Why do public policies fail so often? Exploring health policy-making as an imaginary and symbolic construction

Although it is widely accepted that public policies are difficult to implement, most analyses of policy failures are conceived of as predominantly rational processes. This article questions that assumption by introducing ideas of a desiring subject and socio-symbolic order drawn from Lacanian psychoanalytic theory to suggest that public policies are also a product of social fantasy, and to draw attention to the implications of this unrecognized function of policy-making. It also employs the idea of defensive splitting borrowed from Kleinian object relations theory to explain the difficulty of translating policy into public organizations, which have to perform often conflicting societal tasks. The example of patient choice in the UK National Health Service (the NHS) is used to illustrate theoretical arguments and to propose an alternative understanding of public policy-making by way of bridging fantasy with reality.