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.

2. 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.

3. 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)

2. 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.

3. 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.

2. 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.

3. 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

4. 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.

5. 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.

6. 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?

7. 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?

8. 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?

9. 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

 

 

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

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

What is prevention policy and policymaking?

When engaged in ‘prevention’, governments seek to:

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

Three reasons why they never seem to succeed

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

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

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

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

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

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

 

‘Co-producing’ comparative policy research: how far should we go to secure policy impact?

See also our project website IMAJINE.

Two recent articles explore the role of academics in the ‘co-production’ of policy and/or knowledge.

• Matt Flinders, Matt Wood, and Malaika Cunningham, in The politics of co-production: risks, limits and pollution, examine: the perception by some academics that co-producing knowledge with other actors ‘pollutes’ the research; and, the risks of building up the expectations of your partners when the impact of this work (and of the partners in helping to produce it) is often limited.
• Kathryn Oliver and I, in Evidence-based policymaking is not like evidence-based medicine, so how far should you go to bridge the divide between evidence and policy?, examine the dilemmas faced by researchers when they try to ‘co-produce’ evidence-informed policy, including whether to ‘frame’ evidence in relation to the beliefs of policymakers, and assert superior knowledge claims to influence policy delivery.

Both papers suggest (I think) that academic engagement in the ‘real world’ is highly valuable, and that we should not pretend that we can remain aloof from politics when producing new knowledge (research production is political even if it is not overtly party political). They also suggest that it is fraught with difficulty and, perhaps, an often-thankless task with no guarantee of professional or policy payoffs (intrinsic motivation still trumps extrinsic motivation).

So, what should we do?

I plan to experiment a little bit while conducting some new research over the next 4 years. For example, I am part of a new project called IMAJINE, and plan to speak with policymakers, from the start to the end, about what they want from the research and how they’ll use it. My working assumption is that it will help boost the academic value and policy relevance of the research.

I have mocked up a paper abstract to describe this kind of work:

In this paper, we use policy theory to explain why the ‘co-production’ of comparative research with policymakers makes it more policy relevant: it allows researchers to frame their policy analysis with reference to the ways in which policymakers frame policy problems; and, it helps them identify which policymaking venues matter, and the rules of engagement within them.  In other words, theoretically-informed researchers can, to some extent, emulate the strategies of interest groups when they work out ‘where the action is’ and how to adapt to policy agendas to maximise their influence. Successful groups identify their audience and work out what it wants, rather than present their own fixed views to anyone who will listen.

Yet, when described so provocatively, our argument raises several practical and ethical dilemmas about the role of academic research. In abstract discussions, they include questions such as: should you engage this much with politics and policymakers, or maintain a critical distance; and, if you engage, should you simply reflect or seek to influence the policy agenda? In practice, such binary choices are artificial, prompting us to explore how to manage our engagement in politics and reflect on our potential influence.

We explore these issues with reference to a new Horizon 2020 funded project IMAJINE, which includes a work package – led by Cairney – on the use of evidence and learning from the many ways in which EU, national, and regional policymakers have tried to reduce territorial inequalities.

So, in the paper we (my future research partner and I), would:

• Outline the payoffs to this engage-early approach. Early engagement will inform the research questions you ask, how you ask them, and how you ‘frame’ the results. It should also help produce more academic publications (which is still the key consideration for many academics), partly because this early approach will help us speak with some authority about policy and policymaking in many countries.
• Describe the complications of engaging with different policymakers in many ‘venues’ in different countries: you would expect very different questions to arise, and perhaps struggle to manage competing audience demands.
• Raise practical questions about the research audience, including: should we interview key advocacy groups and private sources of funding for applied research, as well as policymakers, when refining questions? I ask this question partly because it can be more effective to communicate evidence via policy influencers rather than try to engage directly with policymakers.
• Raise ethical questions, including: what if policymaker interviewees want the ‘wrong’ questions answered? What if they are only interested in policy solutions that we think are misguided, either because the evidence-base is limited (and yet they seek a magic bullet) or their aims are based primarily on ideology (an allegedly typical dilemma regards left-wing academics providing research for right-wing governments)?

