Q: If ‘prevention is better than cure’ …


Our study of prevention policy provides a simple cautionary tale for policy scholars and policymakers: focus on the need to make choices and gauge their unequal effect on target populations, rather than seeking or describing mythical solutions that will benefit all populations.

However, this field is complex, and so we have juggled several different messages and forms of analysis. For example, here is a 500 word summary:

Prevention puzzle 500 words 2017

Here is a longer summary, followed by some further reading …

Why do governments promote but fail to deliver their radically new ‘preventive’ policy agendas?

Prevention represents the most important social policy agenda in modern history, but governments do not know how to take it forward. In the name of prevention, the UK and Scottish Governments propose to radically change policy and policymaking across the whole of government. Their deceptively simple definition of ‘prevention policy’ is: a major shift in resources, from the delivery of reactive public services to solve acute problems, to the prevention of those problems before they occur. The results they promise are transformative, to address three crises in politics simultaneously: a major reduction in socioeconomic equalities by focusing on their ‘root causes’; a solution to unsustainable public spending which is pushing public services to breaking point; and, new forms of localised policymaking, built on community and service user engagement, to restore trust in politics.

Yet, they may never fulfil their aims. We do not identify the usual implementation or expectations gap, in which policymakers only fulfil some of their objectives. Rather, there is great potential for governments to pursue contradictory policies at the complete expense of their prevention agendas. Their most important domestic policy agenda may never get off the ground.

Why do governments fail to deliver on such a massive scale?

We go beyond the usual cynical answer at the heart of low trust in politics and politicians: ‘politicians always make promises they know they won’t keep’. This assertion can only take us so far, partly because governments tend to articulate pledges to allow them to demonstrate success in government, and most governments fulfil a high proportion of pre-election pledges (Bara, 2005). They rarely propose specific policies that they know are too difficult to achieve. This is what makes the pursuit of prevention policies puzzling: why would they make a specific and enthusiastic commitment to an almost impossible policy agenda?

Our simple answer is that, when they make a sincere commitment to prevention, they do not know what it means or appreciate scale of their task. They soon find a set of policymaking constraints that will always be present. When they ‘operationalise’ prevention, they face several fundamental problems, including: the identification of ‘wicked’ problems (Rittell and Webber, 1973) which are difficult to define and seem impossible to solve; inescapable choices on how far they should go to redistribute income, distribute public resources, and intervene in people’s lives; major competition from more salient policy aims which prompt them to maintain existing public services; and, a democratic system which limits their ability to reform the ways in which they make policy. These problems may never be overcome. More importantly, policymakers soon think that their task is impossible.  Therefore, there is high potential for an initial period of enthusiasm and activity to be replaced by disenchantment and inactivity, and for this cycle to be repeated without resolution.

How does the range of theoretical and explanatory issues we describe help deliver that aim?

We combine theoretical, empirical, and normative analysis to provide a full account of, and explanation for, this problem. We focus on ‘what happens next’: what goes wrong after governments make that initial commitment to radical changes in policy and policymaking?

The role of policy theories: explaining the limits to prevention policy

Analytical frameworks help us identify key variables or explanatory factors (Ostrom, 2007: 26). In policy analysis, they include the role of actors at multiple levels of government, institutions, networks, socioeconomics, and ideas (Cairney and Heikkila, 2014). We use theories to help us define these factors and identify how they interact to influence policy processes. Theories help us structure empirical analysis by giving us a language to make sense of, and explain, events and decisions, and produce general insights from many case studies. Further, combining the insights of several theories is not straightforward, but it helps us fill gaps in analysis or generate more than one perspective on empirical data (Cairney, 2013).

In the case of prevention, we show the value of three theoretical approaches which help illuminate three key aspects of the policy process:

  1. the initial definition of an ambiguous problem and selection of an unclear solution
  2. the limited effect of that solution on existing practices in a complex policymaking system
  3. the simple, but often profoundly important, rules that policymakers use to respond to ambiguity and complexity.

First, ‘multiple streams analysis’ helps explain a process of agenda setting and initial choice. We highlight a perception within the UK and Scottish governments that an idea’s time has come. Both governments suggest that they have produced prevention policy during what Kingdon (1984) calls a ‘window of opportunity’: they paid high attention to the problems of high inequalities, costs, and low trust in politics; produced feasible solutions to each problem; and, had the motive and opportunity to select prevention as the best solution. Yet, the actual development of prevention policy suggests that they paid attention to an ill-defined problem and produced a solution which proved to be too vague to operationalise in a simple way. In other words, we identify a ‘window of opportunity’ to adopt a vague solution, prevention, to address a very broad and often ill-defined policy problem: reduce inequalities and ‘service demand’, and find new ways to make policy and deliver public services. The consequences of such an unclear decision are difficult to predict, and therefore require considerable empirical analysis.

