Category Archives: Prevention policy

Prevenir es mejor que curar, entonces, ¿por qué no hacemos más?

Serie: El proceso de las políticas públicas.

Paul Cairney, Profesor de Política y Políticas Públicas en la Universidad de Stirling, Escocia. Enlace a texto original en inglés.

Esta publicación proporciona una amplia cantidad de antecedentes de mi plática en la Escuela de Gobierno de Australia y Nueva Zelanda (ANZSOG, por sus siglas en inglés), la cual se titula “Prevenir es mejor que curar, entonces, ¿por qué no hacemos más?” [en inglés] Si lo lees todo, es una lectura larga. Si no, es una lectura corta antes de la lectura larga. Aquí está la descripción de la plática:

“¿Te suena familiar? Comienza una nueva administración en el gobierno, la cual promete cambiar el equilibrio en las políticas sociales y de salud, – de costosos remedios y atención de alta dependencia o complejidad, a prevención e intervención temprana-. Se comprometen a una mejor formulación de políticas públicas; y dicen que la entrega de políticas y programas se hará de forma coordinada, delegando responsabilidades a nivel local y enfocándose en resultados a largo plazo en lugar de soluciones a corto plazo; y que garantizarán que la política se base en evidencia. Y luego todo se vuelve demasiado difícil y el ciclo comienza nuevamente, dejando a su paso algunos especialistas exhaustos y desilusionados. ¿Por qué sucede esto repetidamente, en diferentes países y con gobiernos de diferentes doctrinas, incluso con la mejor voluntad del mundo?

  • De acuerdo con la pregunta verás que no estoy sugiriendo que todas las políticas públicas de prevención o intervención temprana fallen. Por el contrario, utilizo teorías de políticas públicas para proporcionar una explicación general de la brecha significativa entre las expectativas (realistas) expresadas en las estrategias de prevención y los resultados reales. Luego se puede discutir sobre cómo disminuir esa brecha.
  • También verás la frase “incluso con la mejor voluntad del mundo”, que considero clave para esta plática. Nadie necesita que yo ensaye las formas comunes y generalmente vagas de explicar las políticas de prevención fallidas, incluida la “intratabilidad” [en inglés] de los problemas de políticas públicas o la “patología” [en inglés] de las mismas. Más bien, demuestro que tales políticas públicas pueden “fracasar” incluso cuando existe un acuerdo franco y amplio entre las partes sobre la necesidad de pasar del diseño de políticas reactivas a más preventivas. También sugiero que la explicación general del fracaso (baja “voluntad política”) a menudo es perjudicial para posibilidades de éxito en el futuro.
  • Comencemos por definir la política pública de prevención y la formulación de políticas públicas.

Cuando los gobiernos se involucran en la “prevención”, buscan:

  1. Reformar las políticas públicas

La política pública de prevención es realmente un conjunto de políticas diseñadas para intervenir lo antes posible en la vida de las personas para mejorar su bienestar y reducir las desigualdades o la demanda de servicios agudos. El objetivo es pasar de los servicios públicos reactivos a los preventivos, interviniendo de manera temprana en la vida de las personas para abordar una amplia gama de problemas de largo alcance, incluidos el crimen y el comportamiento antisocial, la mala salud y los comportamientos no saludables, el bajo nivel educativo, el desempleo y la baja empleabilidad, antes de que se vuelvan demasiado severos.

  1. Reformar la formulación de la política pública

La formulación de políticas públicas preventivas describe las formas en que los gobiernos reforman sus prácticas para apoyar las políticas de prevención, incluido el compromiso de:

  • “Unir” a departamentos y servicios gubernamentales para resolver “problemas intratables” que trascienden áreas.
  • Producir objetivos a largo plazo para obtener mayores resultados a través de otorgar mayor responsabilidad en el diseño del servicio a los organismos públicos locales, las partes interesadas, las “comunidades” y los usuarios del servicio
  • Reducir los objetivos a corto plazo en favor de resultados a largo plazo.
  1. Asegurar que la política pública es “basada en evidencia”

Tres razones generales por las cuales las políticas públicas de “prevención” nunca parecen tener éxito.

  1. Los formuladores de política pública no saben el significado de la prevención

Expresan un compromiso con la prevención antes de definirla completamente. Cuando comienzan a dar sentido a la prevención, descubren lo difícil que es perseguirla y las elecciones controvertidas que esto implica (ver también incertidumbre versus ambigüedad)

  1. Se involucran en un sistema de formulación de políticas públicas que es demasiado complejo para controlarse

Intentan compartir la responsabilidad entre varios actores y coordinan acciones para direccionar los resultados de las políticas públicas. Sin embargo, no poseen la capacidad de diseñar dichas relaciones y controlar los resultados de las políticas públicas.

Sin embargo, también deben demostrarle al electorado que tienen el control y descubrir lo difícil que es localizar y centralizar las políticas públicas.

  1. No pueden y no quieren producir la “formulación de la política pública basada en evidencia”

Los formuladores buscan atajos cognitivos (y sus equivalentes organizacionales) para recopilar suficiente información para tomar decisiones “suficientemente buenas”. Cuando buscan evidencia sobre la prevención, descubren que es irregular, poco concluyente y a menudo contraria a sus creencias, y no una “bala mágica” para ayudar a justificar las elecciones.

A lo largo de este proceso, su compromiso con la política pública de prevención puede ser sincero, pero no se materializa. No articulan completamente lo que significa prevención ni aprecian la dimensión de dicha tarea. Cuando intentan ofrecer estrategias de prevención, se enfrentan a varios problemas que por sí solos parecerían desalentadores. Muchos de los problemas que tratan de “prevenir” son “intratables” o difíciles de definir y aparentemente imposibles de resolver, como la pobreza, el desempleo, las viviendas de baja calidad y la falta de ellas, el crimen y las desigualdades en salud y educación. Se enfrentan a elecciones difíciles sobre cuán lejos deberían llegar para cambiar el equilibrio entre el Estado y el mercado, redistribuir la riqueza y los ingresos, distribuir recursos públicos e intervenir en la vida de las personas para cambiar su comportamiento y sus formas de pensar. Su enfoque en el largo plazo se enfrenta a una gran competencia por problemas de políticas públicas cortoplacistas más destacados que los impulsan a mantener servicios públicos “reactivos”. Su deseo puro de “localizar” la formulación de políticas, a menudo cede el paso a la política electoral nacional, en la que los gobiernos centrales se enfrentan a la presión para formular políticas públicas desde “arriba” y ser decisivos. Su búsqueda de políticas “basadas en evidencia” a menudo revela una falta de evidencia sobre qué intervenciones políticas funcionan y la medida en que se pueden “expandir” con éxito.

Un mal diagnostico por parte de los encargados de la formulación de la política pública y actores influyentes hará que los problemas no se resuelvan

  • Si los actores con poder en las políticas públicas hacen la suposición simplista de que un problema es causado por cuestiones que no son vitales para el Estado, darán malos consejos.
  • Si los nuevos formuladores realmente piensan que el problema fue la falta de compromiso y la competencia de sus predecesores, comenzarán con las mismas esperanzas sobre el impacto que pueden tener, solo para desencantarse cuando vean la diferencia entre sus objetivos abstractos y los resultados del mundo real.
  • La mala explicación del éxito limitado contribuye en gran medida a observar (a) un período inicial de entusiasmo y actividad, reemplazado por (b) desencanto e inactividad, y (c) la repetición de este ciclo.

Agreguemos más detalles a estas explicaciones generales:

  1. ¿Qué hace que la prevención sea tan difícil de definir?

Cuando se ve como un eslogan simple, “prevención” parece un objetivo intuitivamente atractivo. Puede generar un consenso entre los partidos políticos, reuniendo grupos de la “izquierda”, buscando reducir las desigualdades, y de la “derecha”, buscando reducir la inactividad económica y el costo de servicios.

Tal consenso es superficial e ilusorio. Al hacer una estrategia detallada, la prevención está abierta a muchas interpretaciones por parte de muchos formuladores de políticas públicas. Imagina los muchos tipos de políticas de prevención y formulación de políticas que podríamos producir:

 

     1. ¿Qué problema tratamos de resolver?

La formulación de políticas públicas de prevención representa una solución heroica a varias crisis: grandes desigualdades, servicios públicos con recursos insuficientes y un gobierno disfuncional.

 

     2. ¿En qué medidas debemos centrarnos?

