Category Archives: Public health

Institutionalising preventive health: what are the key issues?

By Paul Cairney and John Boswell. This post first appeared on the Public Health Reform Scotland blog.

On the 17th May, Professor Paul Cairney (University of Stirling) and Dr John Boswell (University of Southampton) led a discussion on ‘institutionalising’ preventive health with key people working with the Scottish Government and COSLA to reform public health in Scotland, including members of the Programme Board, the Oversight Board, Commission leads and members of the senior teams in NHS Health Scotland and Public Health and Intelligence. They drew on their published work, co-authored with 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, reflections from the panel, group-work in the afternoon, and post-event feedback.

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 set up 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.

The Panel Discussion

The panel discussion produced a series of positive and sensible suggestions about the way forward, including the need to:

  • Make a strong political case for the idea of a ‘social return on investment’, in which every £1 spent on preventive work produces far more valuable long term returns.
  • Establish respect for the work of a public health agency in a political context.
  • Build on the fact that the broad argument for prevention has been won within Scottish central and local government.
  • Ensure a shift in culture, to maximise partnership working and foster leadership skills among a larger number of people (than associated with a hierarchical model of leadership).
  • Take forward work by the Christie Commission on reforming public services (such as to ‘empower individuals and communities’, ‘integrate service provision’, ‘prevent negative outcomes from arising’, and ‘become more efficient’).

However, we noted that Christie – and the Scottish Government’s ‘decisive shift to prevention’ – took place eight years ago. We also describe (in Why Isn’t Government Policy More Preventive?) a historic tendency for the ‘same cycle to be repeated without resolution’: an ‘initial period of enthusiasm and activity’ is replaced in a few years by ‘disenchantment and inactivity’.

In that context, our challenge is: what will make the difference this time?

The group discussion

The group discussion took on a ‘world café’ format in which people moved around each space, providing ideas according to theme. The main questions – and three key answers per question – include:

How can we engage well with members of the public?

  1. Establish a brand, digital presence, public role, and approach to ‘social marketing’.
  2. Choose a consistent model of ‘co-production’ based on what you want from your relationship with service users.
  3. Choose how to balance the need to give consistent population-wide advice, and advice tailored to specific communities.

How can we encourage and maintain a public health community?

  1. Address perceptions of power and status in the NHS and local government.
  2. Clarify what evidence counts, and how to gather and use it.
  3. Balance the need for modest ‘quick wins’ (for PHS endurance) with the need to maintain an ambitious advocacy-focused agenda (for community morale).

How can the NHS and local government work well in partnership?

  1. Address immediate important issues: contracts of employment, union recognition and support, location.
  2. Identify cross-system partnership issues: the boundaries between NHS/ Local authority work, working with local governments directly or via COSLA, how to balance your time between core work and partnership work, and how to work with each other’s stakeholders.
  3. Address the possible tensions between national NHS work and local variation and accountability.

How can PHS keep public health high on the ministerial agenda?

  1. Use advocacy to generate public attention to evidence-informed policy solutions.
  2. Frame solutions in different ways to different audiences, to appeal to national ministers and local politicians.
  3. Generate an understanding of how to work closely with stakeholders and policymakers without undermining an image of PHS independence.

How can PHS focus on the bigger picture?

  1. Develop a strategy to stay informed about, and seek to influence, policies reserved to the UK.
  2. Develop a more detailed ‘health in all policies’ strategy: clarify aims, identify key policymakers, develop a strategy to influence policymakers beyond ‘health’.
  3. Develop a strategy to deal with a complex media landscape: from personal relationships with key journalists to less personal messaging for social media.

Post Event Feedback

Feedback from the event was generally positive. Attendees appreciated the time and space to come together with PHS team leaders to discuss next steps. The feedback suggests that the academic presentation helped challenge or shape group assumptions, by:

  • Questioning if attendees agreed on key issues. What is prevention? What counts as good evidence? What models of evidence-informed policy should we recommend? From whom should we learn?
  • Shifting attitudes about what counts as agency success (survival!) and what strategies help achieve it (such as by stealth rather than always speaking truth to power).

