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The Demand and Supply of Parliamentary Policy Advocacy: Evidence from UK Health Policy, 1997–2005

  • Anthony M. Bertelli and Rachel M. Dolan


Fundamental to democratic politics is the quality of representation of constituents' interests by elected officials. This article statistically examines a case of substantive policy advocacy in Great Britain: the issues of wait times and health rationing by the National Health Service (NHS), salient throughout the Blair years. An increase in constituent need for care implies an increase in demand for parliamentary representation, yet representation will not necessarily be supplied, because legislators juggle conflicting interests. We measure representative action using parliamentary questions from 1997–2005. Party and parliamentary status and a set of indicators of the health of British citizens provide measures of political supply and constituent demand. Employing count-regression techniques, we find increased parliamentary questions as the proportion of individuals with some high health risks rises, but opposite results for other health risks. Evidence of political supply is much more consistent, suggesting that political careerism goes a long way towards explaining whether MPs table any questions at all in this policy area.



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2 Pitkin, Hanna Fenichel, The Concept of Representation, Berkeley, University of California Press, [1967] 1972.

3 Fenno, Richard, Home Style: House Members in their Districts, Boston, Little, Brown, 1978 ; Norton, Philip and Wood, David M., Back from Westminster: British Members of Parliament and their Constituents, Lexington, University Press of Kentucky, 1993.

4 Stokes, Donald E. and Miller, Warren E., ‘Constituency Influence in Congress’, American Political Science Review, 57: 1 (1963), pp. 4556.

5 Norton and Wood, Back from Westminster.

6 Ibid.

7 Poole, Keith T. and Rosenthal, Howard, Congress: A Political-Economic History of Roll-call Voting, New York, Cambridge University Press, 1997.

8 Judge, David, Representation: Theory and Practice in Britain, London, Routledge, 1999.

9 Pattie, Charles, Fieldhouse, Edward and Johnston, R. J., ‘The Price of Conscience: The Electoral Correlates and Consequences of Free Votes and Rebellions in the British House of Commons, 1987–92’, British Journal of Political Science, 24: 3 (1994), pp. 359–80.

10 Diana Woodhouse, Ministers and Parliament: Accountability in Theory and Practice, Oxford, Oxford University Press, 1994.

11 Saalfeld, Thomas, ‘Members of Parliament and Governments in Western Europe: Agency Relations and Problems of Oversight’, European Journal of Political Research, 37: 3 (2000), pp. 353–76.

12 Pitkin, The Concept of Representation.

13 Stimson, James A., MacKuen, Michael B. and Erickson, Robert S., ‘Dynamic Representation’, American Political Science Review, 89: 3 (1995), pp. 543–65.

14 Pattie, Fieldhouse and Johnston, ‘The Price of Conscience’.

15 Norton and Wood, Back from Westminster.

16 Pattie, Fieldhouse and Johnston, ‘The Price of Conscience’.

17 Gaines, Brian J., ‘The Impersonal Vote? Constituency Service and Incumbency Advantage in British Elections, 1950–92’, Legislative Studies Quarterly, 23: 2 (1998), pp. 167–95.

18 Saalfeld, ‘Members of Parliament and Governments in Western Europe’.

19 Norton, and Wood, Back from Westminster.

20 Ibid.; Cain, Bruce E., Ferejohn, John A. and Fiorina, Morris P., ‘The House is Not a Home: British MPs in Their Constituencies’, Legislative Studies Quarterly, 4: 4 (1979), pp. 501–23; Gaines, ‘The Impersonal Vote?’.

21 Norton and Wood, Back from Westminster.

22 Fenno, Home Style.

23 Norton and Wood, Back from Westminster.

24 Ibid.; Fenno, Home Style.

25 Norton, Philip and Wood, David M., ‘Constituency Service by Members of Parliament: Does it Contribute to a Personal Vote?’, Parliamentary Affairs, 43 (1990), pp. 196208.

26 Ibid.

27 Norton, Philip, ‘Dissent in the British House of Commons: Rejoinder to Franklin, Baxter, Jordan’, Legislative Studies Quarterly, 12: 1 (1987), pp. 143–52.

28 Cole, Michael, ‘Accountability and Quasi-Government: The Role of Parliamentary Questions’, Journal of Legislative Studies, 5: 1 (1999), pp. 77101.

29 Matti Wiberg, ‘Parliamentary Questioning: Control by Communication?’, in H. Döring (ed.), Parliaments and Majority Rule in Western Europe, New York, St Martin's Press, 1995, pp. 179–222. The reasons are: ‘To request information[;] To press for action[;] To gain personal publicity[;] To demand an explanation[;] To test ministers in controversial areas of their policies[;] To attack ministers in difficult political situations[;] To dispose of a large number of heterogeneous topics rapidly and conveniently[;] To show concern for the interests of constituents[;] To help build up a reputation in some particular matters[;] To force compromises on an unwilling government[;] To delay a headstrong government until other forces and events make their influence felt[;] To demonstrate the government's faults[;] To rally the troops within an opposition party, with only a remote intention of forcing change on the government[;] To create elements of drama’ (p. 181).

30 Norton and Wood, Back from Westminster.

31 Wiberg, ‘Parliamentary Questioning’.

32 Norheim, Ole Frithjof, ‘Healthcare Rationing – Are Additional Criteria Needed for Assessing Evidence Based Clinical Practice Guidelines?’, British Medical Journal, 319: 7222 (1999), pp. 1426–9.

