Category Archives: Public health

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.

 

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There is no blueprint for evidence-based policy, so what do you do?

In my speech to COPOLAD I began by stating that, although we talk about our hopes for evidence-based policy and policymaking (EBP and EBPM), we don’t really know what it is.

I also argued that EBPM is not like our image of evidence-based medicine (EBM), in which there is a clear idea of: (a) which methods/ evidence counts, and (b) the main aim, to replace bad interventions with good.

In other words, in EBPM there is no blueprint for action, either in the abstract or in specific cases of learning from good practice.

To me, this point is underappreciated in the study of EBPM: we identify the politics of EBPM, to highlight the pathologies of/ ‘irrational’ side to policymaking, but we don’t appreciate the more humdrum limits to EBPM even when the political process is healthy and policymakers are fully committed to something more ‘rational’.

Examples from best practice

The examples from our next panel session* demonstrated these limitations to EBPM very well.

The panel contained four examples of impressive policy developments with the potential to outline good practice on the application of public health and harm reduction approaches to drugs policy (including the much-praised Portuguese model).

However, it quickly became apparent that no country-level experience translated into a blueprint for action, for some of the following reasons:

  • It is not always clear what problems policymakers have been trying to solve.
  • It is not always clear how their solutions, in this case, interact with all other relevant policy solutions in related fields.
  • It is difficult to demonstrate clear evidence of success, either before or after the introduction of policies. Instead, most policies are built on initial deductions from relevant evidence, followed by trial-and-error and some evaluations.

In other words, we note routinely the high-level political obstacles to policy emulation, but these examples demonstrate the problems that would still exist even if those initial obstacles were overcome.

A key solution is easier said than done: if providing lessons to others, describe it systematically, in a form that describes the steps to take to turn this model into action (and in a form that we can compare with other experiences). To that end, providers of lessons might note:

  • The problem they were trying to solve (and how they framed it to generate attention, support, and action, within their political systems)
  • The detailed nature of the solution they selected (and the conditions under which it became possible to select that intervention)
  • The evidence they used to guide their initial policies (and how they gathered it)
  • The evidence they collected to monitor the delivery of the intervention, evaluate its impact (was it successful?), and identify cause and effect (why was it successful?)

Realistically this is when the process least resembles (the ideal of) EBM because few evaluations of success will be based on a randomised control trial or some equivalent (and other policymakers may not draw primarily on RCT evidence even when it exists).

Instead, as with much harm reduction and prevention policy, a lot of the justification for success will be based on a counterfactual (what would have happened if we did not intervene?), which is itself based on:

(a) the belief that our object of policy is a complex environment containing many ‘wicked problems’, in which the effects of one intervention cannot be separated easily from that of another (which makes it difficult, and perhaps even inappropriate, to rely on RCTs)

(b) an assessment of the unintended consequence of previous (generally more punitive) policies.

So, the first step to ‘evidence-based policymaking’ is to make a commitment to it. The second is to work out what it is. The third is to do it in a systematic way that allows others to learn from your experience.

The latter may be more political than it looks: few countries (or, at least, the people seeking re-election within them) will want to tell the rest of the world: we innovated and we don’t think it worked.

*I also discuss this problem of evidence-based best practice within single countries

 

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What does it take to turn scientific evidence into policy? Lessons for illegal drugs from tobacco

This post contains preliminary notes for my keynote speech ‘The politics of evidence-based policymaking’ for the COPOLAD annual conference, ‘From evidence to practice: challenges in the field of drugs policies’ (14th June). I may amend them in the run up to the speech (and during their translation into Spanish).

COPOLAD (Cooperation Programme on Drugs Policies) is a ‘partnership cooperation programme between the European Union, Latin America and the Caribbean countries aiming at improving the coherence, balance and impact of drugs policies, through the exchange of mutual experiences, bi-regional coordination and the promotion of multisectoral, comprehensive and coordinated responses’. It is financed by the EU.

