion. Examples of this style can be found in areas where ethical concerns are important and experts are seen to have failed to listen to public opinion. Alternatively, big infrastructure projects like high-speed rail links often lead to politicians criticising experts where their advice has led to houses needlessly being bulldozed. In such instances, politicians often build in mechanisms for public input into decision-making, often through extensive consultation and ‘stakeholder engagement’ processes.

This book has shown that experts widely assumed to have been given much autonomy over governance over the past three decades are in fact intimately linked to the state. Governments defend them from public attack (see Chapter 3), empower them with more resources to fight crises (Chapter 4) and include a wider range of ‘experts’ in their working (Chapter 5). Successful areas of public policy widely claimed to be the domain of experts – monetary policy and electoral administration specifically – are designed to be closely connected with, and steered by, public authorities. This chapter turns to the theoretical implications of this argument and, in particular, delves deeper into explaining the ‘pathological’ aspects of the case studies, noted in Chapters 3–5.

In October 2016, The Guardian published a story about what it called ‘The Cult of the Expert’, which had dominated the first decade of the twenty-first century (Mallaby, 2016). Following the global financial crisis, the chair of the US Federal Bank, Ben Bernanke, was asked by a congressional committee whether he had $85 billion to inject into the economy. ‘I have $800 billion’, he replied. ‘Somehow’, the Guardian noted, ‘America’s famous apparatus of democratic checks and balances did not apply to the monetary priesthood. Their authority derived from technocratic virtuosity’. Scholars have noted since the 1990s how political issues have tended to be put in the hands of so-called experts; scientists, lawyers, clinicians, economists and the like (Fischer, 1990; Barker and Peters, 1993; Hoppe, 1999; Maasen and Weingart, 2006). As political scientist Alasdair Roberts argued in his evocative 2011 book The Logic of Discipline, ‘the pervading sense was that liberal democracies lacked the capacity to make hard choices and that mechanisms were necessary to force those choices or empower technocrat-guardians who would make them on society’s behalf’ (Roberts, 2011, p. 144). Following the fall of the Soviet Union and the rise of Francis Fukuyama’s famously flawed ‘End of History’ thesis, ‘by the turn of the 21st century, a new elite consensus had emerged: democracy had to be managed’ (Mallaby, 2016).