This book has examined three case studies of policy areas in which it is possible to observe dynamics of hyper-active governance. In each area, politicians must manage the dual demands of relying upon ‘independent’ experts in delegated agencies – what Alasdair Roberts (2011) called the ‘logic of discipline’ – with a wish to impose democratically legitimated state authority – a ‘logic of democracy’. This tension is constantly managed, and the international analysis of developments in each policy area and process-tracing cases identify the distinctive dynamics in each area. These were summed up in terms of three styles: defence (the protection of expert independence), empowerment (the provision of resources to experts to tackle policy problems) and inclusion (the reform of agencies to include diverse stakeholders and conceptions of expertise). This chapter looks at how these styles can be distinguished more clearly from one another. In particular, it argues that the ‘defence’ style can operate alongside the ‘empowerment’ and ‘inclusion’ styles, both in the institutional design of agencies and how they work in practice.

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.