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.

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.