¿En qué desigualdades debemos concentrarnos principalmente? Riqueza, ocupación y empleo, ingresos, raza, etnia, género, sexualidad, discapacidad, salud mental.

¿De acuerdo a cuál medida de desigualdad? Económica, salud, comportamiento saludable, educación, bienestar, castigo.

     3. ¿En qué solución deberíamos centrarnos?

Para reducir la pobreza y las desigualdades socioeconómicas, mejorar la calidad de vida nacional, reducir los costos de los servicios públicos o aumentar la relación precio-calidad.

     4. ¿Qué “herramientas” o instrumentos de política debemos utilizar?

¿Políticas redistributivas para abordar las causas “estructurales” de pobreza y desigualdad?

O tal vez políticas centradas en el individuo para: (a) aumentar la “resistencia” mental de los usuarios de servicios públicos, (b) obligar o (c) exhortar a las personas a cambiar su comportamiento. 

     5. ¿Cómo se interviene lo antes posible en la vida de las personas?

Prevención primaria. Concentrándose en toda la población para evitar que ocurra un problema invirtiendo de forma temprana o modificando el entorno social o físico. Similar a la vacunación del total de la población.

Prevención secundaria. Enfocándose en los grupos en riesgo para identificar un problema en una etapa temprana con el objetivo de minimizar el daño.

Prevención terciaria. Concentrándose en los grupos afectados para evitar que un problema empeore.

 

     6. ¿Cómo se alcanza la “formulación de políticas públicas basada en evidencia”? 3 modelos ideales (en preparación).

¿Usando ensayos controlados aleatorios y revisión sistemática para identificar las mejores intervenciones?

¿Narrativas para compartir las mejores prácticas de gobernanza?

¿Métodos de “mejora” para experimentar a menor escala y compartir las mejores prácticas?

 

     7. ¿Cómo se relaciona la recopilación de evidencia con la formulación de políticas públicas a largo plazo? 

¿Una estrategia nacional impulsa resultados a largo plazo?

¿El gobierno central produce acuerdos u objetivos para las autoridades locales?

 

  1. ¿La formulación de políticas públicas preventivas es una filosofía o un profundo proceso de reforma?

¿Qué tan serios son los gobiernos nacionales (sobre el localismo, los servicios públicos impulsados por los usuarios del servicio y la formulación de políticas integrales u holísticas), cuando los responsables del resultado son políticos electos?

 

  1. ¿Cuál es la naturaleza de la intervención del Estado?

Puede ser punitivo o de apoyo. Ver: ¿Cómo harían Lisa Simpson y Monty Burns una política social progresista? [en inglés]

 

  1. Tomar “decisiones difíciles”: ¿Qué problemas surgen cuando la política se enfrenta a la formulación de políticas públicas?

 

Cuando los formuladores de políticas se mueven desde un amplia filosofía y lenguaje hacia políticas y prácticas específicas, encuentran una serie de obstáculos, que incluyen:

La escala de la tarea se vuelve abrumadora y no se adapta a los ciclos electorales.

Desarrollar políticas públicas y reformar su formulación lleva tiempo, su efecto puede tardar una generación en verse.

 

Existe competencia por los recursos para la formulación de las políticas públicas, tales como la atención y el dinero.

La prevención es general, a largo plazo y de poca importancia. Compite contra los principales problemas a corto plazo que los políticos se sienten obligados a resolver primero.

La prevención es similar a la inversión de capital sin garantía de retorno sobre la inversión. Las reducciones en los fondos de “lucha contra incendios”, “servicios de primera línea” para solventar las iniciativas de prevención, son difíciles de vender. Los gobiernos invierten en pequeñas acciones, y la inversión es vulnerable cuando se necesita dinero rápidamente para financiar crisis en el servicio público.

 

Los beneficios son difíciles de ver y medir.

Los impactos a corto plazo son difíciles de medir, los impactos a largo plazo son difíciles de atribuir a una sola intervención, y la prevención no necesariamente implica ahorrar dinero (ni proporciona ahorros “canjeables”).

Las políticas reactivas tienen un impacto más visible, como reducir los tiempos de espera en el hospital o aumentar el número de maestros u oficiales de policía.

 

Los problemas son “intratables”.

Llegar a la “causa raíz” de los problemas no es sencillo; los formuladores de políticas públicas a menudo no tienen certeza de la causa de los problemas o el efecto de sus soluciones. Pocos aspectos de la prevención en la política social se asemejan a la prevención de enfermedades, en la que se conocen las causas de muchas enfermedades, así como sus formas de detección y prevención.

 

La gestión del desempeño no conduce a la prevención.

Los sistemas de gestión del desempeño alientan a los administradores del sector público a considerar servicios cuyos objetivos sean medibles a corto plazo, sobre aquellos compartidos con socios de prestación de servicios públicos o referentes al bienestar de sus pobladores.

La gestión del desempeño consiste en establecer prioridades cuando los gobiernos tienen demasiados objetivos que cumplir. Cuando los gobiernos centrales alientan a los órganos de gobierno locales a formar asociaciones a largo plazo para abordar las desigualdades y cumplir los objetivos a corto plazo, lo último es lo primero.

 

Los gobiernos enfrentan grandes dilemas éticos.

Las elecciones políticas coexisten con juicios normativos sobre el papel del Estado y la responsabilidad personal, a menudo socavando acuerdos entre partidos políticos.

 

Un aspecto de la prevención puede debilitar al otro.

Una visión cínica de las iniciativas de prevención es que representan una solución política rápida en lugar de una solución significativa a largo plazo:

  • Los gobiernos centrales describen la prevención como la solución a los costos del sector público. A la vez, delegan la responsabilidad de la formulación de políticas públicas y reducen los presupuestos de los organismos públicos subnacionales.
  • Luego los organismos públicos de acuerdo a la urgencia priorizan sus responsabilidades legales.

 

Alguien debe rendir cuentas.

Si todos están involucrados en la formulación y elaboración de políticas públicas, no queda claro quién puede será responsable de los resultados. Esto es incompatible con la responsabilidad democrática al estilo de “Westminster” en donde se sabe quién es responsable y, por lo tanto, a quién culpar o reconocerle el buen desempeño.

 

     3. La evidencia no es una “bala mágica”

 

En una serie de pláticas [en inglés], identifico las razones por las cuales la “formulación de políticas públicas basada en evidencia” (EBPM) [en inglés] no describe bien el proceso de la política pública.

En otras publicaciones también sugiero que es más difícil para la evidencia “ganar la batalla” [en inglés] en las extensas áreas de la política de prevención en comparación con campos más específicos, por ejemplo el control del tabaco.

En general, una regla simple sobre EBPM es que nunca hay una panacea que sustituya al juicio. La política se trata de tomar decisiones que beneficien a algunos mientras que otros pierden. Puedes usar la evidencia para ayudar a comprender esas opciones, pero no para producir una solución “técnica”.

Una regla adicional con los problemas “intratables” es que la evidencia no es lo suficientemente buena como para generar claridad sobre la causa del problema. O simplemente encuentras cosas que no quieres saber.

La intervención temprana en las “políticas públicas familiares” parece ser un buen candidato para este último, por tres razones principales:

 

  1. Muy pocas intervenciones cumplen con los más altos estándares de evidencia

Hay dos tipos principales de intervenciones relevantes “basadas en evidencia” en este campo [en inglés].

Los primeros son “proyectos de intervención familiar” (FIPs, por sus siglas en inglés). En general, se centran en familias de bajos ingresos a menudo de padres solteros, en riesgo de desalojo y vinculados a comportamientos antisociales. Dichos proyectos proporcionan dos formas de intervención:

  • Apoyo intensivo las 24 horas del día, los 7 días de la semana. Los programas incluyen grupos y actividades después de la escuela (para niños) y clases de habilidades (para padres). En algunos casos también consideran tratamiento para las adicciones o la depresión. Dicho tratamiento se lleva a cabo en alojamientos destinados para este fin con reglas estrictas sobre acceso y comportamiento.
  • Un modelo de apoyo y capacitación.

 

La evidencia del éxito proviene de la evaluación más un contrafáctico: esta intervención es costosa, pero se cree que habría costado mucho más dinero y esfuerzo si no se hubiese intervenido. En general, no existe un ensayo controlado aleatorio (RCT, por sus siglas en inglés) para establecer la causa de los mejores resultados, o demostrar que esos resultados no habrían sucedido sin esta intervención.

