Institutionalising preventive health: what are the key issues for Public Health England?

By Paul Cairney (University of Stirling, blue shirt), John Boswell (University of Southampton, check), Richard Gleave (Public Health England, tie), and Kathryn Oliver (London School of Hygiene and Tropical Medicine, black jacket). This post first appeared on the University of Stirling public policy blog and University of Bristol IEUREKA! blog.

On the 12^th June, at the invitation of Richard Gleave (Deputy Chief Executive and Chief Operating Officer, PHE), Professor Paul Cairney (University of Stirling) and Dr John Boswell (University of Southampton) led a discussion on ‘institutionalising’ preventive health with senior members of PHE. It follows a similar event in Scotland, to inform the development of Public Health Scotland, and the PHE event enjoyed contributions from key members of NHS Health Scotland. Cairney and Boswell drew on their published work – co-authored with Dr Kathryn Oliver (London School of Hygiene and Tropical Medicine) and Dr Emily St Denny (University of Stirling) – to examine the role of evidence in policy and the lessons from comparable experiences in other public health agencies (in England, New Zealand and Australia). This post summarises their presentation and reflections from the workshop (gathered using the Chatham House rule).

The Academic Argument

Governments face two major issues when they try to improve population health and reduce health inequalities:

1. Should they ‘mainstream’ policies – to help prevent ill health and reduce health inequalities – across government and/ or maintain a dedicated government agency?
2. Should an agency ‘speak truth to power’ and seek a high profile to set the policy agenda?

Our research provides three messages to inform policy and practice:

1. When governments have tried to mainstream ‘preventive’ policies, they have always struggled to explain what prevention means and reform services to make them more preventive than reactive.
2. Public health agencies could set a clearer and more ambitious policy agenda. However, successful agencies keep a low profile and make realistic demands for policy change. In the short term, they measure success according to their own survival and their ability to maintain the positive attention of policymakers.
3. Advocates of policy change often describe ‘evidence based policy’ as the answer. However, a comparison between (a) specific tobacco policy change and (b) very general prevention policy shows that the latter’s ambiguity hinders the use of evidence for policy. Governments use three different models of evidence-informed policy. These models are internally consistent but they draw on assumptions and practices that are difficult to mix and match. Effective evidence use requires clear aims driven by political choice.

Overall, they warn against treating any response – (a) the idiom ‘prevention is better than cure’, (b) setting up a public health agency, or (c) seeking ‘evidence based policy’ – as a magic bullet. Major public health changes require policymakers to define their aims, and agencies to endure long enough to influence policy and encourage the consistent use of models of evidence-informed policy. To do so, they may need to act like prevention ninjas, operating quietly and out of the public spotlight, rather than seeking confrontation and speaking truth to power.

The Workshop Discussion

The workshop discussion highlighted an impressive level of agreement between the key messages of the presentation and the feedback from most members of the PHE audience.

One aspect of this agreement was predictable, since Boswell et al’s article describes PHE as a relative success story and bases its analysis of prevention ‘ninjas’ on interviews with PHE staff. However, this strategy is subject to frequent criticism. PHE has to manage the way it communicates with multiple audiences, which is a challenge in itself.  One key audience is a public health profession in which most people see their role as to provoke public debate, shine a light on corporate practices (contributing to the ‘commercial determinants of health’), and criticise government inaction. In contrast, PHE often seeks to ensure that quick wins are not lost, must engage with a range of affected interests, and uses quiet diplomacy to help maintain productive relationships with senior policymakers. Four descriptions of this difference in outlook and practice stood out:

1. Walking the line. Many PHE staff gauge how well they are doing in relation to the criticism they receive. Put crudely, they may be doing well politically if they are criticised equally by proponents of public health intervention and vocal opponents of the ‘nanny state’.
2. Building and maintaining relationships. PHE staff recognise the benefit of following the rules of the game within government, which include not complaining too loudly in public if things do not go your way, expressing appreciation (or at least a recognition of policy progress) if they do, and being a team player with good interpersonal skills rather than simply an uncompromising advocate for a cause. This approach may be taken for granted by interest groups, but tricky for public health researchers who seek a sense of critical detachment from policymakers.
3. Managing expectations. PHE staff recognise the need to prioritise their requirements from government. Phrases such as ‘health in all policies’ often suggest the need to identify a huge number of crucial, and connected, policy changes. However, a more politically feasible strategy is to identify a small number of discrete priorities on which to focus intensely.
4. Linking national and local. PHE staff who work closely with local government, the local NHS, and other partners, described how they can find it challenging to link ‘place-based’ and ‘national policy area’ perspectives.  Local politics are different from national politics, though equally important in implementation and practice.

There was also high agreement on how to understand the idea of ‘evidence based’ or ‘evidence informed’ policymaking (EBPM). Most aspects of EBPM are not really about ‘the evidence’. Policy studies often suggest that, to improve evidence use requires advocates to:

• find out where the action is, and learn the rules and language of debate within key policymaking venues, and
• engage routinely with policymakers, to help them understand their audience, build up trust based on an image of scientific credibility and personal reliability, and know when to exploit temporary opportunities to propose policy solutions.
• To this we can add the importance of organisational morale and a common sense of purpose, to help PHE staff operate effectively while facing unusually high levels of external scrutiny and criticism. PHE staff are in the unusual position of being (a) part of the meetings with ministers and national leaders, and (b) active at the front-line with professionals and key publics.