Overall, you can see the potential problems: you ‘enter’ the political arena to find that it is highly political! You find that policymakers are mostly interested in (what you believe are) ineffective or inappropriate solutions and/ or they think about the problem in ways that make you, say, uncomfortable. So, should you engage in a critical way, risking exclusion from the ‘coproduction’ of policy, or in a pragmatic way, to ‘coproduce’ knowledge and maximise your chances of their impact in government?

The case study of territorial inequalities is a key source of such dilemmas …

…partly because it is difficult to tell how policymakers define and want to solve such policy problems. When defining ‘territorial inequalities’, they can refer broadly to geographical spread, such as within the EU Member States, or even within regions of states. They can focus on economic inequalities, inequalities linked strongly to gender, race or ethnicity, mental health, disability, and/ or inequalities spread across generations. They can focus on indicators of inequalities in areas such as health and education outcomes, housing tenure and quality, transport, and engagement with social work and criminal justice. While policymakers might want to address all such issues, they also prioritise the problems they want to solve and the policy instruments they are prepared to use.

When considering solutions, they can choose from three basic categories:

1. Tax and spending to redistribute income and wealth, perhaps treating economic inequalities as the source of most others (such as health and education inequalities).
2. The provision of public services to help mitigate the effects of economic and other inequalities (such as free healthcare and education, and public transport in urban and rural areas).
3. The adoption of ‘prevention’ strategies to engage as early as possible in people’s lives, on the assumption that key inequalities are well-established by the time children are three years old.

Based on my previous work with Emily St Denny, I’d expect that many governments express a high commitment to reduce inequalities – and it is often sincere – but without wanting to use tax/ spending as the primary means, and faced with limited evidence on the effectiveness of public services and prevention. Or, many will prefer to identify ‘evidence-based’ solutions for individuals rather than to address ‘structural’ factors linked to factors such as gender, ethnicity, and class. This is when the production and use of evidence becomes overtly ‘political’, because at the heart of many of these discussions is the extent to which individuals or their environments are to blame for unequal outcomes, and if richer regions should compensate poorer regions.

‘The evidence’ will not ‘win the day’ in such debates. Rather, the choice will be between, for example: (a) pragmatism, to frame evidence to contribute to well-established beliefs, about policy problems and solutions, held by the dominant actors in each political system; and, (b) critical distance, to produce what you feel to be the best evidence generated in the right way, and challenge policymakers to explain why they won’t use it. I suspect that (a) is more effective, but (b) better reflects what most academics thought they were signing up to.

For more on IMAJINE, see New EU study looks at gap between rich and poor and The theory and practice of evidence-based policy transfer: can we learn how to reduce territorial inequalities?

For more on evidence/ policy dilemmas, see Kathryn Oliver and I have just published an article on the relationship between evidence and policy

 

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

Politics 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.

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 …

…but also

• …the space in which local authorities can fund the most ‘evidence-based’ interventions according to the Early Intervention Foundation.

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:

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.

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

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):

https://twitter.com/jamesrbuk/status/808599364230909952

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.

 

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

Imagine this as your ‘early intervention’ policy choice: (a) a universal and non-stigmatising programme for all parents/ children, with minimal evidence of effectiveness, high cost, and potential public opposition about the state intervening in family life; or (b) a targeted, stigmatising programme for a small number, with more evidence, less cost, but the sense that you are not really intervening ‘early’ (instead, you are waiting for problems to arise before you intervene). What would you do, and how would you sell your choice to the public?

I ask this question because ‘early intervention’ seems to the classic valence issue with a twist. Most people seem to want it in the abstract: isn’t it best to intervene as early as possible in a child’s life to protect them or improve their life chances?

However, profound problems or controversies arise when governments try to pursue it. There are many more choices than I presented, but the same basic trade-offs arise in each case. So, at the start, it looks like you have lucked onto a policy that almost everyone loves. At the end, you realise that you can’t win. There is no such thing as a valence issue at the point of policy choice and delivery.

To expand on these dilemmas in more depth, I compare cases of Scottish and UK Government ‘families policies’. In previous posts, I portrayed their differences – at least in the field of prevention and early intervention policies – as more difficult to pin down than you might think. Often, they either say the same things but ‘operationalise’ them in very different ways, or describe very different problems then select very similar solutions.

This basic description sums up very similar waves of key ‘families policies’ since devolution: an initial focus on social inclusion, then anti-social behaviour, followed by a contemporary focus on ‘whole family’ approaches and early intervention. I will show how they often go their own ways, but note the same basic context for choice, and similar choices, which help qualify that picture.