My aim is to draw on policy studies, and the case study of tobacco/ public health policy, to identify four lessons:

  1. ‘Evidence-based policymaking’ is difficult to describe and understand, but we know it’s a highly political process which differs markedly from ‘evidence based medicine’.
  2. Actors focus as much on persuasion to reduce ambiguity as scientific evidence to reduce uncertainty. They also develop strategies to navigate complex policymaking ‘systems’ or ‘environments’.
  3. Tobacco policy demonstrates three conditions for the proportionate uptake of evidence: it helps ‘reframe’ a policy problem; it is used in an environment conducive to policy change; and, policymakers exploit ‘windows of opportunity’ for change.
  4. Even the ‘best cases’ of tobacco control highlight a gap of 20-30 years between the production of scientific evidence and a proportionate policy response. In many countries it could be 50. I’ll use this final insight to identify some scenarios on how evidence might be used in areas, such as drugs policy, in which many of the ‘best case’ conditions are not met.

‘Evidence-based policymaking’ is highly political and difficult to understand

Evidence-based policymaking (EBPM) is so difficult to understand that we don’t know how to define it or each word in it! People use phrases like ‘policy-based evidence’, to express cynicism about the sincere use of evidence to guide policy, or ‘evidence informed policy’, to highlight its often limited impact. It is more important to try to define each element of EBPM – to identify what counts as evidence, what is policy, who are the policymakers, and what an ‘evidence-based’ policy would look like – but this is easier said than done.

In fact, it is far easier to say what EBPM is not:

It is not ‘comprehensively rational’

Comprehensive rationality’ describes, in part, the absence of ambiguity and uncertainty:

  • Policymakers translate their values into policy in a straightforward manner – they know what they want and about the problem they seek to solve.
  • Policymakers and governments can gather and understand all information required to measure the problem and determine the effectiveness of solutions.

Instead, we talk of ‘bounded rationality’ and how policymakers deal with it. They employ two kinds of shortcut: ‘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 what is familiar to them, to make decisions quickly.

It does not take place in a policy cycle with well-ordered stages

Policy cycle’ describes the ides that there is a core group of policymakers at the ‘centre’, making policy from the ‘top down’, and pursuing their goals in a series of clearly defined and well-ordered stages, such as: agenda setting, policy formulation, legitimation, implementation, and evaluation.

It does not describe or explain policymaking well. Instead, we tend to identify the role of environments or systems.

When describing less ordered and predictable policy environments, we describe:

  • a wide range of actors (individuals and organisations) influencing policy at many levels of government
  • a proliferation of rules and norms followed by different levels or types of government
  • important relationships (‘networks’) between policymakers and powerful actors (with material resources, or the ability to represent a profession or social group)
  • a tendency for certain ‘core beliefs’ or ‘paradigms’ to dominate discussion
  • shifting policy conditions and events that can prompt policymaker attention to lurch at short notice.

When describing complex policymaking systems we show that, for example, (a) the same inputs of evidence or policy activity can have no, or a huge, effect, and (b) policy outcomes often ‘emerge’ in the absence of central government control (which makes it difficult to know how, and to whom, to present evidence or try to influence).

It does not resemble ‘evidence based medicine’ or the public health culture

In health policy we can identify an aim, associated with ‘evidence-based medicine’ (EBM), to:

(a) gather the best evidence on the effectiveness of policy interventions, based on a hierarchy of research methods which favours, for example, the systematic review of randomised control trials (RCTs)

(b) ensure that this evidence has a direct impact on healthcare and public health, to exhort practitioners to replace bad interventions with good, as quickly as possible.

Instead, (a) policymakers can ignore the problems raised by scientific evidence for long periods of time, only for (b) their attention to lurch, prompting them to beg, borrow, or steal information quickly from readily available sources. This can involve many sources of evidence (such as the ‘grey literature’) that some scientists would not describe as reliable.

Actors focus as much on persuasion to reduce ambiguity as scientific evidence to reduce uncertainty.