Second, complexity theory helps explain the subsequent patterns of policymaking that seem to ‘emerge’ from policymaking systems in the absence of central government control (Geyer and Cairney, 2015).  It is not obvious how policymakers should make sense of prevention policy or how they should engage with a complex policymaking system to turn their aims into long term policy outcomes. Even if they had clear aims, and prevention remained at the top of the policy agenda, they would face the need to transform the functions and role of government fundamentally. Their task involves the management of a huge number of issues across many departments, and changing the rules of government departments, public bodies and delivery partnerships. However, ministers can only pay attention to, and seek to influence, a small proportion of that activity. They inherit the commitments of their predecessors, reproduce many of the rules that already exist in organisations, and rely on a large number of actors – in the public, third, and private sectors – to help deliver their policies, many of which have their own ideas about how to make sense of prevention. We draw on complexity theory to show how such policymaking systems operate, to process issues that affect multiple government departments and public services, and how actors within them incorporate new ideas such as prevention. Our expectations for policy practices and outcomes can vary dramatically: the prevention agenda can have no impact whatsoever, or produce a change in rules in key institutions to prompt a completely different way to consider and produce policy.

Third, social construction theory helps explain how policymakers act in the face of complexity, uncertainty and ambiguity. The problems we identify do not stop policymakers doing something, and the policy process continues regardless (Zahariadis, 2007: 66). So, what happens next? They seek ways to manage complexity. One simple, but profoundly important, solution is to use a series of decision-making short cuts to turn a complex problem into a small set of solutions and rules.  Social construction, drawing on gut-level, emotional and deeply held ideological beliefs, is one of those solutions (Schneider et al, 2014). Simple decisions, about which ‘target populations’ are most deserving of public benefits and sanctions, provide key context for government departments and public bodies. They operate alongside the more ‘rational’ processes associated with terms such as ‘evidence based policy making’ (Cairney, 2016).

The role of empirical analysis: explaining how governments address the limits to prevention

Since it is such an ambiguous concept, governments can produce a wide range of different policies in the name of prevention. There is high potential for ‘business as usual’, as government departments and public services rearticulate their actions as preventive while maintaining existing practices. Alternatively, key actors can seek to use the prevention agenda as a way to challenge existing practices.

In other words, a window of opportunity for prevention policy becomes a prompt for potentially numerous policies, as different policymaking rules exist across government and many policymakers make quick, emotional judgements about target populations. Consequently, to understand what happens next, we need to examine in depth, and compare, several case studies of prevention policy. In each case, this requires us to identify which actors are involved, their ways of thinking, the rules they follow, the networks in which they participate, the socioeconomic context in which they operate, and their use of knowledge to underpin decisions.

We also need to understand which ‘tools’ policymakers use to turn broad prevention aims into specific objectives designed to produce policy outcomes (Hood and Margetts, 2007: 5-6). Prevention policy’s rise on the agenda has coincided with a reduction in government spending and a shift of governance strategy. The UK and Scottish governments are searching for new ways to deliver services at a lower cost. The articulation of an agenda based on localism, and policy strategies designed to foster partnerships and involve communities and service users, combined with a reduction in budgets, has major implications for the study of prevention. Both governments are pursuing a prevention agenda in a meaningful way, but also making funding and governance decisions that could undermine that agenda. Or, at least, they produce major uncertainty about the links between the expectations of central government policymakers, driven largely by exhortation and information sharing rather than regulation or by forming new organisations, and local practices and outcomes, driven increasingly by public bodies with greater control over reduced budgets.

A focus on either the UK or Scottish Government would be important, to show how vague ideas impact on existing policymaking practices across a wide range of departments and services. The additional comparative element allows us to examine the extent to which the explanations we find for outcomes are ‘universal’, driven by policy processes that we could find in any system, or ‘territorial’, linked to specific ways of thinking and making policy in particular systems. We argue that, if almost anything can happen next, common patterns are significant: both governments may face the same problems and act the same way to solve them, even when they use different rhetoric and pursue change in different institutional settings. However, their outcomes will not be identical. Rather, they introduce policies in different systems, with the potential for variations in outcome. Their quick judgements on target populations help produce variations in policy intervention. Consequently, through a series of case studies in the most relevant areas – healthcare, social care and ‘troubled families’, employability, and criminal justice – we show how their respective policy agendas play out in practice.

The role of normative analysis: explaining how governments try and fail to redefine their role

We show that governments contribute to a major ‘expectations gap’ even if they are completely sincere in their aims when they pursue prevention policies. A key element is the overarching political system in which they operate. Their major political dilemma is that their political aims are contradictory: a focus on local devolution and community engagement contradicts their commitment to traditional forms of democratic accountability. Governments seek ways to share policymaking responsibility with delegated public bodies, elected local authorities, communities, and service users. However, they know that, particularly in Westminster systems, the dominant way of articulating policymaking authority, responsibility, and accountability is via the accountability of ministers to the public via Parliament. To maintain this image requires governments to try to appear to be in control.