Early intervention & prevention policies are valence issues …

A valence (or ‘motherhood and apple pie’) issue is one in which you can generate huge support because the aim seems, to most people, to be obviously good. Broad aims include ‘freedom’ and ‘democracy’. In the UK specific aims include a national health service free at the point of use. We often focus on valence issues to highlight the importance of a political party’s or leader’s image of governing competence: it is not so much what we want (when the main parties support very similar things), but who you trust to get it.

Early intervention seems to fit the bill: who would want you to intervene late or too late in someone’s life when you can intervene early, to boost their life chances at an early stage as possible? All we have to do is work out how to do it well, with reference to some good evidence. Yet, as I discuss below, things get complicated as soon as we consider the types of early intervention available, generally described roughly as a spectrum from primary (stop a problem occurring and focus on the whole population – like a virus inoculation) to secondary (address a problem at an early stage, using proxy indicators to identify high-risk groups), and tertiary (stop a problem getting worse in already affected groups).

Similarly, look at how Emily St Denny and I describe prevention policy. Would many people object to the basic principles?

“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”.

… but the evidence on their effectiveness is inconvenient …

A good simple rule about ‘evidence-based policymaking’ is that there is never a ‘magic bullet’ to tell you what to do or take the place of judgement. Politics is about making choices which benefit some people 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 seems to be a good candidate for the latter, for three main reasons:

1. Very few interventions live up to high 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; and an outreach model of support and training. The evidence of success comes from evaluation and a counterfactual: this intervention is expensive, but we think that it would have cost far more money and heartache if we had not intervened to prevent (for example) family homelessness. 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 an intervention of this sort.

The second are projects imported from other countries (primarily the US and Australia) based on their reputation for success. This reputation has been generated according to evidential rules associated with ‘evidence based medicine’ (EBM), in which there is relatively strong adherence to a hierarchy of evidence, with RCTs and their systematic review at the top, and the belief that there should be ‘fidelity’ to programmes to make sure that the ‘dosage’ of the intervention is delivered properly and its effect measured. Key examples include the Family Nurse Partnership (although its first UK RCT evaluation was not promising), Triple P (although James Coyne has his doubts!), and Incredible Years (but note the importance of ‘indicated’ versus ‘selective’ programmes, below). In this approach, there may be 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 levels of existing services. We know that some interventions are associated with positive outcomes, but we struggle to establish definitively that they caused them (solely, separate from their context).

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

Kenneth Dodge (2009) sums up a general problem with primary prevention in this field. It is difficult to see much evidence of success because: 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); and, 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’.

… so governments have to make and defend highly ‘political’ choices …

I think this is key context in which we can try to understand the often-different choices by the UK and Scottish Governments. Faced with the same broad aim, to intervene early to prevent poor outcomes, the same uncertainty and lack of evidence that their interventions will produce the desired effect, and the same need to DO SOMETHING rather than wait for the evidence that may never arise, what do they do?

Both governments often did remarkably similar things before they did different things

From the late 1990s, both governments placed primary emphasis initially on a positive social inclusion agenda, followed by a relatively negative focus on anti-social behaviour (ASB), before a renewed focus on the social determinants of inequalities and the use of early intervention to prevent poor outcomes.

Both governments link families policies strongly to parenting skills, reinforcing the idea that parents are primarily responsible for the life chances of their children.

Both governments talk about getting away from deficit models of intervention (the Scottish Government in particular focuses on the ‘assets’ of individuals, families, and communities) but use deficit-model proxies to identify families in need of support, including: lone parenthood, debt problems, ill health (including disability and depression), and at least one member subject to domestic abuse or intergenerational violence, as well as professional judgements on the ‘chaotic’ or ‘dysfunctional’ nature of family life and of the likelihood of ‘family breakdown’ when, for example, a child it taken into care.

So, when we consider their headline-grabbing differences, note this common set of problems and drivers, and similar responses.

… and selling their early intervention choices is remarkably difficult …

Although our starting point was valence politics, prevention and early intervention policies are incredibly hard to get off the ground. As Emily St Denny and I describe elsewhere, when policymakers ‘make a sincere commitment to prevention, they do not know what it means or appreciate the 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 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’.