In that context, ‘evidence-based policymaking’ is about framing problems and adapting to complexity.

Framing refers to the ways in which policymakers understand, portray, and categorise issues. Problems are multi-faceted, but bounded rationality limits the attention of policymakers, and actors compete to highlight one ‘image’ at the expense of others. The outcome of this process determines who is involved (for example, portraying an issue as technical limits involvement to experts), who is responsible for policy, how much attention they pay, their demand for evidence on policy solutions, and what kind of solution they favour.

Scientific evidence plays a part in this process, but we should not exaggerate the ability of scientists to win the day with reference to evidence. Rather, policy theories signal the strategies that actors adopt to increase demand for their evidence:

  • to combine facts with emotional appeals, to prompt lurches of policymaker attention from one policy image to another (punctuated equilibrium theory)
  • to tell simple stories which are easy to understand, help manipulate people’s biases, apportion praise and blame, and highlight the moral and political value of solutions (narrative policy framework)
  • to interpret new evidence through the lens of the pre-existing beliefs of actors within coalitions, some of which dominate policy networks (advocacy coalition framework)
  • to produce a policy solution that is feasible and exploit a time when policymakers have the opportunity to adopt it (multiple streams analysis).

This takes place in complex ‘systems’ or ‘environments’

A focus on this bigger picture shifts our attention from the use of evidence by an elite group of elected policymakers at the ‘top’ to its use by a wide range of influential actors in a multi-level policy process. It shows actors that:

  • They are competing with many others to present evidence in a particular way to secure a policymaker audience.
  • Support for particular solutions varies according to which organisation takes the lead and how it understands the problem.
  • Some networks are close-knit and difficult to access because bureaucracies have operating procedures that favour particular sources of evidence and some participants over others
  • There is a language – indicating which ideas, beliefs, or ways of thinking are most accepted by policymakers and their stakeholders – that takes time to learn.
  • Well-established beliefs provide the context for policymaking: new evidence on the effectiveness of a policy solution has to be accompanied by a shift of attention and successful persuasion.
  • In some cases, social or economic ‘crises’ can prompt lurches of attention from one issue to another, and some forms of evidence can be used to encourage that shift. However, major policy shifts are rare.

In other words, successful actors develop pragmatic strategies based on the policy process that exists, not the process they’d like to see

We argue that successful actors: identify where the ‘action is’ (in networks and organisations in several levels of government); learn and follow the ‘rules of the game’ within networks to improve strategies and help build up trust; form coalitions with actors with similar aims and beliefs; and, frame the evidence to appeal to the biases, beliefs, and priorities of policymakers.

Tobacco policy demonstrates three conditions for the proportionate uptake of evidence

Case studies allow us to turn this general argument into insights generated from areas such as public health.

There are some obvious and important differences between tobacco and (illegal) drugs policies, but an initial focus on tobacco allows us to consider the conditions that might have to be met to use the best evidence on a problem to promote (what we consider to be) a proportionate and effective solution.

We can then use the experience of a ‘best case scenario’ to identify the issues that we face in less ideal circumstances (first in tobacco, and second in drugs).

With colleagues, I have been examining:

Our studies help us identify the conditions under which scientific evidence, on the size of the tobacco problem and the effectiveness of solutions, translates into a public policy response that its advocates would consider to be proportionate.

  1. Actors are able to use scientific evidence to persuade policymakers to pay attention to, and shift their understanding of, policy problems.

Although scientific evidence helps reduce uncertainty, it does not reduce ambiguity. Rather, there is high competition to define problems, and the result of this competition helps determine the demand for subsequent evidence.

In tobacco, the evidence on smoking and then passive smoking helped raise attention to public health, but it took decades to translate into a proportionate response, even in ‘leading’ countries such as the UK.

The comparison with ‘laggard’ countries is crucial to show that the same evidence can produce a far more limited response, as policymakers compare the public health imperative with other ‘frames’, relating to their beliefs on personal responsibility, civil liberties, and the economic consequences of tobacco controls.