We draw on complexity and social construction theories, and empirical analysis, to help us understand how such normative dilemmas play out in practice. Both governments seek pragmatic responses to their dilemma, by delegating responsibility while maintaining an image of governing competence. In that context, to what extent can other actors meaningfully hold them to account? In particular, we highlight social construction as a means for governments to signal, and to some extent be held accountable for, their values as much as their competence.

Our book, articles, and posts on ‘prevention policy’

Our book – Why Isn’t Government Policy More Preventive? – is in press (Oxford University Press) and will be out in January 2020. It combines a conceptual focus with several case studies – public health, mental health and employability, ‘families policy’, and justice – to give a in-depth study of the theory and practice of prevention. Here are some sample drafts:

Cairney St Denny OUP chapter 0 Preface 6.5.19

Cairney St Denny OUP Chapter 1 defining prevention 6.5.19

Cairney St Denny OUP Chapter 9 Families 9.5.19

Cairney St Denny OUP Chapter 11 Conclusion 10.5.19

Cairney St Denny OUP References 10.5.19

Our longer term agenda – via IMAJINE – is to examine how policymakers try to address ‘spatial justice’ and reduce territorial inequalities across Europe partly by pursuing prevention and reforming public services.

Below are some short articles or blog posts on the key topics, and this link is to a wider discussion on prevention and ‘evidence based policymaking‘.

Prevention is Better Than Cure, So Why isn’t Government Policy More Preventive?

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

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

A ‘decisive shift to prevention’

How would Lisa Simpson and Monty Burns make progressive social policy?

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

Two myths about the politics of inequality in Scotland

What can governments learn from each other about prevention policy?

Using evidence to guide policy

Evidence-based Family Policy: Combining evidence, values, and rules to make good decisions

The politics of evidence-based best practice: 4 messages

We also make reference to these related studies:

  1. Paul Cairney, Tanya Heikkila, and Matthew Wood (2019) Making Policy in a Complex World (Cambridge: Cambridge Elements) PDF TFPDF AM
  2. John Boswell, Paul Cairney, and Emily St Denny (2019) ‘The Politics of Institutionalizing Preventative Health’, Social Science and Medicine 228, May, 202-10 PDF
  3. Donley Studlar and Paul Cairney (2019) ‘Multilevel Governance, Public Health and the Regulation of Food: Is Tobacco Control Policy a Model?’ Journal of Public Health Policy Free-to-view
  4. Paul Cairney and Kathryn Oliver (2017) ‘Evidence-based policymaking is not like evidence-based medicine, so how far should you go to bridge the divide between evidence and policy?’ Health Research Policy and Systems (HARPS), DOI: 10.1186/s12961-017-0192-x PDF AM
  5. Paul Cairney (2019) ‘The UK government’s imaginative use of evidence to make policy’, British Politics, 14, 1, 1-22 Open Access PDF AM
  6. Paul Cairney and Kirstein Rummery (2018) ‘Feminising politics to close the evidence-policy gap: the case of social policy in Scotland’, Australian Journal of Public Administration, 77, 4, 542-53 (Open AccessPDF AM
  7. Paul Cairney and Mikine Yamazaki (2018) ‘A comparison of tobacco policy in the UK and Japan: if the scientific evidence is identical, why is there a major difference in policy?’ Journal of Comparative Policy Analysis, 20, 3, 253-68 PDF
  8. Paul Cairney (2017) “Evidence-based best practice is more political than it looks: a case study of the ‘Scottish Approach’”, Evidence and Policy, 13, 3, 499-515 PDF
  9. Paul Cairney, Siabhainn Russell and Emily St Denny (2016) “The ‘Scottish approach’ to policy and policymaking: what issues are territorial and what are universal?” Policy and Politics, 44, 3, 333-50 PDF
  10. Paul Cairney (2015) ‘Scotland’s Future Political System’, Political Quarterly, 86, 2, 217-25 PDF
  11. Paul Cairney and Donley Studlar (2014) ‘Public Health Policy in the United Kingdom: After the War on Tobacco, Is a War on Alcohol Brewing?’ World Medical and Health Policy6, 3, 308-323 PDF

These recent conference papers highlights the conceptual issues: A window of opportunity for prevention (ICPP) and Cairney St Denny PSA 2016 Prevention 17.3.16

The Scottish Parliament Finance Committee’s examination of preventative spending in 2015-16 includes Cairney’s summary of written evidence, which it used (from p43) while gathering oral evidence (p64) from the Scottish Governments Deputy First Minister (3rd Meeting, Monday 18 January 2016).

This work was funded initially by the Economic and Social Research Council as part of the Centre on Constitutional Change.