These constraints refer to the broad idea of prevention policy, while specific policies can involve different drivers and constraints. With general prevention policy, it is difficult to know what government policy is and how you measure its success. ‘Prevention’ is vague, plus governments encourage local discretion to adapt the evidence of ‘what works’ to local circumstances.

Governments don’t get away with this regarding specific policies. Instead, Westminster politics is built on a simple idea of accountability in which you know who is in charge and therefore to blame. UK central governments have to maintain some semblance of control because they know that people will try to hold them to account in elections and general debate. This ‘top down’ perspective has an enduring effect, particularly in the UK, but also the Scottish, government.

… so the UK Government goes for it and faces the consequences ….

‘Troubled Families’ in England: the massive expansion of secondary prevention?

So, although prevention policy is vague, individual programmes such as ‘troubled families’ contain enough detail to generate intense debate on central government policy and performance and contain elements which emphasise high central direction, including sustained ministerial commitment, a determination to demonstrate early success to justify a further rollout of policy, and performance management geared towards specific measurable short term outcomes – even if the broader aim is to encourage local discretion and successful long term outcomes.

In the absence of unequivocally supportive evidence (which may never appear), the UK government relied on a crisis (the London riots in 2011) to sell policy, and ridiculous processes of estimation of the size of the problem and performance measurement to sell the success of its solution. In this system, ministers perceive the need to display strength, show certainty that they have correctly diagnosed a problem and its solution, and claim success using the ‘currency’ of Westminster politics – and to do these things far more quickly than the people gathering evidence of more substantive success. There is a lot of criticism of the programme in terms of its lack, or cynical use, of evidence but little of it considers policy from an elected government’s perspective.

…while the Scottish Government is more careful, but faces unintended consequences

This particular UK Government response has no parallel in Scotland. The UK Government is far more likely than its Scottish counterpart to link families policies to a moral agenda in response to crisis, and there is no Scottish Government equivalent to ‘payment by results’ and massive programme expansion. Instead, it continued more modest roll-outs in partnership with local public bodies. Indeed, if we ‘zoom in’ to this one example, at this point in time, the comparison confirms the idea of a ‘Scottish Approach’ to policy and policymaking.

Yet, the Scottish Government has not solved the problems I describe in this post: it has not found an alternative ‘evidence based’ way to ‘scale up’ early intervention significantly and move from secondary/ tertiary forms of prevention to the more universal/ primary initiatives that you might associate intuitively with prevention policy.

Instead, its different experiences have highlighted different issues. For example, its key vehicle for early intervention and prevention is the ‘collaborative’ approach, such as in the Early Years Collaborative. Possibly, it represents the opposite of the UK’s attempt to centralise and performance-manage-the-hell-out-of the direction of major expansion.

Certainty, with this approach, your main aim is not to generate evidence of the success of interventions – at least not in the way we associate with ‘evidence based medicine’, randomised control trials, and the star ratings developed by the Early Intervention Foundation. Rather, the aim is to train local practitioners to use existing evidence and adapt it to local circumstances, experimenting as you go, and gathering/using data on progress in ways not associated with, for example, the family nurse partnership.

So, in terms of the discussion so far, perhaps its main advantage is that a government does not have to sell its political choices (it is more of a delivery system than a specific intervention) or back them up with evidence of success elsewhere. In the absence of much public, media, or political party attention, maybe it’s a nice pragmatic political solution built more on governance principles than specific evidence.

Yet, despite our fixation with the constitution, some policy issues do occasionally get discussed. For our purposes, the most relevant is the ‘named person’ scheme because it looks like a way to ‘scale up’ an initiative to support a universal or primary prevention approach and avoid stigmatising some groups by offering a service to everyone (in this respect, it is the antithesis to ‘troubled families’). In this case, all children in Scotland (and their parents or guardians) get access to a senior member of a public service, and that person acts as a way to ‘join up’ a public sector response to a child’s problems.

Interestingly, this universal approach has its own problems. ‘Troubled families’ sets up a distinction between troubled/ untroubled to limit its proposed intervention in family life. Its problem is the potential to stigmatise and demoralise ‘troubled’ families. ‘Named person’ shows the potential for greater outcry when governments try to not identify and stigmatise specific families. The scheme is largely a response to the continuous suggestion – made after high profile cases of child abuse or neglect – that children can suffer when no agency takes overall responsibility for their care, but has been opposed as excessive infringement on normal family life and data protection, successfully enough to delay its implementation.