  1. The policy environment becomes conducive to policy change.

Public health debates take place in environments more or less conducive to policy change. In the UK, actors used scientific evidence to help reframe the problem. Then, this new understanding helped give the Department of Health a greater role, the health department fostered networks with public health and medical groups at the expense of the industry and, while pursuing policy change, policymakers emphasised the reduced opposition to tobacco control, smoking prevalence, and economic benefits to tobacco,.

In many other countries, these conditions are far less apparent: there are multiple tobacco frames (including economic and civil liberties); economic and trade departments are still central to policy; the industry remains a key player; and, policymakers pay more attention to opposition to tobacco controls (such as bans on smoking in public places) and their potential economic consequences.

Further, differences between countries have largely endured despite the fact that most countries are parties to the FCTC. In other words, a commitment to evidence basedpolicy transfer’ does not necessarily produce actual policy change.

  1. Actors generate and exploit ‘windows of opportunity’ for major policy change.

Even in favourable policy environments, it is not inevitable that major policy changes will occur. Rather, the UK’s experience of key policy instruments – such as legislation to ban smoking in public places (a major commitment of the FCTC) – shows the high level of serendipity involved in the confluence of three necessary but insufficient conditions:

  1. high policymaker attention to tobacco as a policy problem
  2. the production of solutions, introducing partial or comprehensive bans on smoking in public places, that are technically and politically feasible
  3. the willingness and ability of policymakers to choose the more restrictive solution.

In many other countries, there has been no such window of opportunity, or only an opportunity for a far weaker regulation.

So, this condition – the confluence of three ‘streams’ during a ‘window of opportunity’ – shows the major limits to the effect of scientific evidence. The evidence on the health effects of passive smoking have been available since the 1980s, but they only contributed to comprehensive smoking bans in the UK in the mid-2000s, and they remain unlikely in many other countries.

Comparing ‘best case’ and ‘worst case’ scenarios for policy change

These discussions help us clarify the kinds of conditions that need to be met to produce major ‘evidence based’ policy change, even when policymakers have made a commitment to it, or are pursuing an international agreement.

I provide a notional spectrum of ‘best’ and ‘worst’ case scenarios in relation to these conditions:

  1. Actors agree on how to gather and interpret scientific evidence.
  • Best case: governments fund effective ways to gather and interpret the most relevant evidence on the size of policy problems and the effectiveness of solutions. Policymakers can translate large amounts of evidence on complex situations into simple and effective stories (that everyone can understand) to guide action. This includes evidence of activity in one’s own country, and of transferable success from others.
  • Worst case: governments do not know the size of the problem or what solutions have the highest impacts. They rely on old stories that reinforce ineffective action, and do not know how to learn from the experience of other regions (note the ‘not invented hereissue).
  1. Actors ‘frame’ the problem simply and/or unambiguously.
  • Best case: governments maintain a consensus on how best to understand the cause of a policy problem and therefore which evidence to gather and solutions to seek.
  • Worst case: governments juggle many ‘frames’, there is unresolved competition to define the problem, and the best sources of evidence and solutions remain unclear.
  1. A new policy frame is not undermined by the old way of thinking about, and doing, things
  • Best case: the new frame sets the agenda for actors in existing organisations and networks; there is no inertia linked to the old way of thinking about and doing things.
  • Worst case: there is a new policy, but it is undermined by old beliefs, rules, pre-existing commitments (for example, we talk of ‘path dependence’ and ‘inheritance before choice’), or actors opposed to the new policy.
  1. There is a clear ‘delivery chain’ from policy choice to implementation
  • Best case: policymakers agree on a solution, they communicate their aims well, and they secure the cooperation of the actors crucial to policy delivery in many levels and types of government.
  • Worst case: policymakers communicate an ambiguous message and/ or the actors involved in policy delivery pursue different – and often contradictory – ways to try to solve the same problem.

