This post is based on my paper for the Political Studies Association annual conference in 2015.
In policy studies we are used to defining policy as a collection of three things: the statements of intent by policymakers, policy delivery, and policy outcomes. This allows us to identify important disconnects between these processes, such as when governments don’t deliver on their promises, or there are unintended consequences to their actions. It is normal to expect a substantial gap between intention, delivery and outcome. However, in many cases, the gap is so large that it may prompt us to reconsider the nature of policy: if it is so distant from the stated intentions of government, do we actually know what policy is? A good example is mental health policy for England.
In the modern history of mental health legislation, you can get the broad sense of a direction of travel undermined, to some extent, by a gap between intention and outcomes. Mental Health Acts in 1959 and 1983 began to include reference to the right to adequate therapeutic treatment – the idea that, if the state deprived you of your liberty based on your mental illness, it should also provide services to treat the illness. However, those services were often inadequate. A policy statement, involving a promise to be treated by suitable services, often remained unfulfilled; services were not delivered and the outcomes were often unintended. ‘Policy’ appeared very different if you focused on the long term outcomes rather than the initial choices.
Three more recent examples provide an additional element.
Mental health legislation meets opposition
First, in the case of the Mental Health Act 2007, much of the UK Labour Government’s policy did not even make it to the statute book. Instead, after rejecting an initial report in 1998 – summed up by the statement ‘if you enforce compulsory powers over an individual, then they are entitled to a minimum quality of care’ – in favour of an approach based much more on preventive detention and public safety, it engaged in a 9-year standoff with the ‘Mental Health Alliance’ (a major collection of professional, third sector and service user groups), which led to legislation that neither side favoured. Indeed, the 1983 and 2007 Acts are still in need of further reform to deal with issues regarding, for example: the relationship between police detention to provide a ‘place of safety’ (under s136 of the 1983 Act) and low hospital capacity to provide follow-up treatment; the inappropriate use of the 1983 Act to secure access to in-patient hospital services; the negligible effect of community treatment orders (CTOs) on hospital admissions; and, the greater use of CTOs for black patients (see the House of Commons Health Committee, report; press release). ‘Policy’ is a combination of a partly-fulfilled statement, problematic delivery, and often-unintended outcomes.
Parity meets localism
Second, the UK Coalition government’s policy of ‘parity’ between mental and physical services marks a major contrast in consultation style – No Health Without Mental Health received widespread support – but not outcomes. It contains a major principle – ‘We are clear that we expect parity of esteem between mental and physical health services’ – and a set of aims on improving mental health in the population, helping people ‘recover’ from mental health illnesses, improving the physical health of people with mental health problems, improving care and support, enhancing services to prevent the development of some mental health problems, and reduce the stigma associated with mental illness. Yet, it also contains a major commitment to ‘localism’, through a mixture of delegating policy delivery to NHS England, devolving service delivery to local areas, and encouraging long term and often-vague outcome-measures (not specific, short term, high salience, NHS targets). This has contributed to a major disconnect between policy intention and outcomes: funding decisions by NHS England and local commissioners have undermined this parity strategy. In the past, we expected ministers to intervene directly in the running of the NHS. The phrase ‘command and control’ was a feature of the previous Labour government. Now, they criticise the decisions of public bodies without intervening to change them. A policy statement on parity, combined with a localism and ‘hands off strategy, has produced nothing of the sort.
Public mental health meets troubled families and fit notes
Third, the idea of public mental health – and related terms such as ‘prevention’ and ‘wellbeing’ – relates to wider ‘root causes’ of ill health, joined increasingly to strategies to identify connections between socio-economic status, housing, education, employment and health. There is some hope that ‘early intervention’ will address many problems before they become acute, reducing inequalities and/ or costs in the process. In general, this is often problematic in mental health, since many conditions are not preventable and early intervention is unlikely to reduce costs in highly pressured acute services. There is also a localist approach to service delivery in this area, built around the user and/ or involving major cooperation between a range of public bodies (such as local authorities and Public Health England), with the emphasis on central government delegating policy and sharing responsibility for outcomes with the public sector.
In this case, a combination of public mental health and localism can be a tempting solution for governments, since they can reduce budgets at the same time as delegating responsibility for policy outcomes to local authorities and their partners, knowing that they can exhort local public bodies to shift to preventative policies to reduce long term costs even though long term policymaking suffers during periods of austerity.
Or, we may simply not know how policy will play out, since preventive public mental health potentially means everything and nothing. A focus on wellbeing can involve positive frames, relating to the production of measures to compete with GDP as a measure of a country’s progress, or negative frames about anti-social behaviour, when a focus on ‘prevention’ and an appeal to the root causes of inequalities is be used to describe ‘Troubled Families’, in which the government seeks to identify a core group of families with intergenerational problems (regarding, for example, unemployment, chaotic lifestyles and low education attainment) and ‘turn them around’ in a relatively short space of time.
Or, public mental health and an ‘assets based approach’ (focusing on the assets people have, not their problems or limitations), can be combined with the UK Government’s framing of economic inactivity and excessive welfare dependence, to describe its controversial reform of social security policy, replacing ‘the paper-based sick note’ with ‘an electronic fit note’. This policy’s implementation is perhaps the most criticised aspect of government policy by the mental health third sector, even though in principle it can be framed as an important aspect of preventive public health.
What are the implications?
Who is accountable?
It is difficult to know for which part of this policy we hold elected policymakers to account: their statements, organisational practices, and/ or the outcomes? This broad movement towards sharing responsibility, for public service delivery and outcomes, between ministers and public and private organisations, might be (a) a pragmatic response to the complexities of government and the inability of ministers to control what goes on in their name, but is certainly (b) replacing the traditional idea of democratic accountability, in which ministers account to the public via Parliament and regular elections, with forms of institutional and service user accountability in which it is much more difficult to know who to blame when things go wrong.
What is the role of evidence based policymaking?
To know if policy is ‘evidence based’ we need to know what policy is. If we conclude that the UK’s sincere policy is parity between mental and physical health services, we can conclude that it is based on a growing intellectual consensus and the accumulation of evidence on the links between mental and physical health, as well as the importance of a wide range of environmental factors. If policy is a range of practices, or outcomes (including the unintended consequences), who knows what its link to the evidence is? If a long term focus on parity is undermined by short term funding decisions on salient acute physical services, we know that evidence plays a part only some of the time.
If the outcomes are so different, is a statement of intent really a policy?
Most of these problems are faced by most policymakers, however cynical or sincere they may be – but note how much of the ‘what is policy?’ question we answer by filling in the gaps with our assumptions about the motivation of politicians. If we say that they are cynical policymakers, we conclude that it is their policy to use a commitment to parity as a veneer; that they know they won’t achieve their stated aims and are happy to accept or contribute to the factors that undermine it. If we say that they are sincere, we conclude that it is their policy to pursue parity as an ideal and do all they can to address obstacles and unintended consequences. Only in the latter case can we meaningfully say that their policy is parity (even though it makes no practical difference).
Is this an England-only problem?
The policy process in Scotland is often described as different in style and substance (often by me). However, all governments face the need to account for their high-profile choices while accepting that they will struggle to control the nature of public sector delivery and its outcomes. Many, if not most, of these problems are ‘universal’ rather than ‘territorial’.