El segundo son proyectos transferidos de otros países (principalmente los Estados Unidos de América. y Australia) en función de su exitosa reputación que se basa en la evidencia de los RCTs. Hay más evidencia cuantitativa de éxito, pero aún es difícil saber si el proyecto puede transferirse de manera efectiva y si su éxito puede replicarse en otro país con impulsores, problemas y servicios políticos muy diferentes.

 

  1. La evidencia sobre la “expansión” de la prevención primaria es relativamente débil

 Kenneth Dodge [en inglés] (2009) resume un problema general:

  • Hay pocos ejemplos de proyectos efectivos que especialistas llevan a cabo a “a escala”.
  • Existen problemas importantes en torno a la “fidelidad” al proyecto original cuando se amplía (incluida la necesidad de supervisar una expansión de profesionales bien capacitados)
  • Es difícil predecir el efecto de un programa, que se mostró prometedor cuando se aplicó a una determinada población, a una nueva y diferente.

 

  1. La evidencia sobre la intervención temprana secundaria también es débil

 Este punto sobre diferentes poblaciones con diferentes motivaciones se demuestra en un estudio (publicado en 2014) por Stephen Scott y otros [en inglés], acerca de dos intervenciones de Incredible Years para abordar los “síntomas de trastorno de oposición desafiante y los rasgos de personalidad antisocial” en niños de 3 a 7 años (para una discusión más amplia de tales programas, ver Fundamentos para la vida: ¿qué funciona para apoyar la interacción entre padres e hijos en los primeros años? [en inglés], publicado por la Early Intervention Foundation (Fundación de Intervención Temprana)).

Destacan un dilema clásico en la intervención temprana: la evidencia de efectividad solo es clara cuando los niños han sido remitidos clínicamente (“enfoque indicado”), pero no está claro cuando los niños han sido identificados como de alto riesgo utilizando predictores socioeconómicos (“enfoque selectivo”):

 

Un enfoque indicado es más sencillo de administrar, ya que hay menos niños con problemas graves, son más fáciles de identificar y sus padres generalmente están preparados para participar en el tratamiento; sin embargo, los problemas podrían ya estar demasiado arraigados para tratarlos. Por el contrario, un enfoque selectivo se centra en casos menos severos, pero debido a que los problemas están menos establecidos se debe evaluar a poblaciones enteras y algunos casos desarrollarán problemas graves.

 

Para nuestros propósitos, esto podría representar la forma más inconveniente de evidencia sobre intervención temprana: se podría intervenir temprano con respaldo limitado de evidencia que resulte probablemente exitoso o se podría tener una probabilidad mucho mayor de éxito cuando se interviene más tarde, en otras palabras, cuando se está acabando de tiempo para llamarlo ‘intervención temprana’.

Conclusión: Un vago consenso no sustituye la elección política.

Los gobiernos comienzan con la sensación de que han encontrado la solución a muchos problemas, solo para descubrir que tienen que tomar y defender elecciones altamente “políticas”.

Por ejemplo, considera el uso “creativo” de evidencia del gobierno del Reino Unido para hacer una política familiar [en inglés]. En pocas palabras, el gobierno eligió actuar rápido y a la ligera con la evidencia, demonizando a 117,000 familias para proporcionarle cobertura política a una redistribución de recursos hacia proyectos de intervención familiar.

Con justa razón, se podría objetar este estilo de política. Sin embargo, también se tendría que producir una alternativa factible.

Por ejemplo, el Gobierno escocés ha adoptado un enfoque diferente (quizás más cercano a lo que se esperaría en Nueva Zelanda), pero aún necesita producir y defender una narrativa acerca de sus elecciones. El gobierno de Escocia enfrenta casi las mismas limitaciones que el Reino Unido, su auto descripción hacia un “cambio decisivo” hacia la prevención [en inglés], no lo es.

Después de todo, la prevención no es diferente de cualquier otra área de política pública, excepto que ha demostrado ser mucho más complicada y difícil de mantener que la mayoría de las demás. La prevención es parte de un lenguaje excelente pero no una panacea para los problemas de política pública.

 

Otras lecturas:

Prevención [en inglés]

 

Vea también:

¿Qué haces cuando el 20% de la población causa el 80% de sus problemas? Posiblemente nada [en inglés].

Política de intervención temprana, desde “familias con problemas” hasta “personas nombradas”: problemas con la evidencia y encuadre de problemas [en inglés]

 

Traductores

Anette Bonifant Cisneros anette.bonifant@york.ac.uk

Juan Guillermo Vieira jgvieiras@unal.edu.co

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Filed under Evidence Based Policymaking (EBPM), Políticas Públicas, Prevention policy

Public health policy: assumptions and expectations

Rather misleadingly, this very draft paper is called The Politics of Evidence-based ‘Health in All Policies’It’s for Integrating Science and Politics for Public Health, convened by Patrick Fafard and Adèle Cassola at the Global Strategy Lab.

The most interesting section, for me, is the attempt to sense check the following list of assumptions/ expectations that I associate with public health studies of public policy. Unless stated otherwise, this list is based on literature reviews and documentary analysis underpinning studies of tobacco policy and prevention policy (Cairney and St Denny, 2020), as well as more impressionistic reflections from peer-reviewing many papers on this topic and attending relevant conferences (usually to speak to practitioners about the politics of EBPM). I am relying primarily on (a) the sense, often described in qualitative research, of a ‘saturation point’ to feel confident that more research will not unearth more categories, than (b) counting the frequency of term-use in each category, or (c) network analysis to identify the nature of a self-defined public health profession or community. As such, the focus is on the assumptions that scholars in this field often seem to take for granted, and often do not feel the need to explain. Its purpose is logical and conditional: if these are the assumptions, these are the expectations.

On that basis, I present a common public health narrative of the policy problem, how to understand it, and the processes necessary to address it:

  • Focus on preventing ill health rather than treating it when it becomes too severe.
  • Distinguish between types of prevention: primary (focus on the whole population to stop a problem occurring by investing early and/or modifying the social or physical environment); secondary (focus on at-risk groups to identify a problem at a very early stage to minimise harm); tertiary (focus on affected groups to stop a problem getting worse)
  • Focus on the social determinants of health inequalities, defined by the WHO (2019) as ‘the unfair and avoidable differences in health status’ that are ‘shaped by the distribution of money, power and resources’ and ‘the conditions in which people are born, grow, live, work and age’.
  • Promote ‘upstream’ measures designed to influence the health of the whole population (or health inequalities) rather than ‘downstream’ measures targeting individuals (although we discussed some debate/ confusion about the meaning of upstream).
  • Use scientific evidence to identify the nature of problems and most effective solutions.
  • Define scientific evidence in a particular way, such as in relation to a ‘hierarchy’ in which (a) the systematic review of randomised control trials often represents the gold standard, and (b) systems modelling plays a key role. Or, in fewer cases, challenge that hierarchy energetically.
  • Promote major policymaking reforms, including a focus on holistic or joined-up government, since the responsibility for health improvement goes well beyond health departments.  Prevention (or preventive policymaking) is a classic term, and ‘health in all policies’ (HIAP) is currently a key term.
  • Focus strongly on the role of industry as ‘vested interests’ causing public health problems (the ‘commercial determinants of health’) and, often, the lack of political will to regulate commercial activity.
  • Treat public health and prevention as a form of social protection (new category after PHE). Often, actors describe a moral imperative to intervene (in which case, the opposite argument relates to individual responsibility and opposition to the ‘nanny state’ – see also Cairney et al, 2012 on ‘secular morality’).
  • Use tobacco control as a model for other specific issues (e.g. alcohol use, obesity, salt) and the prevention agenda more generally (Studlar and Cairney, 2019).
  • Focus on identifying policy changes that represent a ‘win-win’ scenario in which all parties benefit from the policy outcome (in terms of their health), rather than identifying political winners and losers from the policy choice itself (new category – Baum et al, 2014).

Such assumptions underpin expectations for the role of government, and provide a frame of reference for assessing the overall direction of policy (such as for ‘prevention’). Please let me know if there is a big missing category, or one of them doesn’t seem quite right.

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Filed under Prevention policy, Public health, public policy, tobacco policy

Prevention is better than cure, so why aren’t we doing more of it?