Next Steps

From this discussion, it is clear that Public Health Scotland will happen, and its general remit and ambition is clear. However, to ensure that PHS becomes successful requires grappling with the inevitable dilemmas that confront policymakers – and advisers to policymakers – in such complex terrain. Perhaps the key theme of the reflective discussion was the role of clear choice to address important trade-offs:

  1. balancing the imperative to speak ‘uncomfortable truths’ with the need to retain the trust and attention of government
  2. pursuing evidence-informed policymaking but with sufficient flexibility to enable cooperation across different approaches
  3. choosing with whom to collaborate to maximise impact but maintain credibility
  4. working out how to retain long-term support from the public health community in the face of short-term disagreements and disappointments
  5. to work for the public (in the background) or with the public (in the foreground) in pursuit of preventive aims.

Some of these strategic choices are more pressing than others. Some can be resolved decisively while others will require an ongoing balancing act. However, each choice requires a commitment to realistic and continuous dialogue and reflection on what (a) PHS can seek to achieve, and (b) what it can realistically expect central and local governments to do.

Leave a comment

Filed under Public health, public policy, Scottish politics

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.

Leave a comment

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

 

 

1 Comment

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

Why don’t policymakers listen to your evidence?

Since 2016, my most common academic presentation to interdisciplinary scientist/ researcher audiences is a variant of the question, ‘why don’t policymakers listen to your evidence?’

I tend to provide three main answers.

1. Many policymakers have many different ideas about what counts as good evidence

Few policymakers know or care about the criteria developed by some scientists to describe a hierarchy of scientific evidence. For some scientists, at the top of this hierarchy is the randomised control trial (RCT) and the systematic review of RCTs, with expertise much further down the list, followed by practitioner experience and service user feedback near the bottom.

Yet, most policymakers – and many academics – prefer a wider range of sources of information, combining their own experience with information ranging from peer reviewed scientific evidence and the ‘grey’ literature, to public opinion and feedback from consultation.

While it may be possible to persuade some central government departments or agencies to privilege scientific evidence, they also pursue other key principles, such as to foster consensus driven policymaking or a shift from centralist to localist practices.

Consequently, they often only recommend interventions rather than impose one uniform evidence-based position. If local actors favour a different policy solution, we may find that the same type of evidence may have more or less effect in different parts of government.

2. Policymakers have to ignore almost all evidence and almost every decision taken in their name

Many scientists articulate the idea that policymakers and scientists should cooperate to use the best evidence to determine ‘what works’ in policy (in forums such as INGSA, European Commission, OECD). Their language is often reminiscent of 1950s discussions of the pursuit of ‘comprehensive rationality’ in policymaking.

The key difference is that EBPM is often described as an ideal by scientists, to be compared with the more disappointing processes they find when they engage in politics. In contrast, ‘comprehensive rationality’ is an ideal-type, used to describe what cannot happen, and the practical implications of that impossibility.

The ideal-type involves a core group of elected policymakers at the ‘top’, identifying their values or the problems they seek to solve, and translating their policies into action to maximise benefits to society, aided by neutral organisations gathering all the facts necessary to produce policy solutions. Yet, in practice, they are unable to: separate values from facts in any meaningful way; rank policy aims in a logical and consistent manner; gather information comprehensively, or possess the cognitive ability to process it.

Instead, Simon famously described policymakers addressing ‘bounded rationality’ by using ‘rules of thumb’ to limit their analysis and produce ‘good enough’ decisions. More recently, punctuated equilibrium theory uses bounded rationality to show that policymakers can only pay attention to a tiny proportion of their responsibilities, which limits their control of the many decisions made in their name.

More recent discussions focus on the ‘rational’ short cuts that policymakers use to identify good enough sources of information, combined with the ‘irrational’ ways in which they use their beliefs, emotions, habits, and familiarity with issues to identify policy problems and solutions (see this post on the meaning of ‘irrational’). Or, they explore how individuals communicate their narrow expertise within a system of which they have almost no knowledge. In each case, ‘most members of the system are not paying attention to most issues most of the time’.

This scarcity of attention helps explain, for example, why policymakers ignore most issues in the absence of a focusing event, policymaking organisations make searches for information which miss key elements routinely, and organisations fail to respond to events or changing circumstances proportionately.

