It is safe to say that institutional and policy change has been one of the main preoccupations of political scientists for decades, indeed since institutionalism first arose as a movement in political science. No matter the school of institutionalism, theories built on the impact of institutions on society immediately have to explain institutional change somehow. Not all of them do it well. In a sense, difficulty with change fits well with an entire discipline that resists putting too much stock in leaders and leadership, and is a variable worth studying.

Carolyn Tuohy, who previously wrote one of the best comparative studies of how political and health care institutions interacted to shape and constrain health policy (Tuohy, Reference Tuohy1999), has written a sort of mirror image book about why and how leaders try to reform. It is an empirical and theoretical landmark in health politics, social policy and comparative politics.

She brings to this book, in particular, her understanding of both the big-p politics of formal political systems and the small-p politics of how actors within health care systems interact. Political scientists are often deterred from studying health precisely because the actors within the system are so powerful and yet their interests and ways of working are obscure to those trained in the study of legislators, voters, civil servants and lobbyists. Even when political scientists do work on health policy, the weak spot is often a lack of interest or understanding of feedbacks that can turn policies within the health care system in quite unexpected ways (such as the people who emerge to exploit policies and thereby change their content and political fate – “institutional entrepreneurs” in Tuohy’s terms – e.g. trust executives who entrenched and fought for increasing autonomy in the Foundation Trusts).

The theoretical core of the book starts with a new conceptualization of change in terms of its scale and pace. Scale is the extent of change, in breadth and depth, with something like the legislation creating the NHS in Great Britain marking the high end of the scale. Many readers in the US will surely be surprised to see Medicare and Medicaid, or the Affordable Care Act (ACA), categorized as small-scale reforms, but they are. Medicare and Medicaid jointly cover 35% of the population. Compared to the creation of the NHS, or many other universal systems, they are not such big policies even if the absolute numbers of people covered are big. Pace is what it says it is – the speed at which politicians try to pass and implement a law.

Fast-paced large-scale changes are big bangs, such as the creation of the NHS in 1948. Fast paced congeries of small changes are mosaics; the immensely complex Patient Protection and Affordable Care Act passed under President Obama in the United States is such a mosaic. Small-scale gradual change is incremental, and is the kind of policy we constantly see everywhere. Finally, large-scale slow change is called a blueprint, and denotes a kind of politics in which agreement on policies transcends individual governments.

Political institutions and policy inheritances then re-enter as factors shaping the strategies politicians adopt. They shape what is possible but also shape politicians’ time horizons and coalitions. Politicians who are worried about the future strength of their coalition, such as any sensible Democrats looking at the veto-ridden and thermostatic US system, will try to move as quickly as possible even if that makes their coalitions even more fragile (since there is no time to work on recalcitrant actors such as the two Senators who kept the public option out of the ACA) and their policies less coherent. Politicians confident they will gain power, such as Canada’s Paul Martin, may bide their time and choose incrementalism, expecting they will be better positioned for bigger changes later. Martin bet wrong but that is just life; he placed a bad bet. The Clintons, in Tuohy’s account, placed a still worse bet in trying to force through a large-scale reform at a fast pace. The United States, her argument implies, is condemned to mosaic changes – a thesis that will be subject to an interesting test given that other arguments point to Democrats drawing the conclusion from the Obama years that big, popular, simple, well-known policies are the way to address health care (e.g. Medicare for all, or Medicaid for all). England, it should be no surprise to learn, is prone to big-bang changes just as its institutions would predict.

The book does not just map out its four-cell diagram; it brings new empirical research and a great deal of reading to bear on making its case over its seven hundred pages. Each country’s health system and reform politics since approximately World War Two gets extensive analytic treatment, with lots of interesting new facts and interpretations for country specialists to think about, or perhaps dispute.

The most troublesome category, in a sense, is the blueprint. Tuohy is explicit that the Dutch system, with a culture of consultation and consensus underpinned by a very stable party system, allowed the blueprint reforms she described. Dutch politics is no longer so stable or consensual and another blueprint reform would probably be impossible today even if the politicians were as talented and inclined to health reform as the ones she studied. Nobody else’s politics are becoming cozier and more consensual right now. So is it an empty cell? It may be that, even if the kind of cozy extended reciprocity that used to operate in the Netherlands is gone, external constraints are now the principal factor precipitating blueprint strategies. Eurozone entrance, Eurozone crisis response, and EU accession are all projects that led countries of all kinds to establish multiparty consensus on tough policies and implement them across governments.

Politics is the art of the possible – a truism, but a true one. Identifying what is possible is much of the art of the policymaker, and the best policymakers are therefore the ones likeliest to belie political science generalizations about what is and isn’t possible in their countries. Tuohy brings us further towards understanding institutional change and leadership and, in the course of doing so, gives us the best comparative health policy study published in years – since her last one, in fact.