This post provides a generous amount of background for my ANZSOG talk Prevention is better than cure, so why aren’t we doing more of it? If you read all of it, it’s a long read. If not, it’s a short read before the long read. Here is the talk’s description:

‘Does this sound familiar? A new government comes into office, promising to shift the balance in social and health policy from expensive remedial, high dependency care to prevention and early intervention. They commit to better policy-making; they say they will join up policy and program delivery, devolving responsibility to the local level and focusing on long term outcomes rather than short term widgets; and that they will ensure policy is evidence-based.  And then it all gets too hard, and the cycle begins again, leaving some exhausted and disillusioned practitioners in its wake. Why does this happen repeatedly, across different countries and with governments of different persuasions, even with the best will in the world?’ 

  • You’ll see from the question that I am not suggesting that all prevention or early intervention policies fail. Rather, I use policy theories to provide a general explanation for a major gap between the (realistic) expectations expressed in prevention strategies and the actual outcomes. We can then talk about how to close that gap.
  • You’ll also see the phrase ‘even with the best will in the world’, which I think is key to this talk. No-one needs me to rehearse the usually-vague and often-stated ways to explain failed prevention policies, including the ‘wickedness’ of policy problems, or the ‘pathology’ of public policy. Rather, I show that such policies may ‘fail’ even when there is wide and sincere cross-party agreement about the need to shift from reactive to more prevention policy design. I also suggest that the general explanation for failure – low ‘political will’ – is often damaging to the chances for future success.
  • Let’s start by defining prevention policy and policymaking.

When engaged in ‘prevention’, governments seek to:

  1. Reform policy.

Prevention policy is really a collection of policies designed to intervene as early as possible in people’s lives to improve their wellbeing and reduce inequalities and/or demand for acute services. The aim is to move from reactive to preventive public services, intervening earlier in people’s lives to address a wide range of longstanding problems – including crime and anti-social behaviour, ill health and unhealthy behaviour, low educational attainment, unemployment and low employability – before they become too severe.

  1. Reform policymaking.

Preventive policymaking describes the ways in which governments reform their practices to support prevention policy, including a commitment to:

  • ‘join up’ government departments and services to solve ‘wicked problems’ that transcend one area
  • give more responsibility for service design to local public bodies, stakeholders, ‘communities’ and service users produce long term aims for outcomes, and
  • reduce short term performance targets in favour of long term outcomes agreements.
  1. Ensure that policy is ‘evidence based’.

Three general reasons why ‘prevention’ policies never seem to succeed.

  1. Policymakers don’t know what prevention means.

They express a commitment to prevention before defining it fully. When they start to make sense of prevention, they find out how difficult it is to pursue, and how many controversial choices it involves (see also uncertainty versus ambiguity)

  1. They engage in a policymaking system that is too complex to control.

They try to share responsibility with many actors and coordinate action to direct policy outcomes, without the ability to design those relationships and control policy outcomes.

Yet, they also need to demonstrate to the electorate that they are in control, and find out how difficult it is to localise and centralise policy.

  1. They are unable and unwilling to produce ‘evidence based policymaking’.

Policymakers seek cognitive shortcuts (and their organisational equivalents) to gather enough information to make ‘good enough’ decisions. When they seek evidence on prevention, they find that it is patchy, inconclusive, often counter to their beliefs, and not a ‘magic bullet’ to help justify choices.

Throughout this process, their commitment to prevention policy can be sincere but unfulfilled. They do not articulate fully what prevention means or appreciate the scale of their task. When they try to deliver prevention strategies, they face several problems that, on their own, would seem daunting. Many of the problems they seek to ‘prevent’ are ‘wicked’, or difficult to define and seemingly impossible to solve, such as poverty, unemployment, low quality housing and homelessness, crime, and health and education inequalities. They face stark choices on how far they should go to shift the balance between state and market, redistribute wealth and income, distribute public resources, and intervene in people’s lives to change their behaviour and ways of thinking. Their focus on the long term faces major competition from more salient short-term policy issues that prompt them to maintain ‘reactive’ public services. Their often-sincere desire to ‘localise’ policymaking often gives way to national electoral politics, in which central governments face pressure to make policy from the ‘top’ and be decisive. Their pursuit of ‘evidence based’ policymaking often reveals a lack of evidence about which policy interventions work and the extent to which they can be ‘scaled up’ successfully.

These problems will not be overcome if policy makers and influencers misdiagnose them

  • If policy influencers make the simplistic assumption that this problem is caused by low political they will provide bad advice.
  • If new policymakers truly think that the problem was the low commitment and competence of their predecessors, they will begin with the same high hopes about the impact they can make, only to become disenchanted when they see the difference between their abstract aims and real world outcomes.
  • Poor explanation of limited success contributes to the high potential for (a) an initial period of enthusiasm and activity, replaced by (b) disenchantment and inactivity, and (c) for this cycle to be repeated without resolution.

Let’s add more detail to these general explanations:

1. What makes prevention so difficult to define?

When viewed as a simple slogan, ‘prevention’ seems like an intuitively appealing aim. It can generate cross-party consensus, bringing together groups on the ‘left’, seeking to reduce inequalities, and on the ‘right’, seeking to reduce economic inactivity and the cost of services.

Such consensus is superficial and illusory. When making a detailed strategy, prevention is open to many interpretations by many policymakers. Imagine the many types of prevention policy and policymaking that we could produce:

  1. What problem are we trying to solve?

Prevention policymaking represents a heroic solution to several crises: major inequalities, underfunded public services, and dysfunctional government.

  1. On what measures should we focus?

On which inequalities should we focus primarily? Wealth, occupation, income, race, ethnicity, gender, sexuality, disability, mental health.

On which measures of inequality? Economic, health, healthy behaviour, education attainment, wellbeing, punishment.

  1. On what solution should we focus?

To reduce poverty and socioeconomic inequalities, improve national quality of life, reduce public service costs, or increase value for money

  1. Which ‘tools’ or policy instruments should we use?

Redistributive policies to address ‘structural’ causes of poverty and inequality?

Or, individual-focused policies to: (a) boost the mental ‘resilience’ of public service users, (b) oblige, or (c) exhort people to change behaviour.

  1. How do we intervene as early as possible in people’s lives?

Primary prevention. Focus on the whole population to stop a problem occurring by investing early and/or modifying the social or physical environment. Akin to whole-population immunizations.

Secondary prevention. Focus on at-risk groups to identify a problem at a very early stage to minimise harm.

Tertiary prevention. Focus on affected groups to stop a problem getting worse.

  1. How do we pursue ‘evidence based policymaking’? 3 ideal-types

Using randomised control trials and systematic review to identify the best interventions?

Storytelling to share best governance practice?

‘Improvement’ methods to experiment on a small scale and share best practice?

  1. How does evidence gathering connect to long-term policymaking?

Does a national strategy drive long-term outcomes?

Does central government produce agreements with or targets for local authorities?

  1. Is preventive policymaking a philosophy or a profound reform process?

How serious are national governments – about localism, service user-driven public services, and joined up or holistic policymaking – when their elected policymakers are held to account for outcomes?

  1. What is the nature of state intervention?

It may be punitive or supportive. See: How would Lisa Simpson and Monty Burns make progressive social policy?

2.     Making ‘hard choices’: what problems arise when politics meets policymaking?

When policymakers move from idiom and broad philosophy towards specific policies and practices, they find a range of obstacles, including:

The scale of the task becomes overwhelming, and not suited to electoral cycles.

Developing policy and reforming policymaking takes time, and the effect may take a generation to see.

There is competition for policymaking resources such as attention and money.

Prevention is general, long-term, and low salience. It competes with salient short-term problems that politicians feel compelled to solve first.

Prevention is akin to capital investment with no guarantee of a return. Reductions in funding ‘fire-fighting’, ‘frontline’ services to pay for prevention initiatives, are hard to sell. Governments invest in small steps, and investment is vulnerable when money is needed quickly to fund public service crises.

The benefits are difficult to measure and see.

Short-term impacts are hard to measure, long-term impacts are hard to attribute to a single intervention, and prevention does not necessarily save money (or provide ‘cashable’ savings’).

Reactive policies have a more visible impact, such as to reduce hospital waiting times or increase the number of teachers or police officers.

Problems are ‘wicked’.

Getting to the ‘root causes’ of problems is not straightforward; policymakers often have no clear sense of the cause of problems or effect of solutions. Few aspects of prevention in social policy resemble disease prevention, in which we know the cause of many diseases, how to screen for them, and how to prevent them in a population.