In that context, attempts to describe a policy agenda focusing merely on ‘what works’ are based on misleading expectations. Rather, we can describe key parts of the policymaking environment – such as institutions, policy communities/ networks, or paradigms – as a reflection of the ways in which policymakers deal with their bounded rationality and lack of control of the policy process.

3. Policymakers do not control the policy process (in the way that a policy cycle suggests)

Scientists often appear to be drawn to the idea of a linear and orderly policy cycle with discrete stages – such as agenda setting, policy formulation, legitimation, implementation, evaluation, policy maintenance/ succession/ termination – because it offers a simple and appealing model which gives clear advice on how to engage.

Indeed, the stages approach began partly as a proposal to make the policy process more scientific and based on systematic policy analysis. It offers an idea of how policy should be made: elected policymakers in central government, aided by expert policy analysts, make and legitimise choices; skilful public servants carry them out; and, policy analysts assess the results with the aid of scientific evidence.

Yet, few policy theories describe this cycle as useful, while most – including the advocacy coalition framework , and the multiple streams approach – are based on a rejection of the explanatory value of orderly stages.

Policy theories also suggest that the cycle provides misleading practical advice: you will generally not find an orderly process with a clearly defined debate on problem definition, a single moment of authoritative choice, and a clear chance to use scientific evidence to evaluate policy before deciding whether or not to continue. Instead, the cycle exists as a story for policymakers to tell about their work, partly because it is consistent with the idea of elected policymakers being in charge and accountable.

Some scholars also question the appropriateness of a stages ideal, since it suggests that there should be a core group of policymakers making policy from the ‘top down’ and obliging others to carry out their aims, which does not leave room for, for example, the diffusion of power in multi-level systems, or the use of ‘localism’ to tailor policy to local needs and desires.

Now go to:

What can you do when policymakers ignore your evidence?

Further Reading

The politics of evidence-based policymaking

The politics of evidence-based policymaking: maximising the use of evidence in policy

Images of the policy process

How to communicate effectively with policymakers

Forthcoming special issue in Policy and Politics called ‘Practical lessons from policy theories’, which includes my discussion of how to be a ‘policy entrepreneur’.

8 Comments

Filed under Evidence Based Policymaking (EBPM), Psychology Based Policy Studies, Public health, public policy

How far should you go to secure academic ‘impact’ in policymaking? From ‘honest brokers’ to ‘research purists’ and Machiavellian manipulators

Long read for Political Studies Association annual conference 2017 panel Rethinking Impact: Narratives of Research-Policy Relations. There is a paper too, but I’ve hidden it in the text like an Easter Egg hunt.

I’ve watched a lot of film and TV dramas over the decades. Many have the same basic theme, characters, and moral:

  1. There is a villain getting away with something, such as cheating at sport or trying to evict people to make money on a property deal.
  2. There are some characters who complain that life is unfair and there’s nothing they can do about it.
  3. A hero emerges to inspire the other characters to act as a team/ fight the system and win the day. Think of a range from Wyldstyle to Michael Corleone.

For many scientists right now, the villains are people like Trump or Farage, Trump’s election and Brexit symbolise an unfairness on a grand scale, and there’s little they can do about it in a ‘post-truth’ era in which people have had enough of facts and experts. Or, when people try to mobilise, they are unsure about what to do or how far they are willing to go to win the day.

These issues are playing out in different ways, from the March for Science to the conferences informing debates on modern principles of government-science advice (see INGSA). Yet, the basic question is the same when scientists are trying to re-establish a particular role for science in the world: can you present science as (a) a universal principle and (b) unequivocal resource for good, producing (c) evidence so pure that it speaks for itself, regardless of (d) the context in which specific forms of scientific evidence are produced and used?

Of course not. Instead, we are trying to privilege the role of science and scientific evidence in politics and policymaking without always acknowledging that these activities are political acts:

(a) selling scientific values rather than self-evidence truths, and

(b) using particular values to cement the status of particular groups at the expense of others, either within the scientific profession (in which some disciplines and social groups win systematically) or within society (in which scientific experts generally enjoy privileged positions in policymaking arenas).

Politics is about exercising power to win disputes, from visible acts to win ‘key choices’, to less visible acts to keep issues off agendas and reinforce the attitudes and behaviours that systematically benefit some groups at the expense of others.

To deny this link between science, politics and power – in the name of ‘science’ – is (a) silly, and (b) not scientific, since there is a wealth of policy science out there which highlights this relationship.