In international cooperation, it is natural to anticipate and try to minimise at least some of these worst case scenarios. Problems are more difficult to solve when they are transnational. Our general sense of uncertainty and complexity is more apparent when there are many governments involved and we cannot rely on a single authoritative actor to solve problems. Each country (and regions within it) has its own beliefs and ways of doing things, and it is not easy to simply emulate another country (even if we think it is successful and know why). Some countries do not have access to the basic information (for example, on health and mortality, alongside statistics on criminal justice) that others take for granted when they monitor the effectiveness of policies.

Further, these obstacles exist in now-relatively-uncontroversial issues, such as tobacco, in which there is an international consensus on the cause of the problem and the appropriateness and effectiveness of public solutions. It is natural to anticipate further problems when we also apply public health (and, in this case, ‘harm reduction’) measures to more controversial areas such as illegal drugs.

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

I have reblogged this post on EBPM and the Family Nurse Partnership, with an update, at the bottom, on its first RCT-based evaluation (which did not recommend continuing the programme in its current form).

Paul Cairney: Politics & Public Policy

We await the results of the randomised control trial (RCT) on family nurse partnerships in England. While it looks like an innocuous review of an internationally well-respected programme, and will likely receive minimal media attention, I think it has high-stakes symbolic value in relation to the role of RCTs in British government.

EBM versus EBPM?

We know a lot about the use of evidence in politics – and we hear that politicians play fast and loose with it. We also know that some professions have a very clear idea about what counts as evidence, and that this view is not shared by politicians and policymakers. Somehow, ‘politics’ gets in the way of the good production and use of evidence.

A key example is the ideal of ‘Evidence Based Medicine’ (EBM), which is associated with a hierarchy of evidence in which the status of the RCT is only exceeded by…

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The politics of evidence-based policymaking: focus on ambiguity as much as uncertainty

There is now a large literature on the gaps between the production of scientific evidence and a policy or policymaking response. However, the literature in key fields – such as health and environmental sciences – does not use policy theory to help explain the gap. In this book, and in work that I am developing with Kathryn Oliver and Adam Wellstead, I explain why this matters by identifying the difference between empirical uncertainty and policy ambiguity. Both concepts relate to ‘bounded rationality’: policymakers do not have the ability to consider all evidence relevant to policy problems. Instead, they employ two kinds of shortcut: ‘rational’, by pursuing clear goals and prioritizing certain kinds and sources of information, and ‘irrational’, by drawing on emotions, gut feelings, deeply held beliefs, and habits to make decisions quickly. This takes place in a complex policymaking system in which policymaker attention can lurch from issue to issue, policy is made routinely in subsystems, and the ‘rules of the game’ take time to learn.

The key problem in the health and environmental sciences is that studies focus only on the first short cut. They identify the problem of uncertainty that arises when policymakers have incomplete information, and seek to solve it by improving the supply of information and encouraging academic-practitioner networks and workshops. They ignore the importance of a wider process of debate, coalition formation, lobbying, and manipulation, to reduce ambiguity and establish a dominant way to frame policy problems. Further, while scientific evidence cannot solve the problem of ambiguity, persuasion and framing can help determine the demand for scientific evidence.

Therefore, the second solution is to engage in a process of framing and persuasion by, for example, forming coalitions with actors with the same aims or beliefs, and accompanying scientific information with simple stories to exploit or adapt to the emotional and ideological biases of policymakers. This is less about packaging information to make it simpler to understand, and more about responding to the ways in which policymakers think – in general, and in relation to emerging issues – and, therefore, how they demand information.

In the book, I present this argument in three steps. First, I bring together a range of insights from policy theory, to show the huge amount of accumulated knowledge of policymaking on which other scientists and evidence advocates should draw. Second, I discuss two systematic reviews – one by Oliver et al, and one that Wellstead and I developed – of the literature on ‘barriers’ to evidence and policy in health and environmental studies. They show that the vast majority of studies in each field employ minimal policy theory and present solutions which focus only on uncertainty. Third, I identify the practical consequences for actors trying to maximize the uptake of scientific evidence within government.