[Update 20.9.19: Named person scheme scrapped by Scottish Government]

The punchline to early intervention as a valence issue

Problems arise almost instantly when you try to turn a valence issue into something concrete. A vague and widely-supported policy, to intervene early to prevent bad outcomes, becomes a set of policy choices based on how governments frame the balance between ideology, stigma, and the evidence of the impact and cost-effectiveness of key interventions (which is often very limited).

Their experiences are not always directly comparable, but the UK and Scottish Governments have helped show us the pitfalls of concrete approaches to prevention and early intervention. They help us show that your basic policy choices include: (a) targeted programmes which increase stigma, (b) ‘indicated’ approaches which don’t always look like early intervention; (c) ‘selective’ approaches which seem to be less effective despite intervening at an earlier stage, (d) universal programmes which might cross a notional line between the state and the family, and (e) approaches which focus primarily on local experimentation with uncertain outcomes.

None of these approaches provide a solution to the early intervention dilemmas that all governments face, and there is no easy way to choose between approaches. We can make these choices more informed and systematic, by highlighting how all of the pieces of the jigsaw fit together, and somehow comparing their intended and unintended consequences. However, this process does not replace political judgement – and quite right too – because there is no such thing as a valence issue at the point of policy choice and delivery.

See also:

Paul Cairney (2019) ‘The UK government’s imaginative use of evidence to make policy’, British Politics, 14, 1, 1-22 Open Access PDF

Paul Cairney and Emily St Denny (in press, January 2020) Why Isn’t Government Policy More Preventive? (Oxford: Oxford University Press) Preview Introduction Preview Conclusion

 

 

 

 

The politics of evidence-based best practice: 4 messages

Well, it’s really a set of messages, geared towards slightly different audiences, and summed up by this table:

1. This academic journal article (in Evidence and Policy) highlights the dilemmas faced by policymakers when they have to make two choices at once, to decide: (1) what is the best evidence, and (2) how strongly they should insist that local policymakers use it. It uses the case study of the ‘Scottish Approach’ to show that it often seems to favour one approach (‘approach 3’) but actually maintains three approaches. What interests me is the extent to which each approach contradicts the other. We might then consider the cause: is it an explicit decision to ‘let a thousand flowers bloom’ or an unintended outcome of complex government?
2. I explore some of the scientific  issues in more depth in posts which explore: the political significance of the family nurse partnership (as a symbol of the value of randomised control trials in government), and the assumptions we make about levels of control in the use of RCTs in policy.
3. For local governments, I outline three ways to gather and use evidence of best practice (for example, on interventions to support prevention policy).
4. For students and fans of policy theory, I show the links between the use of evidence and policy transfer.

Further reading (links):

My academic articles on these topics

The Politics of Evidence Based Policymaking

Key policy theories and concepts in 1000 words

Prevention policy

Case studies: early years, compulsory, further, and higher education #POLU9SP

This is the third of three posts which use case studies of cross-cutting and specific policy areas to add more depth to our discussion of Scottish politics and policymaking.

One of the SNP Government’s main aims is to abolish inequalities in education attainment. First Minister Nicola Sturgeon put it in this stark way in a speech in Wester Hailes in August:

‘My aim – to put it bluntly – is to close the attainment gap completely. It will not be done overnight – I accept that. But it must be done. After all, its existence is more than just an economic and social challenge for us all. It is a moral challenge. Indeed, I would argue that it goes to the very heart of who we are and how we see ourselves as a nation’.

This specific aim raises important questions about the likely success of such policies when governments (a) seek to reduce the impact, not existence, of socioeconomic inequalities, (b) recognise the limits of their powers, and (c) make choices which seem to undermine their aims. In other words, we need to compare these high expectations with other statements, expectations, and policies pursued in other parts of education and government.

Sturgeon’s uncompromising language is important for three reasons

First, it implies that governments can have this profound level of influence on socio-economic outcomes. It reminds me of two former ambitions of the post-war UK governments: to maintain ‘full employment’, an aim long abandoned by both UK political parties; and to reduce health inequalities by setting up a National Health Service, an ambition exposed as unfulfilled by almost every major publication since the Black Report in 1980 (see also the previous lecture on health). These days, ministers don’t tend to make such bold statements of their likely success (for good reason).