In other words, political science-informed policy studies, and workshop discussions, highlighted the need for evidence advocates to accept that they are political actors seeking to win policy arguments, not objective scientists simply seeking the truth. Scientific evidence matters, but only if its advocates have the political skills to know how to communicate and when to act.

Although there was high agreement, there was also high recognition of the value of internal reflection and external challenge. In that context, one sobering point is that, although PHE may be relatively successful now (it has endured for some time), we know that government agencies are vulnerable to disinvestment and major reform. This vulnerability underpins the need for PHE staff to recognise political reality when they pursue evidence-informed policy change. Put bluntly, they often have to strike a balance between two competing pressures – being politically effective or insisting on occupying the moral high ground – rather than assuming that the latter always helps the former.

Making an impact with research: how to engage critically with well-meaning advice

This post appeared first on the UPEN blog.

The ‘impact’ agenda has prompted many academics and organisations to recommend how to use research to influence policy and practice. In this post, Paul Cairney and Kathryn Oliver reflect on the value of this advice and warn against taking it too firmly to heart. The post trails their forthcoming contribution to ‘UoN Engaged’, hosted at the University of Nottingham on the 17th of September. 

In 2019, we published two articles about the most frequently-offered advice to academics about how to use research to make an impact on policy. Both articles are based on a systematic review of the many ‘how to’ guides produced by unusually successful scientists or knowledge brokerage organisations in blogs and short reports.

In ‘How Should Academics Engage in Policymaking to Achieve Impact?’, we show that this advice is highly consistent, ‘largely because it is necessarily vague, safe, and focused primarily on individuals’. In most cases, high profile researchers are asked to reflect on their personal experiences rather than produce research on impact. This type of advice has two biases. First, most are written from the perspective of high status white, male, global north scientists, who have relatively easy access and good support to do policy engagement. Their advice often does not apply to more junior scholars who lack access and resources, and it rarely addresses the higher risk of engagement to women and people of colour. Second, it tends to emphasise the role of individuals rather than the policymaking environments in which they operate.

In ‘dos and don’ts of influencing policy: a systematic review of advice to academics ’, we provide a fuller account of the eight most common ‘tips’ on how to influence policy and practice with research:

1. Do high quality research
2. Make your research relevant and readable
3. Understand policy processes
4. Be accessible to policymakers. Engage routinely, flexibly, and humbly
5. Decide if you want to be an issue advocate or honest broker
6. Build relationships (and ground rules) with policymakers
7. Be ‘entrepreneurial’ or find someone who is
8. Reflect continuously: should you engage, do you want to, and is it working?

We then reflect on the key dilemmas for researchers that tend to be covered more patchily in this work. First, there is insufficient reflection on the moral purpose behind such engagement: why, and for whose benefit, do we engage in impact activities. Second, few agree on how to engage, and where to draw the mythical line between providing dispassionate advice and making a political case. Third, there is little acknowledgement of the unintended consequences and costs of (a) the ‘tokenistic’ and instrumental engagement by many, on (b) the more meaningful and longer term engagement by some.

However, our impression is that most attention to these articles has been to highlight the value of the eight top tips! We have become part of the problem that we sought to reduce. Our initial response was to dispense with subtle titles in subsequent blogs, in favour of ‘Beware the well-intentioned advice of unusually successful academics’, and we see this UPEN blog post as an opportunity to accentuate two more reflective aspects to our review. The first is to reproduce the ‘top tips’ table, but this time with more emphasis on their problematic aspects:

The second is to accentuate the questions raised in the last tip: to think about whether, how and why to engage. We identify three dilemmas and suggest that a meaningful discussion of each should be a key part of any University’s impact and engagement strategy.

First, whether or not to engage. Opinions are split over the public duty of academics to influence policy, versus the need to protect independence and reduce possible costs. Many have pointed to conflicting advice over whether to represent one’s own research, or rather – seeking greater impact – to represent a whole field or profession. In practice, they are false dichotomies, because most researchers are required to demonstrate intent to engage. If Universities expect researchers to engage, they should address the unequal distribution of costs and resources.The second is to accentuate the questions raised in the last tip: to think about whether, how and why to engage. We identify three dilemmas and suggest that a meaningful discussion of each should be a key part of any University’s impact and engagement strategy.

Second, how best to engage. If a researcher is willing and able, should they use every tool available to maximise their impact, such as emotional appeals, over-confident conclusions or direct policy recommendations? Or should they try to appear disinterested, to maximise their credibility in the eyes of their policymaker and academic audiences? Attempting to be omnipotent yet credible; humble but authoritative; straightforward yet not over-simplifying – all while still appearing authentic – is beyond the scope of anyone’s acting abilities.