Performance management is not conducive to prevention.

Performance management systems encourage public sector managers to focus on their services’ short-term and measurable targets over shared aims with public service partners or the wellbeing of their local populations.

Performance management is about setting priorities when governments have too many aims to fulfil. When central governments encourage local governing bodies to form long-term partnerships to address inequalities and meet short-term targets, the latter come first.

Governments face major ethical dilemmas.

Political choices co-exist with normative judgements concerning the role of the state and personal responsibility, often undermining cross-party agreement.

One aspect of prevention may undermine the other.

A cynical view of prevention initiatives is that they represent a quick political fix rather than a meaningful long-term solution:

  • Central governments describe prevention as the solution to public sector costs while also delegating policymaking responsibility to, and reducing the budgets of, local public bodies.
  • Then, public bodies prioritise their most pressing statutory responsibilities.

Someone must be held to account.

If everybody is involved in making and shaping policy, it becomes unclear who can be held to account over the results. This outcome is inconsistent with Westminster-style democratic accountability in which we know who is responsible and therefore who to praise or blame.

3.      ‘The evidence’ is not a ‘magic bullet’

In a series of other talks, I identify the reasons why ‘evidence based policymaking’ (EBPM) does not describe the policy process well.

Elsewhere, I also suggest that it is more difficult for evidence to ‘win the day’ in the broad area of prevention policy compared to the more specific field of tobacco control.

Generally speaking, a good simple rule about EBPM is that there is never a ‘magic bullet’ to take the place of judgement. Politics is about making choices which benefit some while others lose out. You can use evidence to help clarify those choices, but not produce a ‘technical’ solution.

A further rule with ‘wicked’ problems is that the evidence is not good enough even to generate clarity about the cause of the problem. Or, you simply find out things you don’t want to hear.

Early intervention in ‘families policies’ seems to be a good candidate for the latter, for three main reasons:

  1. Very few interventions live up to the highest evidence standards

There are two main types of relevant ‘evidence based’ interventions in this field.

The first are ‘family intervention projects’ (FIPs). They generally focus on low income, often lone parent, families at risk of eviction linked to factors such as antisocial behaviour, and provide two forms of intervention:

  • intensive 24/7 support, including after school clubs for children and parenting skills classes, and treatment for addiction or depression in some cases, in dedicated core accommodation with strict rules on access and behaviour
  • an outreach model of support and training.

The evidence of success comes from evaluation plus a counterfactual: this intervention is expensive, but we think that it would have cost far more money and heartache if we had not intervened. There is generally no randomised control trial (RCT) to establish the cause of improved outcomes, or demonstrate that those outcomes would not have happened without this intervention.

The second are projects imported from other countries (primarily the US and Australia) based on their reputation for success built on RCT evidence. There is more quantitative evidence of success, but it is still difficult to know if the project can be transferred effectively and if its success can be replicated in another country with a very different political drivers, problems, and services.

2. The evidence on ‘scaling up’ for primary prevention is relatively weak

Kenneth Dodge (2009) sums up a general problem:

  • there are few examples of taking effective specialist projects ‘to scale’
  • there are major issues around ‘fidelity’ to the original project when you scale up (including the need to oversee a major expansion in well-trained practitioners)
  • it is difficult to predict the effect of a programme, which showed promise when applied to one population, to a new and different population.

3. The evidence on secondary early intervention is also weak

This point about different populations with different motivations is demonstrated in a more recent (published 2014) study by Stephen Scott et al of two Incredible Years interventions – to address ‘oppositional defiant disorder symptoms and antisocial personality character traits’ in children aged 3-7 (for a wider discussion of such programmes see the Early Intervention Foundation’s Foundations for life: what works to support parent child interaction in the early years?).

They highlight a classic dilemma in early intervention: the evidence of effectiveness is only clear when children have been clinically referred (‘indicated approach’), but unclear when children have been identified as high risk using socioeconomic predictors (‘selective approach’):

An indicated approach is simpler to administer, as there are fewer children with severe problems, they are easier to identify, and their parents are usually prepared to engage in treatment; however, the problems may already be too entrenched to treat. In contrast, a selective approach targets milder cases, but because problems are less established, whole populations have to be screened and fewer cases will go on to develop serious problems.

For our purposes, this may represent the most inconvenient form of evidence on early intervention: you can intervene early on the back of very limited evidence of likely success, or have a far higher likelihood of success when you intervene later, when you are running out of time to call it ‘early intervention’.

Conclusion: vague consensus is no substitute for political choice

Governments begin with the sense that they have found the solution to many problems, only to find that they have to make and defend highly ‘political’ choices.

For example, see the UK government’s ‘imaginative’ use of evidence to make families policy. In a nutshell, it chose to play fast and loose with evidence, and demonise 117000 families, to provide political cover to a redistribution of resources to family intervention projects.

We can, with good reason, object to this style of politics. However, we would also have to produce a feasible alternative.

For example, the Scottish Government has taken a different approach (perhaps closer to what one might often expect in New Zealand), but it still needs to produce and defend a story about its choices, and it faces almost the same constraints as the UK. It’s self-described ‘decisive shift’ to prevention was no a decisive shift to prevention.

Overall, prevention is no different from any other policy area, except that it has proven to be much more complicated and difficult to sustain than most others. Prevention is part of an excellent idiom but not a magic bullet for policy problems.

Further reading:

Prevention

See also

What do you do when 20% of the population causes 80% of its problems? Possibly nothing.

Early intervention policy, from ‘troubled families’ to ‘named persons’: problems with evidence and framing ‘valence’ issues

 

 

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Filed under Evidence Based Policymaking (EBPM), Prevention policy, Public health, public policy

The UK government’s imaginative use of evidence to make policy

This post describes a new article published in British Politics (Open Access). Please find:

(1) A super-exciting video/audio powerpoint I use for a talk based on the article

(2) The audio alone (link)

(3) The powerpoint to download, so that the weblinks work (link) or the ppsx/ presentation file in case you are having a party (link)

(4) A written/ tweeted discussion of the main points

In retrospect, I think the title was too subtle and clever-clever. I wanted to convey two meanings: imaginative as a euphemism for ridiculous/ often cynical and to argue that a government has to be imaginative with evidence. The latter has two meanings: imaginative (1) in the presentation and framing of evidence-informed agenda, and (2) when facing pressure to go beyond the evidence and envisage policy outcomes.

So I describe two cases in which its evidence-use seems cynical, when:

  1. Declaring complete success in turning around the lives of ‘troubled families’
  2. Exploiting vivid neuroscientific images to support ‘early intervention’

Then I describe more difficult cases in which supportive evidence is not clear:

  1. Family intervention project evaluations are of limited value and only tentatively positive
  2. Successful projects like FNP and Incredible Years have limited applicability or ‘scalability’

As scientists, we can shrug our shoulders about the uncertainty, but elected policymakers in government have to do something. So what do they do?

At this point of the article it will look like I have become an apologist for David Cameron’s government. Instead, I’m trying to demonstrate the value of comparing sympathetic/ unsympathetic interpretations and highlight the policy problem from a policymaker’s perspective:

Cairney 2018 British Politics discussion section

I suggest that they use evidence in a mix of ways to: describe an urgent problem, present an image of success and governing competence, and provide cover for more evidence-informed long term action.

The result is the appearance of top-down ‘muscular’ government and ‘a tendency for policy to change as is implemented, such as when mediated by local authority choices and social workers maintaining a commitment to their professional values when delivering policy’

I conclude by arguing that ‘evidence-based policy’ and ‘policy-based evidence’ are political slogans with minimal academic value. The binary divide between EBP/ PBE distracts us from more useful categories which show us the trade-offs policymakers have to make when faced with the need to act despite uncertainty.

Cairney British Politics 2018 Table 1

As such, it forms part of a far wider body of work …

In both cases, the common theme is that, although (1) the world of top-down central government gets most attention, (2) central governments don’t even know what problem they are trying to solve, far less (3) how to control policymaking and outcomes.

In that wider context, it is worth comparing this talk with the one I gave at the IDS (which, I reckon is a good primer for – or prequel to – the UK talk):

See also:

Early intervention policy, from ‘troubled families’ to ‘named persons’: problems with evidence and framing ‘valence’ issues

Why doesn’t evidence win the day in policy and policymaking?