Instead, academic and working scientists should make better use of their political-thinking-time to consider this basic dilemma regarding political engagement: how far are you willing to go to make an impact and get what you want?  Here are three examples.

  1. How energetically should you give science advice?

My impression is that most scientists feel most comfortable with the unfortunate idea of separating facts from values (rejected by Douglas), and living life as ‘honest brokers’ rather than ‘issue advocates’ (a pursuit described by Pielke and critiqued by Jasanoff). For me, this is generally a cop-out since it puts the responsibility on politicians to understand the implications of scientific evidence, as if they were self-evident, rather than on scientists to explain the significance in a language familiar to their audience.

On the other hand, the alternative is not really clear. ‘Getting your hands dirty’, to maximise the uptake of evidence in politics, is a great metaphor but a hopeless blueprint, especially when you, as part of a notional ‘scientific community’, face trade-offs between doing what you think is the right thing and getting what you want.

There are 101 examples of these individual choices that make up one big engagement dilemmas. One of my favourite examples from table 1 is as follows:

One argument stated frequently is that, to be effective in policy, you should put forward scientists with a particular background trusted by policymakers: white men in their 50s with international reputations and strong networks in their scientific field. This way, they resemble the profile of key policymakers who tend to trust people already familiar to them. Another is that we should widen out science and science advice, investing in a new and diverse generation of science-policy specialists, to address the charge that science is an elite endeavour contributing to inequalities.

  1. How far should you go to ensure that the ‘best’ scientific evidence underpins policy?

Kathryn Oliver and I identify the dilemmas that arise when principles of evidence-production meet (a) principles of governance and (b) real world policymaking. Should scientists learn how to be manipulative, to combine evidence and emotional appeals to win the day? Should they reject other forms of knowledge, and particular forms of governance if the think they get in the way of the use of the best evidence in policymaking?

Cairney Oliver 2017 table 1

  1. Is it OK to use psychological insights to manipulate policymakers?

Richard Kwiatkowski and I mostly discuss how to be manipulative if you make that leap. Or, to put it less dramatically, how to identify relevant insights from psychology, apply them to policymaking, and decide how best to respond. Here, we propose five heuristics for engagement:

  1. developing heuristics to respond positively to ‘irrational’ policymaking
  2. tailoring framing strategies to policymaker bias
  3. identifying the right time to influence individuals and processes
  4. adapting to real-world (dysfunctional) organisations rather than waiting for an orderly process to appear, and
  5. recognising that the biases we ascribe to policymakers are present in ourselves and our own groups

Then there is the impact agenda, which describes something very different

I say these things to link to our PSA panel, in which Christina Boswell and Katherine Smith sum up (in their abstract) the difference between the ways in which we are expected to demonstrate academic impact, and the practices that might actually produce real impact:

Political scientists are increasingly exhorted to ensure their research has policy ‘impact’, most notably in the form of REF impact case studies, and ‘pathways to impact’ plans in ESRC funding. Yet the assumptions underpinning these frameworks are frequently problematic. Notions of ‘impact’, ‘engagement’ and ‘knowledge exchange’ are typically premised on simplistic and linear models of the policy process, according to which policy-makers are keen to ‘utilise’ expertise to produce more effective policy interventions”.

I then sum up the same thing but with different words in my abstract:

“The impact agenda prompts strategies which reflect the science literature on ‘barriers’ between evidence and policy: produce more accessible reports, find the right time to engage, encourage academic-practitioner workshops, and hope that policymakers have the skills to understand and motive to respond to your evidence. Such strategies are built on the idea that scientists serve to reduce policymaker uncertainty, with a linear connection between evidence and policy. Yet, the literature informed by policy theory suggests that successful actors combine evidence and persuasion to reduce ambiguity, particularly when they know where the ‘action’ is within complex policymaking systems”.

The implications for the impact agenda are interesting, because there is a big difference between (a) the fairly banal ways in which we might make it easier for policymakers to see our work, and (b) the more exciting and sinister-looking ways in which we might make more persuasive cases. Yet, our incentive remains to produce the research and play it safe, producing examples of ‘impact’ that, on the whole, seem more reportable than remarkable.