Third, the purpose of engagement. Establishing one’s moral identity and purpose as an academic is a long term and iterative process, and it is essential to ethical engagement. Many feel that it is a public duty. Others engage instrumentally, crudely, or rudely, treating policy colleagues as a means to an end. The difficulty is that the radical option – of engaging with the aim of listening and learning – is potentially transformational for research and policy, but not open to academics tied to responsive and short-term funding cycles.

Bad advice based on too-simple top tips, and unresolved dilemmas, can lead to wasted resources and significant risks for academics and policymakers involved in engagement. The tips often seem to describe an ideal form of policymaking, in which policymakers are seeking the most robust evidence from any relevant researcher to make decisions. Unwittingly, well-intentioned advice can perpetuate misunderstandings of the policy process and leading people into dispiriting or even risky situations. The answer is a more reflective discussion about the costs and benefits of engagement, and the choices to be made by individuals and institutions, not a simple how to guide.

Excellent, cautionary presentation by @oliver_kathryn and @CairneyPaul tackling some of the issues and limitations around the advice often given to academics on achieving policy impact. We are studiously taking notes… #UoNEngaged pic.twitter.com/GN60QxQRds

— Nottingham Institute for Policy and Engagement (@UoN_Institute) September 17, 2019

Here is the powerpoint we used: Oliver Cairney Nottingham September 2019

About the authors

Kathryn Oliver is Associate Professor of Sociology and Public Health, London School of Hygiene and Tropical Medicine (@oliver_kathryn ). Her interest is in how knowledge is produced, mobilized and used in policy and practice, and how this affects the practice of research. She co-runs the research collaborative Transforming Evidence with Annette Boaz. https://transformure.wordpress.com and her writings can be found here: https://kathrynoliver.wordpress.com

Paul Cairney is Professor of Politics and Public Policy, University of Stirling, UK (@Cairneypaul). His research interests are in comparative public policy and policy theories, which he uses to explain the use of evidence in policy and policymaking, in one book (The Politics of Evidence-Based Policy Making, 2016), several articles, and many, many blog posts: https://paulcairney.wordpress.com/ebpm/

Why Boris Johnson is so important to Scottish independence

Why is the presence of Boris Johnson so important to the prospect of Scottish independence? Why is it so important to the fate of the Scottish Conservatives? How are both questions connected?

One way to answer these questions is to think back to the relative success of the Scottish Conservatives in the most recent elections in Westminster and Holyrood. During this period, the party’s Scottish strategy was simple and effective:

1. Focus on its leader in Scotland – Ruth Davidson – and downplay the party.
2. Focus almost exclusively on opposing a second referendum on Scottish independence.
3. Promote Ruth Davidson’s image – as a competent, reliable, and therefore trustworthy leader – to give weight to its message on the referendum.

Another is to remember that some key UK factors helped facilitate this approach:

4. UK Prime Ministers – David Cameron and Theresa May – were relatively respectful towards Scottish political actors and relatively sympathetic to the Scottish context.
5. Until the Brexit debate and its aftermath, they were often able to project a sense of order and use it to highlight a set of relatively consistent rules, norms, and expectations about how politics should work.

In that context, think about the extent to which any of these factors now hold:

1. Boris Johnson will often overshadow the Scottish party and its leader, reinforcing the old association between (a) support for constitutional change, and (b) opposition to the Conservatives.
2. He will likely slip up, either by appearing to favour a second Scottish referendum on impulse, or by opposing it in an unhelpful way.
3. His reputation for incompetent buffoonery may seem cute to his supporters, but embarrassing and damaging to Scottish Conservatives.
4. He is already on record as being disrespectful to the Scottish case, and will be under relatively high pressure to ‘stand up for England’ in the way that the SNP has become known as ‘standing up for Scotland’.
5. All bets are off in relation to the idea that there is a standard way to deal with demands for things like referendums.

Put more simply, the person in charge of telling the SNP not to be so gung ho, unreasonable, or obsessed with national identity and independence from an external authority, will be Boris Johnson.

Let’s combine conceptual insights

A short blog post for policy process theory specialists and Gilmore Girls enthusiasts.

Being cited in the bibliography of other scholars is lovely, and I appreciate it very much. Indeed, if you do it to me, early enough in the journal submission, there is a good chance it will come to me for review, and my heart will swell with joy while I read it.

If so, I have one small request:

1. If you want to argue something like “Cairney says ‘hey, let’s compare many theoretical insights, what can possibly go wrong?'”, then you want this one:

Paul Cairney (2007) ‘A Multiple Lens Approach to Policy Change’, British Politics, 2, 1, 45-68 PDF

2. If you want to say something like “here are the three main things that Cairney says will probably go wrong”, then you want this one:

Paul Cairney (2013) ‘Standing on the Shoulders of Giants: How Do We Combine the Insights of Multiple Theories in Public Policy Studies?’ Policy Studies Journal, 41, 1, 1-21 PDF

3. If, after reading this full-of-himself post you want to say something like ‘this joker Cairney should get over himself’, then you should cite them all to project a sense of completeness.

 

 

 

 

 

 

 

I don’t know. You don’t have to think about it much, and Kirk is funny. He’s that guy in Guardians of the Galaxy that sort of causes a mutiny unintentionally then regrets it.