(found by searching for early intervention)

See also:

Here’s why there is always an expectations gap in prevention policy

Social investment, prevention and early intervention: a ‘window of opportunity’ for new ideas?

(found by searching for prevention)

Powerpoint for guest lecture: Paul Cairney UK Government Evidence Policy

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Filed under Evidence Based Policymaking (EBPM), POLU9UK, Prevention policy, UK politics and policy

Here’s why there is always an expectations gap in prevention policy

Prevention is the most important social policy agenda of our time. Many governments make a sincere commitment to it, backed up by new policy strategies and resources. Yet, they also make limited progress before giving up or changing tack. Then, a new government arrives, producing the same cycle of enthusiasm and despair. This fundamental agenda never seems to get off the ground. We aim to explain this ‘prevention puzzle’, or the continuous gap between policymaker expectations and actual outcomes.

What is prevention policy and policymaking?

When engaged in ‘prevention’, governments seek to:

  1. Reform policy. To move from reactive to preventive public services, intervening earlier in people’s lives to ward off social problems and their costs when they seem avoidable.
  2. Reform policymaking. To (a) ‘join up’ government departments and services to solve ‘wicked problems’ that transcend one area, (b) give more responsibility for service design to local public bodies, stakeholders, ‘communities’ and service users, and (c) produce long term aims for outcomes, and reduce short term performance targets.
  3. Ensure that policy is ‘evidence based’.

Three reasons why they never seem to succeed

We use well established policy theories/ studies to explain the prevention puzzle.

  1. They don’t know what prevention means. They express a commitment to something before defining it. When they start to make sense of it, they find out how difficult it is to pursue, and how many controversial choices it involves.
  2. They engage in a policy process that is too complex to control. They try to share responsibility with many actors and coordinate action to direct policy outcomes, without the ability to design those relationships and control policy outcomes. Yet, they need to demonstrate to the electorate that they are in control. When they make sense of policymaking, they find out how difficult it is to localise and centralise.
  3. They are unable and unwilling to produce ‘evidence based policymaking’. Policymakers seek ‘rational’ and ‘irrational’ shortcuts to gather enough information to make ‘good enough’ decisions. When they seek evidence on preventing problems before they arise, they find that it is patchy, inconclusive, often counter to their beliefs, and unable to provide a ‘magic bullet’ to help make and justify choices.

Who knows what happens when they address these problems at the same time?

We draw on empirical and comparative UK and devolved government analysis to show in detail how policymaking differs according to the (a) type of government, (b) issue, and (c) era in which they operate.

Although it is reasonable to expect policymaking to be very different in, for example, the UK versus Scottish, or Labour versus Conservative governments, and in eras of boom versus austerity, a key part of our research is to show that the same basic ‘prevention puzzle’ exists at all times. You can’t simply solve it with a change of venue or government.

Our book – Why Isn’t Government Policy More Preventive? – is in press (Oxford University Press) and will be out in January 2020, with sample chapters appearing here. Our longer term agenda – via IMAJINE – is to examine how policymakers try to address ‘spatial justice’ and reduce territorial inequalities across Europe partly by pursuing prevention and reforming public services.

 

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Filed under Evidence Based Policymaking (EBPM), Prevention policy, public policy, UK politics and policy

Evidence based policymaking: 7 key themes

7 themes of EBPM

I looked back at my blog posts on the politics of ‘evidence based policymaking’ and found that I wrote quite a lot (particularly from 2016). Here is a list based on 7 key themes.

1. Use psychological insights to influence the use of evidence

My most-current concern. The same basic theme is that (a) people (including policymakers) are ‘cognitive misers’ seeking ‘rational’ and ‘irrational’ shortcuts to gather information for action, so you won’t get far if you (b) bombard them with information, or (c) call them idiots.

Three ways to communicate more effectively with policymakers (shows how to use psychological insights to promote evidence in policymaking)

Using psychological insights in politics: can we do it without calling our opponents mental, hysterical, or stupid? (yes)

The Psychology of Evidence Based Policymaking: Who Will Speak For the Evidence if it Doesn’t Speak for Itself? (older paper, linking studies of psychology with studies of EBPM)

Older posts on the same theme:

Is there any hope for evidence in emotional debates and chaotic government? (yes)

We are in danger of repeating the same mistakes if we bemoan low attention to ‘facts’

These complaints about ignoring science seem biased and naïve – and too easy to dismiss

How can we close the ‘cultural’ gap between the policymakers and scientists who ‘just don’t get it’?

2. How to use policy process insights to influence the use of evidence

I try to simplify key insights about the policy process to show to use evidence in it. One key message is to give up on the idea of an orderly policy process described by the policy cycle model. What should you do if a far more complicated process exists?

Why don’t policymakers listen to your evidence?

The Politics of Evidence Based Policymaking: 3 messages (3 ways to say that you should engage with the policy process that exists, not a mythical process that will never exist)

Three habits of successful policy entrepreneurs (shows how entrepreneurs are influential in politics)

Why doesn’t evidence win the day in policy and policymaking? and What does it take to turn scientific evidence into policy? Lessons for illegal drugs from tobacco and There is no blueprint for evidence-based policy, so what do you do? (3 posts describing the conditions that must be met for evidence to ‘win the day’)

Writing for Impact: what you need to know, and 5 ways to know it (explains how our knowledge of the policy process helps communicate to policymakers)

How can political actors take into account the limitations of evidence-based policy-making? 5 key points (presentation to European Parliament-European University Institute ‘Policy Roundtable’ 2016)

Evidence Based Policy Making: 5 things you need to know and do (presentation to Open Society Foundations New York 2016)

What 10 questions should we put to evidence for policy experts? (part of a series of videos produced by the European Commission)

3. How to combine principles on ‘good evidence’, ‘good governance’, and ‘good practice’

My argument here is that EBPM is about deciding at the same time what is: (1) good evidence, and (2) a good way to make and deliver policy. If you just focus on one at a time – or consider one while ignoring the other – you cannot produce a defendable way to promote evidence-informed policy delivery.

Kathryn Oliver and I have just published an article on the relationship between evidence and policy (summary of and link to our article on this very topic)

We all want ‘evidence based policy making’ but how do we do it? (presentation to the Scottish Government on 2016)

The ‘Scottish Approach to Policy Making’: Implications for Public Service Delivery

The politics of evidence-based best practice: 4 messages

The politics of implementing evidence-based policies

Policy Concepts in 1000 Words: the intersection between evidence and policy transfer

Key issues in evidence-based policymaking: comparability, control, and centralisation

The politics of evidence and randomised control trials: the symbolic importance of family nurse partnerships

What Works (in a complex policymaking system)?

How Far Should You Go to Make Sure a Policy is Delivered?

4. Face up to your need to make profound choices to pursue EBPM

These posts have arisen largely from my attendance at academic-practitioner conferences on evidence and policy. Many participants tell the same story about the primacy of scientific evidence challenged by post-truth politics and emotional policymakers. I don’t find this argument convincing or useful. So, in many posts, I challenge these participants to think about more pragmatic ways to sum up and do something effective about their predicament.

Political science improves our understanding of evidence-based policymaking, but does it produce better advice? (shows how our knowledge of policymaking clarifies dilemmas about engagement)

The role of ‘standards for evidence’ in ‘evidence informed policymaking’ (argues that a strict adherence to scientific principles may help you become a good researcher but not an effective policy influencer)

How far should you go to secure academic ‘impact’ in policymaking? From ‘honest brokers’ to ‘research purists’ and Machiavellian manipulators (you have to make profound ethical and strategic choices when seeking to maximise the use of evidence in policy)

Principles of science advice to government: key problems and feasible solutions (calling yourself an ‘honest broker’ while complaining about ‘post-truth politics’ is a cop out)

What sciences count in government science advice? (political science, obvs)

I know my audience, but does my other audience know I know my audience? (compares the often profoundly different ways in which scientists and political scientists understand and evaluate EBPM – this matters because, for example, we rarely discuss power in scientist-led debates)

Is Evidence-Based Policymaking the same as good policymaking? (no)

Idealism versus pragmatism in politics and policymaking: … evidence-based policymaking (how to decide between idealism and pragmatism when engaging in politics)

Realistic ‘realist’ reviews: why do you need them and what might they look like? (if you privilege impact you need to build policy relevance into systematic reviews)

‘Co-producing’ comparative policy research: how far should we go to secure policy impact? (describes ways to build evidence advocacy into research design)

The Politics of Evidence (review of – and link to – Justin Parkhurt’s book on the ‘good governance’ of evidence production and use)

20170512_095446

5. For students and researchers wanting to read/ hear more

These posts are relatively theory-heavy, linking quite clearly to the academic study of public policy. Hopefully they provide a simple way into the policy literature which can, at times, be dense and jargony.