33 Ham, Chris, ‘Tragic Choices in Health Care: Lessons from the Child B Case’, British Medical Journal, 319: 7219 (1999), pp. 1258–61.

34 National Institute for Clinical Excellence. ‘A Guide to NICE’ 2005, available at (accessed 15 February 2007).

35 Ham, Chris, ‘Population-Centered and Patient-Focused Purchasing: The U.K. Experience’, Milbank Quarterly, 74: 2 (1996), pp. 194214.

36 Bevan, Gwyn and Robinson, Ray, ‘The Interplay between Economic and Political Logics: Path Dependency in Health Care in England’, Journal of Health Politics, Policy and Law, 30: 1–2 (2005), pp. 5477.

37 Wailoo, Allan, Roberts, Jennifer, Brazier, John and McCabe, Chris, ‘Efficiency, Equity, and NICE Clinical Guidelines’, British Medical Journal, 328: 7439 (2004), pp. 536–7.

38 Norheim, ‘Healthcare Rationing’.

39 Eddy, D. M., ‘Clinical Decision Making: From Theory to Practice. Guidelines for Policy Statements: The Explicit Approach’, Journal of the American Medical Association, 263: 16 (1990), pp. 2239–40, 2243.

40 O'Boyle, Ciaran P. and Coyle, Richard P., ‘Rationing in the NHS: Audit of Outcome and Acceptance of Restriction Criteria for Minor Operations’, British Medical Journal, 323: 7310 (2001), pp. 428–9.

41 Martin, Stephen and Smith, Peter C., ‘Rationing by Waiting Lists: An Empirical Investigation’, Journal of Public Economics, 71: 1 (1999), pp. 141–64.

42 Goddard, J. A. and Tavakoli, M., ‘Referral Rates and Waiting Lists: Some Empirical Evidence’, Health Economics, 7: 6 (1998), pp. 545–9.

43 Lindsay, Cotton and Feigenbaum, Bernard, ‘Rationing by Waiting Lists’, American Economic Review, 74: 3 (1998), pp. 404–17;

44 Timmins, Nicholas, ‘Use of Private Health Care in the NHS’, British Medical Journal, 331: 7525 (2005), pp. 1141–2.

45 Warden, John, ‘NHS is Commons Combat Zone’, British Medical Journal, 316: 7146 (1998), p. 1694.

46 Erin Penner, Kelly Blidook and Stuart Soroka, ‘Legislative priorities and public opinion: representation of partisan agendas in the Canadian House of Commons,’ Journal of European Public Policy, 13: 7 (2006), pp. 1006–20 employ a similar technique for statistically analysing questions in the Canadian Parliament. However, they use a proportion of ‘column centimetres’, i.e. the amount of space given on each topic as a proportion of all column centimetres to ascertain relative attention across a number of issues. Our use of numbers of questions does not seem biased in this case, as the overwhelming majority of the questions in our dataset are rather brief and we are not interested in cross-topic comparisons.

47 The ‘Question Book’ is available at

48 Our measures of constituency health characteristics are based on census data and do not vary over time. We pool all mentions because of this and employ the count regression model described below to take full advantage of the structure of the data available. To respect the simplifications inherent in such pooling, we measure political variables such as frontbench service with a temporal dimension, rather than simply as indicator variables.

49 CACI Inc., ‘HealthACORN User Guide’, 2006, available at (accessed 29 March 2007).

50 The system is available at

51 Crepon, Bruno and Duguet, Emmanuel, ‘Research and Development, Competition and Innovation Pseudo-Maximum Likelihood and Simulated Maximum Likelihood Methods Applied to Count Data Models with Heterogeneity’, Journal of Econometrics, 79: 2 (1997), pp. 355–78.

52 This is an improvement over the Poisson regression model in cases, such as ours, where the mean of the count variable (μwait times = 0.43, μrationing = 0.48) is not equal to its variance (σ2 wait times = 1.15, σ2 rationing = 2.56).

53 White, Halbert, ‘Maximum Likelihood Estimation of Misspecified Models’, Econometrica, 50: 1 (1982), pp. 124.

54 Wooldridge, Jeffrey M., ‘Cluster-Sample Methods in Applied Econometrics’, American Economic Review (Papers and Proceedings), 93: 2 (2003), pp. 133–8.

55 Variance inflation factors for the models range from 1 to 3.74 with a mean of 2.

56 Vuong, Quang H., ‘Likelihood Ratio Tests for Model Selection and Non-Nested Hypotheses’, Econometrica, 57 (1989), pp. 307–34.

57 Primary care trusts (PCTs) in both the most rural and least deprived fifths of all PCTs were most likely to run a deficit (68 per cent). By contrast, only 3 per cent of PCTs in the least rural and most deprived fifth ran deficits ( Asthana, Sheena and Gibson, Alex, ‘Rationing in Response to NHS Deficits: Rural Patients are Likely to be Affected Most’, British Medical Journal, 331: 7530 (2005), p. 1472).

58 Ibid.

59 Norton and Wood, Back from Westminster; Gaines, ‘The Impersonal Vote?’.

60 Norton and Wood, Back from Westminster.

1 We thank Perri 6 and Jamie Carson for helpful comments. Justin Long provided invaluable research assistance.

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The Demand and Supply of Parliamentary Policy Advocacy: Evidence from UK Health Policy, 1997–2005

  • Anthony M. Bertelli and Rachel M. Dolan


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