Second, we should remember the point that normally remains unsaid: the SNP-led Scottish Government, like the UK Government, has no stated ambition to go to the ‘root cause’ of the problem to reduce the socio-economic inequalities through a far more redistributive tax and benefits system. It is not yet possible for the Scottish Government to take an approach, often linked to the idea of ‘Nordic’ social democracy, to combine (a) spending decisions based on an appeal to universal service provision, and (b) redistribution through fiscal policy. Instead, there is great potential for inconsistent UK/ Scottish strategies: the Scottish Government to oversee a spending regime that favours the wealthy and middle classes (on universal free services with no means testing) while the UK Government maintains a tax and benefits policy that many people will perceive to be insufficiently redistributive. Nor has the SNP made a firm commitment to redistribution in the event of Scottish independence in the future.

Instead, in almost all cases, we are talking instead about the use of public service delivery to mitigate their effects: a strategy that relies largely on the idea of ‘prevention’ policies to intervene as early as possible in people’s lives – through interventions such as parenting programmes – to improve their life chances.

Policymakers’ language is normally more realistic

Third, it is a language that stands out from most other Scottish Government discussions of education attainment, which reflect a more careful, or less ambitious, focus on realistic progress and change at the margins (as well as the continuous reminder of the Scottish Government’s limited policymaking powers while it remains part of the UK Government system).

One aspect of the more careful language relates to the limitations of government, and Scottish Government in particular. In February 2015, Sturgeon stated: ‘We must do all we can within the powers and resources we have to narrow the gap and drive up standards at all levels’.

This statement accompanied Sturgeon’s announcement of a £25m per year (over 4 years) scheme to encourage new initiatives and learn from success stories such as the London Challenge, a project driven by a similar ‘moral imperative’, and combining a focus on leadership/ collaboration and the relative performance in schools situated in areas with similar socio-economic backgrounds.

Sturgeon followed up this announcement with a focus on the partial return of testing pupils at key stages in schools. This plan forms part of a National Improvement Framework for Scottish education, which ‘will ensure that we are making progress in closing the gap in attainment between those in our most and least deprived areas’.

These decisions will take time to play out, and will involve some Scotland-specific debates about more uniform testing. Testing in this way is a strategy that was previously rejected in Scotland, and opposed by teaching groups, largely because of its association with a system in England built increasingly on league tables of performance, increased school autonomy (from local authorities), competition, and parent/ consumer choice. In other words, note the symbolic as well as substantive importance of testing. However, it may be necessary to have some kind of testing regime to gather data to allow the Scottish Government to demonstrate progress in attainment at key stages.

Is this new aim consistent with older Scottish Government choices?

Education policy sums up the political limitations to broad strategies such as ‘prevention’. The broad idea of ‘early intervention’, to make an impact on people’s lives as early as possible, to help reduce inequalities and the costs of public services, enjoys magnificent levels of cross-party support. Yet, it competes badly with more specific political commitments with the potential to undermine these broad aims.

In Scotland, the best example is current policy on free tuition fees in Universities which, in the absence of redistributive fiscal policy, and the presence of an attainment gap, reinforces inequalities in education three-fold. The first relates to the reduced likelihood of University attendance in school leavers from a deprived background. Lower educational attainment is linked strongly to poverty, and Scotland exhibits a significant gap in attainment in key areas.

Second, as Riddell et al argue, funding inequalities are often masked by a ‘universal’ approach in which higher education is free to eligible Scottish students. Yet, the absence of tuition fees benefits the middle classes disproportionately, while the debt burden is higher on poorer students. The maintenance of University funding also seems to come at the expense of the college places more likely to be filled by students from lower income backgrounds.

Third, there is a famous description of education spending by James Heckman, who argues that spending on early intervention and pre-school education is far more effective in reducing inequalities than spending on schools and universities (an argument that seems to be accepted by the Scottish Government). So, although the Scottish Government has made a commitment to extend funding on pre-school provision and early intervention programmes, these efforts at ‘transformational’ change compete with resources to maintain University funding.

Is there much money available for attainment and early intervention?