‘Evidence-based Policymaking’ and the Study of Public Policy

Policy Concepts in 1000 Words: ‘Evidence Based Policymaking’

Practical Lessons from Policy Theories (series of posts on the policy process, offering potential lessons for advocates of evidence use in policy)

Writing a policy paper and blog post 

12 things to know about studying public policy

Can you want evidence based policymaking if you don’t really know what it is? (defines each word in EBPM)

Can you separate the facts from your beliefs when making policy? (no, very no)

Policy Concepts in 1000 Words: Success and Failure (Evaluation) (using evidence to evaluate policy is inevitably political)

Policy Concepts in 1000 Words: Policy Transfer and Learning (so is learning from the experience of others)

Four obstacles to evidence based policymaking (EBPM)

What is ‘Complex Government’ and what can we do about it? (read about it)

How Can Policy Theory Have an Impact on Policy Making? (on translating policy theories into useful advice)

The role of evidence in UK policymaking after Brexit (argues that many challenges/ opportunities for evidence advocates will not change after Brexit)

Why is there more tobacco control policy than alcohol control policy in the UK? (it’s not just because there is more evidence of harm)

Evidence Based Policy Making: If You Want to Inject More Science into Policymaking You Need to Know the Science of Policymaking and The politics of evidence-based policymaking: focus on ambiguity as much as uncertainty and Revisiting the main ‘barriers’ between evidence and policy: focus on ambiguity, not uncertainty and The barriers to evidence based policymaking in environmental policy (early versions of what became the chapters of the book)

6. Using storytelling to promote evidence use

This is increasingly a big interest for me. Storytelling is key to the effective conduct and communication of scientific research. Let’s not pretend we’re objective people just stating the facts (which is the least convincing story of all). So far, so good, except to say that the evidence on the impact of stories (for policy change advocacy) is limited. The major complication is that (a) the story you want to tell and have people hear interacts with (b) the story that your audience members tell themselves.

Combine Good Evidence and Emotional Stories to Change the World

Storytelling for Policy Change: promise and problems

Is politics and policymaking about sharing evidence and facts or telling good stories? Two very silly examples from #SP16

7. The major difficulties in using evidence for policy to reduce inequalities

These posts show how policymakers think about how to combine (a) often-patchy evidence with (b) their beliefs and (c) an electoral imperative to produce policies on inequalities, prevention, and early intervention. I suggest that it’s better to understand and engage with this process than complain about policy-based-evidence from the side-lines. If you do the latter, policymakers will ignore you.

The UK government’s imaginative use of evidence to make policy 

What do you do when 20% of the population causes 80% of its problems? Possibly nothing.

The theory and practice of evidence-based policy transfer: can we learn how to reduce territorial inequalities?

We need better descriptions than ‘evidence-based policy’ and ‘policy-based evidence’: the case of UK government ‘troubled families’ policy

How can you tell the difference between policy-based-evidence and evidence-based-policymaking?

Early intervention policy, from ‘troubled families’ to ‘named persons’: problems with evidence and framing ‘valence’ issues

Key issues in evidence-based policymaking: comparability, control, and centralisation

The politics of evidence and randomised control trials: the symbolic importance of family nurse partnerships

Two myths about the politics of inequality in Scotland

Social investment, prevention and early intervention: a ‘window of opportunity’ for new ideas?

A ‘decisive shift to prevention’: how do we turn an idea into evidence based policy?

Can the Scottish Government pursue ‘prevention policy’ without independence?

Note: these issues are discussed in similar ways in many countries. One example that caught my eye today:

 

All of this discussion can be found under the EBPM category: https://paulcairney.wordpress.com/category/evidence-based-policymaking-ebpm/T

See also the special issue on maximizing the use of evidence in policy

Palgrave C special

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Filed under agenda setting, Evidence Based Policymaking (EBPM), Prevention policy, public policy, Storytelling, UK politics and policy

Why doesn’t evidence win the day in policy and policymaking?

cairney-southampton-evidence-win-the-dayPolitics has a profound influence on the use of evidence in policy, but we need to look ‘beyond the headlines’ for a sense of perspective on its impact.

It is tempting for scientists to identify the pathological effect of politics on policymaking, particularly after high profile events such as the ‘Brexit’ vote in the UK and the election of Donald Trump as US President. We have allegedly entered an era of ‘post-truth politics’ in which ideology and emotion trumps evidence and expertise (a story told many times at events like this), particularly when issues are salient.

Yet, most policy is processed out of this public spotlight, because the flip side of high attention to one issue is minimal attention to most others. Science has a crucial role in this more humdrum day-to-day business of policymaking which is far more important than visible. Indeed, this lack of public visibility can help many actors secure a privileged position in the policy process (and further exclude citizens).

In some cases, experts are consulted routinely. There is often a ‘logic’ of consultation with the ‘usual suspects’, including the actors most able to provide evidence-informed advice. In others, scientific evidence is often so taken for granted that it is part of the language in which policymakers identify problems and solutions.

In that context, we need better explanations of an ‘evidence-policy’ gap than the pathologies of politics and egregious biases of politicians.

To understand this process, and appearance of contradiction between excluded versus privileged experts, consider the role of evidence in politics and policymaking from three different perspectives.

The perspective of scientists involved primarily in the supply of evidence

Scientists produce high quality evidence only for politicians often ignore it or, even worse, distort its message to support their ideologically-driven policies. If they expect ‘evidence-based policymaking’ they soon become disenchanted and conclude that ‘policy-based evidence’ is more likely. This perspective has long been expressed in scientific journals and commentaries, but has taken on new significance following ‘Brexit’ and Trump.

The perspective of elected politicians

Elected politicians are involved primarily in managing government and maximising public and organisational support for policies. So, scientific evidence is one piece of a large puzzle. They may begin with a manifesto for government and, if elected, feel an obligation to carry it out. Evidence may play a part in that process but the search for evidence on policy solutions is not necessarily prompted by evidence of policy problems.

Further, ‘evidence based policy’ is one of many governance principles that politicians should feel the need to juggle. For example, in Westminster systems, ministers may try to delegate policymaking to foster ‘localism’ and/ or pragmatic policymaking, but also intervene to appear to be in control of policy, to foster a sense of accountability built on an electoral imperative. The likely mix of delegation and intervention seems almost impossible to predict, and this dynamic has a knock-on effect for evidence-informed policy. In some cases, central governments roll out the same basic policy intervention and limit local discretion; in others, it identifies broad outcomes and invites other bodies to gather evidence on how best to meet them. These differences in approach can have profound consequences on the models of evidence-informed policy available to us (see the example of Scottish policymaking).

Political science and policy studies provide a third perspective

Policy theories help us identify the relationship between evidence and policy by showing that a modern focus on ‘evidence-based policymaking’ (EBPM) is one of many versions of the same fairy tale – about ‘rational’ policymaking – that have developed in the post-war period. We talk about ‘bounded rationality’ to identify key ways in which policymakers or organisations could not achieve ‘comprehensive rationality’:

  1. They cannot separate values and facts.
  2. They have multiple, often unclear, objectives which are difficult to rank in any meaningful way.
  3. They have to use major shortcuts to gather a limited amount of information in a limited time.
  4. They can’t make policy from the ‘top down’ in a cycle of ordered and linear stages.

Limits to ‘rational’ policymaking: two shortcuts to make decisions

We can sum up the first three bullet points with one statement: policymakers have to try to evaluate and solve many problems without the ability to understand what they are, how they feel about them as a whole, and what effect their actions will have.

To do so, they use two shortcuts: ‘rational’, by pursuing clear goals and prioritizing certain kinds and sources of information, and ‘irrational’, by drawing on emotions, gut feelings, deeply held beliefs, habits, and the familiar to make decisions quickly.

Consequently, the focus of policy theories is on the links between evidence, persuasion, and framing issues to produce or reinforce a dominant way to define policy problems. Successful actors combine evidence and emotional appeals or simple stories to capture policymaker attention, and/ or help policymakers interpret information through the lens of their strongly-held beliefs.