13 Comments

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

9 Comments

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

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

caspi-et-al-abstract

Avshalom Caspi and colleagues have used the 45-year ‘Dunedin’ study in New Zealand to identify the ‘large economic burden’ associated with ‘a small segment of the population’. They don’t quite achieve the 20%-causes-80% mark, but suggest that 22% of the population account disproportionately for the problems that most policymakers would like to solve, including unhealthy, economically inactive, and criminal behaviour. Most importantly, they discuss some success in predicting such outcomes from a 45-minute diagnostic test of 3 year olds.

Of course, any such publication will prompt major debates about how we report, interpret, and deal with such information, and these debates tend to get away from the original authors as soon as they publish and others report (follow the tweet thread):

This is true even though the authors have gone to unusual lengths to show the many ways in which you could interpret their figures. Theirs is a politically aware report, using some of the language of elected politicians but challenging simple responses. You can see this in their discussion which has a lengthy list of points about the study’s limitations.

The ambiguity dilemma: more evidence does not produce more agreement

‘The most costly adults in our cohort started the race of life from a starting block somewhere behind the rest, and while carrying a heavy handicap in brain health’.

The first limitation is that evidence does not help us adjudicate between competing attempts to define the problem. For some, it reinforces the idea of an ‘underclass’ or small collection of problem/ troubled families that should be blamed for society’s ills (it’s the fault of families and individuals). For others, it reinforces the idea that socio-economic inequalities harm the life chances of people as soon as they are born (it is out of the control of individuals).

The intervention dilemma: we know more about the problem than its solution

The second limitation is that this study tells us a lot about a problem but not its solution. Perhaps there is some common ground on the need to act, and to invest in similar interventions, but:

  1. The evidence on the effectiveness of solutions is not as strong or systematic as this new evidence on the problem.
  2. There are major dilemmas involved in ‘scaling up’ such solutions and transferring them from one area to another.
  3. The overall ‘tone’ of debate still matters to policy delivery, to determine for example if any intervention should be punitive and compulsory (you will cause the problem, so you have to engage with the solution) or supportive and voluntary (you face disadvantages, so we’ll try to help you if you let us).

The moral dilemma: we may only pay attention to the problem if there is a feasible solution

Prevention and early intervention policy agendas often seem to fail because the issues they raise seem too difficult to solve. Governments make the commitment to ‘prevention’ in the abstract but ‘do not know what it means or appreciate scale of their task’.

A classic policymaker heuristic described by Kingdon is that policymakers only pay attention to problems they think they can solve. So, they might initially show enthusiasm, only to lose interest when problems seem intractable or there is high opposition to specific solutions.

This may be true of most policies, but prevention and early intervention also seem to magnify the big moral question that can stop policy in its tracks: to what extent is it appropriate to intervene in people’s lives to change their behaviour?

Some may vocally oppose interventions based on their concern about the controlling nature of the state, particularly when it intervenes to prevent (say, criminal) behaviour that will not necessarily occur. It may be easier to make the case for intervening to help children, but difficult to look like you are not second guessing their parents.

Others may quietly oppose interventions based on an unresolved economic question: does it really save money to intervene early? Put bluntly, a key ‘economic burden’ relates to population longevity; the ‘20%’ may cause economic problems in their working years but die far earlier than the 80%. Put less bluntly by the authors:

This is an important question because the health-care burden of developed societies concentrates in older age groups. To the extent that factors such as smoking, excess weight and health problems during midlife foretell health-care burden and social dependency, findings here should extend to later life (keeping in mind that midlife smoking, weight problems and health problems also forecast premature mortality)’.

So, policymakers find initially that ‘early intervention’ a valence issue only in the abstract – who wouldn’t want to intervene as early as possible in a child’s life to protect them or improve their life chances? – but not when they try to deliver concrete policies.

The evidence-based policymaking dilemma

Overall, we are left with the sense that even the best available evidence of a problem may not help us solve it. Choosing to do nothing may be just as ‘evidence based’ as choosing a solution with minimal effects. Choosing to do something requires us to use far more limited evidence of solution effectiveness and to act in the face of high uncertainty. Add into the mix that prevention policy does not seem to be particularly popular and you might wonder why any policymaker would want to do anything with the best evidence of a profound societal problem.

 

3 Comments

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