The new agenda on abolishing the attainment gap in schools has the potential to address only one of these issues, and it is potentially undermined by the high financial costs of the commitment to maintain other policies such as free tuition fees. Further, most of the real rise in education spending since devolution – e.g. 46% from 2000-11 – relates primarily to a combination of a new teacher contract and a commitment to a target of 53000 teachers, in part to further related targets such as on reduced primary school class sizes (Cairney and McGarvey, 2013: 229). In the past, when challenged on the value for money of such initiatives (in the early to mid-2000s), the then First Minister Jack McConnell defended the policy as a way to aid industrial relations and overall education attainment without identifying progress on inequalities in attainment (Cairney, 2011: 194). These policies continue (and take up most education resources) at the same time as new initiatives on inequalities.

Overall, I expect that we will look back on this one speech – on the ‘moral challenge’ to ‘close the attainment gap completely’ – as an outlier. It is an aim that sounds impressive as a rhetorical device, but it is not backed up by a coherent set of public policies designed to fulfil that end (at least in my lifetime).

 

 

Case studies: prevention and early intervention to address austerity and inequality #POLU9SP

This is the first of three posts which use case studies of cross-cutting and specific policy areas to add more depth to our discussion of Scottish politics and policymaking.

We begin with a broad focus on ‘prevention’ policy for 4 reasons:

1. It is a major Scottish Government priority, to use ‘prevention’ and ‘early intervention’ to reduce socioeconomic inequalities and/ or public service costs.
2. It is an integral part of the ‘Scottish approach to policymaking’, with a strong emphasis on the changes to joined-up national government and partnerships in local government.
3. It highlights multi-level policymaking and key overlaps in Scottish and UK Government responsibilities.
4. We can compare the Scottish Government’s initial statement – committing itself to a ‘decisive shit to prevention’ – to actual outcomes.

But what is prevention policy?

Broadly, prevention and ‘preventative spending’ describe a range of policies designed to intervene as early as possible in people’s lives to improve their wellbeing and reduce demand for acute or reactive public services. The argument is that too much government spending is devoted to services to address severe social problems at a late stage. The aim is for governments to address a wide range of longstanding problems – including crime and anti-social behaviour, ill health and unhealthy behaviour, low educational attainment, and unemployment – by addressing them at source, before they become too severe and relatively expensive.

Prevention policy is described periodically as the solution to three major crises in politics.

1. If we don’t make fundamental changes to the way we fund and deliver services they will go bust.

Prevention symbolises the desire to shift from expensive demand-led reactive services – such as acute care hospitals, jails, and police and social work interventions for ‘troubled families’ – towards intervening as early as possible in people’s lives to improve their life chances and reduce their reliance on the state. The classic intervention may be a public health policy to encourage healthy behaviour, or an early intervention programme to improve the life chances of teenage mothers and their children, but prevention is broad enough to include a campaign to reduce falls among older people, aimed at keeping people out of NHS beds.

2. Prevention policies can reduce major inequalities within society.

The broad aim is to address the ‘root causes’ of social problems – such as poverty, social exclusion, and poor accommodation – while specific projects focus on early interventions, such as pre-school provision and parenting programmes, to address major gaps in key indicators, such as education attainment, that can be identified from a young age.

3. Prevention is a solution to modern crises of government.

A prevention philosophy goes hand in hand with a governance philosophy which identifies the failures of top-down centralist government. The general rhetoric is about policy failure when governments try to do things to you, in favour of making policy with you. It comes with a commitment to: ‘holistic’ government in which we foster cooperation between, and secure a common aim for, departments, public bodies and stakeholders; ‘localism’, or fostering the capacity of local communities to tailor national policies to their areas;  tailoring public services to their users, encouraging a focus on the ‘assets’ of individuals, and inviting users to participate and ‘co-produce’ their services; a shift from simplistic short term targets and performance management towards meaningful long term outcomes-based measures of policy success and population wellbeing; as well as some reliance on ‘evidence based policy making’ to identify which interventions produce the most benefit and deserve investment.

How does prevention relate to the ‘Scottish approach’?

In other words, prevention policies generally combine specific ‘interventions’ with the broad governance principles, including ‘localism’ and the inclusion of users in the design of public services, that we discussed in relation to the ‘Scottish approach’ (but which is also pursued, in different ways, by the UK government). For example, the Scottish Government pursues prevention policies primarily via Community Planning Partnerships and the Single Outcome Agreements produced largely by local authorities.

Have a look again at the descriptions of the Scottish approach by Elvidge and Housden (including Elvidge’s belief that ‘traditional policy and operational solutions’ based on a ‘target driven approach’ would not produce the major changes in policy and policymaking required to address major problems such as inequalities).