My conclusion has profound implications for the role of science and scientific experts in policymaking. Scientists have a stark choice: to produce information and accept that it will have a limited impact (but that scientists will maintain an often-useful image of objectivity), or to go beyond one’s comfort zone, and expertise, to engage in a normative enterprise that can increase impact at the expense of objectivity.

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Does anyone know what the UK Government’s mental health policy is?

This post is based on my paper for the Political Studies Association annual conference in 2015.

In policy studies we are used to defining policy as a collection of three things: the statements of intent by policymakers, policy delivery, and policy outcomes. This allows us to identify important disconnects between these processes, such as when governments don’t deliver on their promises, or there are unintended consequences to their actions. It is normal to expect a substantial gap between intention, delivery and outcome. However, in many cases, the gap is so large that it may prompt us to reconsider the nature of policy: if it is so distant from the stated intentions of government, do we actually know what policy is? A good example is mental health policy for England.

In the modern history of mental health legislation, you can get the broad sense of a direction of travel undermined, to some extent, by a gap between intention and outcomes. Mental Health Acts in 1959 and 1983 began to include reference to the right to adequate therapeutic treatment – the idea that, if the state deprived you of your liberty based on your mental illness, it should also provide services to treat the illness. However, those services were often inadequate. A policy statement, involving a promise to be treated by suitable services, often remained unfulfilled; services were not delivered and the outcomes were often unintended. ‘Policy’ appeared very different if you focused on the long term outcomes rather than the initial choices.

Three more recent examples provide an additional element.

Mental health legislation meets opposition

First, in the case of the Mental Health Act 2007, much of the UK Labour Government’s policy did not even make it to the statute book. Instead, after rejecting an initial report in 1998 – summed up by the statement ‘if you enforce compulsory powers over an individual, then they are entitled to a minimum quality of care’ – in favour of an approach based much more on preventive detention and public safety, it engaged in a 9-year standoff with the ‘Mental Health Alliance’ (a major collection of professional, third sector and service user groups), which led to legislation that neither side favoured. Indeed, the 1983 and 2007 Acts are still in need of further reform to deal with issues regarding, for example: the relationship between police detention to provide a ‘place of safety’ (under s136 of the 1983 Act) and low hospital capacity to provide follow-up treatment; the inappropriate use of the 1983 Act to secure access to in-patient hospital services; the negligible effect of community treatment orders (CTOs) on hospital admissions; and, the greater use of CTOs for black patients (see the House of Commons Health Committee, report; press release). ‘Policy’ is a combination of a partly-fulfilled statement, problematic delivery, and often-unintended outcomes.

Parity meets localism

Second, the UK Coalition government’s policy of ‘parity’ between mental and physical services marks a major contrast in consultation style – No Health Without Mental Health received widespread support – but not outcomes. It contains a major principle – ‘We are clear that we expect parity of esteem between mental and physical health services’ – and a set of aims on improving mental health in the population, helping people ‘recover’ from mental health illnesses, improving the physical health of people with mental health problems, improving care and support, enhancing services to prevent the development of some mental health problems, and reduce the stigma associated with mental illness. Yet, it also contains a major commitment to ‘localism’, through a mixture of delegating policy delivery to NHS England, devolving service delivery to local areas, and encouraging long term and often-vague outcome-measures (not specific, short term, high salience, NHS targets). This has contributed to a major disconnect between policy intention and outcomes: funding decisions by NHS England and local commissioners have undermined this parity strategy. In the past, we expected ministers to intervene directly in the running of the NHS. The phrase ‘command and control’ was a feature of the previous Labour government. Now, they criticise the decisions of public bodies without intervening to change them. A policy statement on parity, combined with a localism and ‘hands off strategy, has produced nothing of the sort.

