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Paying people to change their behaviour can work, at least in the short term. However, as Theresa Marteau, Richard Ashcroft, and Adam Oliver explain, there are many unanswered questions about this approach

The Veterans Health Administration (VHA) provides health care for U.S. military veterans. By the early 1990s, the VHA had a reputation for delivering limited, poor‐quality care, which led to health care reforms. By 2000, the VHA had substantially improved in terms of numerous indicators of process quality, and some evidence shows that its overall performance now exceeds that of the rest of U.S. health care. Recently, however, the VHA has started to become a victim of its own success, with increased demands on the system raising concerns from some that access is becoming overly restricted and from others that its annual budget appropriations are becoming excessive. Nonetheless, the apparent turnaround in the VHA's performance offers encouragement that health care that is both financed and provided by the public sector can be an effective organizational form.

The use of behavioural economics to inform policy has over recent years been captured by those who advocate nudge interventions. Nudge is a non-regulatory approach that attempts to motivate individual behaviour change through subtle alterations in the choice environments that people face. It is argued in this article that government interventions ought to be more overt than that traditionally advocated by nudge adherents, and that governments should principally attempt to influence behaviour if the acts of those targeted are causing harm to others. With this in mind, governments can use the findings of behavioural economics, including present bias and loss aversion, to inform where and how to regulate directly against undesirable private sector activities. This behavioural economic-informed method of regulation is hereby termedbudge, to indicate that, rather than nudging citizens, behavioural economics might be used more appropriately in the public sector to help inform regulation that budges harmful private sector activities.

In recent years, behavioural economics has gained considerable traction in the policy discourse, with a particular conceptual framework called libertarian paternalism, which informs nudge policy, dominating. Libertarian paternalism requires policies to protect individual liberty, to be focused specifically upon improving the welfare of those towards whom the intervention is targeted, and to be informed by the findings of behavioural economics. In practice, however, many of the interventions that are being advocated as nudges do not meet all of these criteria. Moreover, libertarian paternalism is not the only framework in which behavioural economics can inform policy. Coercive paternalism and behavioural regulation, frameworks that respectively underpin shove and budge policies, both use behavioural economics to inform public policy, and both face their own set of limitations. This article attempts to bring a degree of intellectual clarity to the potentially important contribution that behavioural economics can make to public policy.

Productive methods for involving consumers require appropriate skills, resources and time to develop and follow appropriate working practices. The more that consumers are involved in determining how this is to be done, the more research programmes will learn from consumers and about how to work with them. Further success might be expected if research programmes embarking on collaborations approach well-networked consumers and provide them with information, resources and support to empower them in key roles for consulting their peers and prioritising topics. To be worthwhile, consultations should engage consumer groups directly and repeatedly in facilitated debate; when discussing health services research, more resources and time are required if consumers are drawn from groups whose main focus of interest is not health. These barriers can largely be overcome with good leadership, purposeful outreach to consumers, investing time and effort in good communication, training and support and thereby building good working relationships and building on experience. Organised consumer groups capable of identifying research priorities also need to find ways of introducing their ideas into research programmes. Further research is suggested to develop and evaluate different training methods, information and education and other support for consumers and those wishing to involve them; to address the barriers to consumers' ideas influencing research agendas; and to carry out prospective comparative studies of different methods for involving consumers. Research about collective decision-making would also be further advanced by addressing the processes and outcomes of consensus development that involves consumers.

This article aims to assess the development of the English National Health Service (NHS) over the period 1979--2005, against the original, and often repeated, core objectives of the system: that it be universal in offering coverage to all members of the population in times of health care need; that it be comprehensive in its provision of health care services; and that it be (largely) free at the point of use. Comprehensiveness is open to interpretation, and may depend upon the wealth of the nation. Universality and (largely) free care at the point of use, which lend themselves to the principle of equal access for equal need, are more concrete, and it is not difficult to ascertain if they have been substantially and/or systematically violated. The article details briefly the developments in resource allocation, provider payment mechanisms, incentives and accountability, and notes that much of the emphasis on health sector change since the mid 1980s has been placed upon improving supply side efficiency and reducing waiting lists/times. Improving NHS efficiency, and indeed related aspirations associated with choice and health outcomes, can be perceived as 'secondary' objectives, in that they should not serve to undermine the core objectives of the system, assuming that the security offered by having an accessible, universal health care system is considered worthy of protection. The overall conclusion is that the NHS has performed quite well against its core objectives to date, although it is possible that the current preoccupation with choice and health outcomes will lead us down a different policy path in the future.

In this article we outline the different schools of new institutionalism and a few other selected political science theories. Moreover, we relate the insights offered by a series of analyses of health sector change in a large number of European countries over the past twenty to thirty years to these theoretical frameworks. Our main conclusion is that it is unlikely that a single explanatory theory will ever be able to account for all of the health sector developments in any one country, let alone across many countries with diverse cultures, histories, institutions, and interest groups. Consequently, a real understanding of health sector change will require a recognition that different theoretical approaches will be more (or less) appropriate in some circumstances than in others.