Scientific evidence plays its part, but scientists often make the mistake of trying to bombard policymakers with evidence when they should be trying to (a) understand how policymakers understand problems, so that they can anticipate their demand for evidence, and (b) frame their evidence according to the cognitive biases of their audience.

Policymaking in ‘complex systems’ or multi-level policymaking environments

Policymaking takes place in less ordered, less hierarchical, and less predictable environment than suggested by the image of the policy cycle. Such environments are made up of:

  1. a wide range of actors (individuals and organisations) influencing policy at many levels of government
  2. a proliferation of rules and norms followed by different levels or types of government
  3. close relationships (‘networks’) between policymakers and powerful actors
  4. a tendency for certain beliefs or ‘paradigms’ to dominate discussion
  5. shifting policy conditions and events that can prompt policymaker attention to lurch at short notice.

These five properties – plus a ‘model of the individual’ built on a discussion of ‘bounded rationality’ – make up the building blocks of policy theories (many of which I summarise in 1000 Word posts). I say this partly to aid interdisciplinary conversation: of course, each theory has its own literature and jargon, and it is difficult to compare and combine their insights, but if you are trained in a different discipline it’s unfair to ask you devote years of your life to studying policy theory to end up at this point.

To show that policy theories have a lot to offer, I have been trying to distil their collective insights into a handy guide – using this same basic format – that you can apply to a variety of different situations, from explaining painfully slow policy change in some areas but dramatic change in others, to highlighting ways in which you can respond effectively.

We can use this approach to help answer many kinds of questions. With my Southampton gig in mind, let’s use some examples from public health and prevention.

Why doesn’t evidence win the day in tobacco policy?

My colleagues and I try to explain why it takes so long for the evidence on smoking and health to have a proportionate impact on policy. Usually, at the back of my mind, is a public health professional audience trying to work out why policymakers don’t act quickly or effectively enough when presented with unequivocal scientific evidence. More recently, they wonder why there is such uneven implementation of a global agreement – the WHO Framework Convention on Tobacco Control – that almost every country in the world has signed.

We identify three conditions under which evidence will ‘win the day’:

  1. Actors are able to use scientific evidence to persuade policymakers to pay attention to, and shift their understanding of, policy problems. In leading countries, it took decades to command attention to the health effects of smoking, reframe tobacco primarily as a public health epidemic (not an economic good), and generate support for the most effective evidence-based solutions.
  2. The policy environment becomes conducive to policy change. A new and dominant frame helps give health departments (often in multiple venues) a greater role; health departments foster networks with public health and medical groups at the expense of the tobacco industry; and, they emphasise the socioeconomic conditions – reductions in smoking prevalence, opposition to tobacco control, and economic benefits to tobacco – supportive of tobacco control.
  3. Actors exploit ‘windows of opportunity’ successfully. A supportive frame and policy environment maximises the chances of high attention to a public health epidemic and provides the motive and opportunity of policymakers to select relatively restrictive policy instruments.

So, scientific evidence is a necessary but insufficient condition for major policy change. Key actors do not simply respond to new evidence: they use it as a resource to further their aims, to frame policy problems in ways that will generate policymaker attention, and underpin technically and politically feasible solutions that policymakers will have the motive and opportunity to select. This remains true even when the evidence seems unequivocal and when countries have signed up to an international agreement which commits them to major policy change. Such commitments can only be fulfilled over the long term, when actors help change the policy environment in which these decisions are made and implemented. So far, this change has not occurred in most countries (or, in other aspects of public health in the UK, such as alcohol policy).

Why doesn’t evidence win the day in prevention and early intervention policy?

UK and devolved governments draw on health and economic evidence to make a strong and highly visible commitment to preventive policymaking, in which the aim is to intervene earlier in people’s lives to improve wellbeing and reduce socioeconomic inequalities and/ or public sector costs. This agenda has existed in one form or another for decades without the same signs of progress we now associate with areas like tobacco control. Indeed, the comparison is instructive, since prevention policy rarely meets the three conditions outlined above:

  1. Prevention is a highly ambiguous term and many actors make sense of it in many different ways. There is no equivalent to a major shift in problem definition for prevention policy as a whole, and little agreement on how to determine the most effective or cost-effective solutions.
  2. A supportive policy environment is far harder to identify. Prevention policy cross-cuts many policymaking venues at many levels of government, with little evidence of ‘ownership’ by key venues. Consequently, there are many overlapping rules on how and from whom to seek evidence. Networks are diffuse and hard to manage. There is no dominant way of thinking across government (although the Treasury’s ‘value for money’ focus is key currency across departments). There are many socioeconomic indicators of policy problems but little agreement on how to measure or which measures to privilege (particularly when predicting future outcomes).
  3. The ‘window of opportunity’ was to adopt a vague solution to an ambiguous policy problem, providing a limited sense of policy direction. There have been several ‘windows’ for more specific initiatives, but their links to an overarching policy agenda are unclear.

These limitations help explain slow progress in key areas. The absence of an unequivocal frame, backed strongly by key actors, leaves policy change vulnerable to successful opposition, especially in areas where early intervention has major implications for redistribution (taking from existing services to invest in others) and personal freedom (encouraging or obliging behavioural change). The vagueness and long term nature of policy aims – to solve problems that often seem intractable – makes them uncompetitive, and often undermined by more specific short term aims with a measurable pay-off (as when, for example, funding for public health loses out to funding to shore up hospital management). It is too easy to reframe existing policy solutions as preventive if the definition of prevention remains slippery, and too difficult to demonstrate the population-wide success of measures generally applied to high risk groups.

What happens when attitudes to two key principles – evidence based policy and localism – play out at the same time?

A lot of discussion of the politics of EBPM assumes that there is something akin to a scientific consensus on which policymakers do not act proportionately. Yet, in many areas – such as social policy and social work – there is great disagreement on how to generate and evaluate the best evidence. Broadly speaking, a hierarchy of evidence built on ‘evidence based medicine’ – which has randomised control trials and their systematic review at the top, and practitioner knowledge and service user feedback at the bottom – may be completely subverted by other academics and practitioners. This disagreement helps produce a spectrum of ways in which we might roll-out evidence based interventions, from an RCT-driven roll-out of the same basic intervention to a storytelling driven pursuit of tailored responses built primarily on governance principles (such as to co-produce policy with users).

At the same time, governments may be wrestling with their own governance principles, including EBPM but also regarding the most appropriate balance between centralism and localism.

If you put both concerns together, you have a variety of possible outcomes (and a temptation to ‘let a thousand flowers bloom’) and a set of competing options (outlined in table 1), all under the banner of ‘evidence based’ policymaking.

Table 1 Three ideal types EBBP

What happens when a small amount of evidence goes a very long way?

So, even if you imagine a perfectly sincere policymaker committed to EBPM, you’d still not be quite sure what they took it to mean in practice. If you assume this commitment is a bit less sincere, and you add in the need to act quickly to use the available evidence and satisfy your electoral audience, you get all sorts of responses based in some part on a reference to evidence.

One fascinating case is of the UK Government’s ‘troubled families’ programme which combined bits and pieces of evidence with ideology and a Westminster-style-accountability imperative, to produce:

  • The argument that the London riots were caused by family breakdown and bad parenting.
  • The use of proxy measures to identify the most troubled families
  • The use of superficial performance management to justify notionally extra expenditure for local authorities
  • The use of evidence in a problematic way, from exaggerating the success of existing ‘family intervention projects’ to sensationalising neuroscientific images related to brain development in deprived children …

normal brain

…but also

In other words, some governments feel the need to dress up their evidence-informed policies in a language appropriate to Westminster politics. Unless we understand this language, and the incentives for elected policymakers to use it, we will fail to understand how to act effectively to influence those policymakers.

What can you do to maximise the use of evidence?

When you ask the generic question you can generate a set of transferable strategies to engage in policymaking:

how-to-be-heard

ebpm-5-things-to-do

Yet, as these case studies of public health and social policy suggest, the question lacks sufficient meaning when applied to real world settings. Would you expect the advice that I give to (primarily) natural scientists (primarily in the US) to be identical to advice for social scientists in specific fields (in, say, the UK)?

No, you’d expect me to end with a call for more research! See for example this special issue in which many scholars from many disciplines suggest insights on how to maximise the use of evidence in policy.

Palgrave C special

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Filed under Evidence Based Policymaking (EBPM), Prevention policy, Public health, public policy, tobacco, tobacco policy