Public mental health meets troubled families and fit notes

Third, the idea of public mental health – and related terms such as ‘prevention’ and ‘wellbeing’ – relates to wider ‘root causes’ of ill health, joined increasingly to strategies to identify connections between socio-economic status, housing, education, employment and health. There is some hope that ‘early intervention’ will address many problems before they become acute, reducing inequalities and/ or costs in the process. In general, this is often problematic in mental health, since many conditions are not preventable and early intervention is unlikely to reduce costs in highly pressured acute services. There is also a localist approach to service delivery in this area, built around the user and/ or involving major cooperation between a range of public bodies (such as local authorities and Public Health England), with the emphasis on central government delegating policy and sharing responsibility for outcomes with the public sector.

In this case, a combination of public mental health and localism can be a tempting solution for governments, since they can reduce budgets at the same time as delegating responsibility for policy outcomes to local authorities and their partners, knowing that they can exhort local public bodies to shift to preventative policies to reduce long term costs even though long term policymaking suffers during periods of austerity.

Or, we may simply not know how policy will play out, since preventive public mental health potentially means everything and nothing. A focus on wellbeing can involve positive frames, relating to the production of measures to compete with GDP as a measure of a country’s progress, or negative frames about anti-social behaviour, when a focus on ‘prevention’ and an appeal to the root causes of inequalities is be used to describe ‘Troubled Families’, in which the government seeks to identify a core group of families with intergenerational problems (regarding, for example, unemployment, chaotic lifestyles and low education attainment) and ‘turn them around’ in a relatively short space of time.

Or, public mental health and an ‘assets based approach’ (focusing on the assets people have, not their problems or limitations), can be combined with the UK Government’s framing of economic inactivity and excessive welfare dependence, to describe its controversial reform of social security policy, replacing ‘the paper-based sick note’ with ‘an electronic fit note’. This policy’s implementation is perhaps the most criticised aspect of government policy by the mental health third sector, even though in principle it can be framed as an important aspect of preventive public health.

What are the implications?

Who is accountable?

It is difficult to know for which part of this policy we hold elected policymakers to account: their statements, organisational practices, and/ or the outcomes? This broad movement towards sharing responsibility, for public service delivery and outcomes, between ministers and public and private organisations, might be (a) a pragmatic response to the complexities of government and the inability of ministers to control what goes on in their name, but is certainly (b) replacing the traditional idea of democratic accountability, in which ministers account to the public via Parliament and regular elections, with forms of institutional and service user accountability in which it is much more difficult to know who to blame when things go wrong.

What is the role of evidence based policymaking?

To know if policy is ‘evidence based’ we need to know what policy is. If we conclude that the UK’s sincere policy is parity between mental and physical health services, we can conclude that it is based on a growing intellectual consensus and the accumulation of evidence on the links between mental and physical health, as well as the importance of a wide range of environmental factors. If policy is a range of practices, or outcomes (including the unintended consequences), who knows what its link to the evidence is? If a long term focus on parity is undermined by short term funding decisions on salient acute physical services, we know that evidence plays a part only some of the time.

If the outcomes are so different, is a statement of intent really a policy?

Most of these problems are faced by most policymakers, however cynical or sincere they may be – but note how much of the ‘what is policy?’ question we answer by filling in the gaps with our assumptions about the motivation of politicians. If we say that they are cynical policymakers, we conclude that it is their policy to use a commitment to parity as a veneer; that they know they won’t achieve their stated aims and are happy to accept or contribute to the factors that undermine it. If we say that they are sincere, we conclude that it is their policy to pursue parity as an ideal and do all they can to address obstacles and unintended consequences. Only in the latter case can we meaningfully say that their policy is parity (even though it makes no practical difference).

Is this an England-only problem?

The policy process in Scotland is often described as different in style and substance (often by me). However, all governments face the need to account for their high-profile choices while accepting that they will struggle to control the nature of public sector delivery and its outcomes. Many, if not most, of these problems are ‘universal’ rather than ‘territorial’.

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Why do people seem so down on e-cigs?

It must be very frustrating to give up smoking, with the help of e-cigarettes, only to find that you are no more welcome in public places with a fake cigarette than a real one. UK governments, and many public health advocates, often seem to want to regulate them in the same way, even though the e-cig could be described as a crucial ‘harm reduction’ measure (it’s not exactly healthy, but it’s much better than the other thing you were doing).

Here is a list of historical explanations for this position which won’t make you happy, but can at least distract you while you’re having a sly puff in the toilets:

  1. We’ve been here before with tobacco and harm reduction. So many post-war examples – like the idea of smoking a pipe, putting filter tips on cigarettes, ‘low tar’ cigarettes (which is a bit like ‘less shite in your sandwich’), and ventilators in public spaces – suggest that ‘harm reduction’ (combined with cheeky advertising) represents a way for members of the tobacco industry to keep people doing what they are doing and avoid government regulation. Someone who has spent decades of their time challenging the industry will see this as just another wheeze.
  2. Harm reduction has long been rejected in tobacco control. The thing you can hang your hat on is that there is no safe level of smoking – which, since the 1970s/80s has influenced the UK public health message.  It’s now very difficult to incorporate a harm reduction message into a field built on a push for abstention – particularly when we don’t yet know how much harm we are reducing.
  3. Denormalisation. The same goes for the idea of ‘denormalisation’, which describes a series of policy instruments to challenge the idea that smoking is a normal part of public life. Maybe if a bunch of people start puffing away at things that look like mini-bongs instead of imitation cigarettes, that will change – but we’d encourage that shift on the basis of hope. Further, and more importantly, some tobacco companies are getting into the e-cig business and branding them in similar ways to real-cigs. So, for example, the government wouldn’t want to go to the trouble of plain-packaging and hiding cigarettes on the supermarket shelves only to allow a tobacco company to put up a huge branded display for its e-cigs right next to the real ones. If this is really about harm reduction, for some it means getting a utilitarian-looking bit of plastic and a pea-flavoured mix from a pharmacy.
  4. The politics of evidence-based policy making. Advocates of e-cig control are playing a clever game, arguing that the only way to know the long term effects of e-cigarettes is to distribute them in a controlled environment, to gather data on their use and effects. The argument is: if an e-cig is medicine, let’s regulate it like any other medicine. You can see why this argument would trump others: we’re all biased, and rely on cherry-picked evidence on their effects, or we point to experts that support our position; but, you’d struggle to trump the medical profession when getting together a posse of experts (recommending systematic evidence-based medicine).
  5. We trust doctors more than tobacco companies. The image of doctors remains of the people on the front line, able to see the damaging effects of unhealthy behaviour. The image of tobacco companies is more likely to relate to the idea that some of them maybe sort-of lied to the US senate about their harmful effects. So, it will always be possible to argue that e-cig advocates are doing the bidding of the tobacco companies. Don’t blame the doctors, blame the companies.
  6. We could see this as a cover for ‘Big Pharma’, trying to make a tonne of money from the NHS from smoking cessation services –  but that’s a difficult argument to make stick when the even less popular ‘Big Tobacco’ seems to be trying to diversify into e-cigs, and use the same branding as it uses for r-cigs.
  7. Demonising the companies, not the smokers. The vast majority of governments across the globe have made a commitment to cutting ties with the tobacco industry (which includes not consulting with the industry on public policy) and will be looking for ways to sort-of encourage e-cigs over r-cigs and bypass a reliance on the old industry.

Overall, maybe some of this new agenda is driven by people who see the benefit of temperance and like to tell you what to do and where to do it – but, even if there were no ‘new puritans’, you’d still have these problems about what to do when a new e-cig opportunity rubs up the wrong way against well-established tobacco control policy.

See also: Linda Bauld ‘There’s no evidence e-cigarettes are as harmful as smoking’

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Filed under Public health, public policy, tobacco, tobacco policy, UK politics and policy