What aspects of ‘prevention’ does the Scottish Government control?

The UK government controls monetary and fiscal policies, largely determining the budget used by the Scottish Government to spend and invest, and limiting its ability to redistribute income to address economic inequalities. It controls most aspects of social security, including the ability to address inequalities through direct payments, and determine the rules relating to benefits and unemployment.

Therefore, although the Scottish Government has primary responsibility for most areas of delivery relevant to prevention – such as health, education, housing, local government, and criminal justice – as well as some aspects of economic regeneration and employability, it does not have the responsibility to ‘join up’ taxation, social security, and the delivery of public services. For example, its ability to address health and education inequalities by using taxation policies to address income inequalities is very limited (even after proposed changes in the Scotland Acts of 2012 and 2016). It could not reform the benefits system to supplement its powers to influence ‘employability’ policy, or emulate the UK Government’s attempts to pass on social security savings to the local authorities implementing its ‘troubled families’ programme.

How does it fit in with the bigger picture of policy change since devolution?

Although the Scottish Government referred rarely to ‘prevention’ before 2010, it identified several ways to address inequalities. From 1999, it began to address ‘social inclusion’, which ‘become a shorthand label to refer to individuals alienated from economic, political, and social processes due to circumstances such as unemployment, poor skills, low incomes, poor neighbourhoods, bad health and lack of access to childcare’ (McGarvey and Cairney, 2008: 211). The most direct responses, to encourage employability or provide social security benefits, were UK responsibilities, and the Scottish Government relied on UK Government’s policies such as ‘welfare to work, the minimum wage and the Working Families Tax Credit’ (2008: 211).

The Scottish Government’s main response was to address disadvantages by focusing on economic regeneration in specific geographical areas, and reducing ‘unequal access to services such as education, health and housing’ (2008: 210). Its approach to governance reflected a developing ‘Scottish approach’, with an emphasis on social inclusion as a cross-departmental theme and the development of ‘Social Inclusion Partnerships’ (SIPs) which resembled CPPs (2008: 211).

Yet, overall, Scottish social inclusion policy did not differ markedly from the UK Government’s ‘social exclusion’ initiatives, and both governments have continued to promote concepts such as community and individual resilience rather than push for redistributive policies to address exclusion.

Further, the Scottish Government shared with the UK Government a tendency to focus on high profile issues or policies designed to improve outcomes overall without necessarily reducing inequalities of outcome (see the next two lectures/ posts on health and education).

Is there an implementation gap? Or, how do outcomes relate to initial expectations?

Until policymakers make sense of prevention, and turn it into a series of specific policies, it remains little more than an idiom – ‘prevention is better than cure’ – with little effect on government policy.

Although it is probably too early to detect an implementation gap associated with the ‘decisive shift’ in 2011, we can identify the great potential for unfulfilled expectations  based on the lack of progress associated with previous efforts. For example, the Christie Commission, which set the Scottish Government’s new prevention agenda in 2011, stated that:

on most key measures social and economic inequalities have remained unchanged or become more pronounced … This country is a paradoxical tapestry of rich resources, inventive humanity, gross inequalities, and persistent levels of poor health and deprivation … In education, the gap between the bottom 20 per cent and the average in learning outcomes has not changed at all since devolution. At the same time, the gap in healthy life expectancy between the 20 per cent most deprived and the 20 per cent least deprived areas has increased from 8 to 13.5 years and the percentage of life lived with poor health has increased from 12 to 15 per cent since devolution. The link between deprivation and the likelihood of being a victim of crime has also become stronger.

However, note the ‘bottom up’ element to this new agenda: does it make sense to identify the top-down idea of an implementation gap, when the Scottish Government is so keen to set a broad strategy and delegate policymaking responsibility? For me, this is a fascinating dilemma for governments: how to they ‘let go’ of policymaking and make sure that their broad aims are met in a meaningful way?

We can explore these issues in more depth in the next two posts which focus on two of the most devolved policy areas: health and education.

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

 

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…

View original post 1,421 more words

What can be done about the UK’s ‘glass floor’?

New research on the ‘glass floor’ presents a striking way to understand socioeconomic inequality in the UK. It also highlights ever-present problems in translating such information into policy: we understand the size of the problem well, speculate on its cause badly, and produce vague calls for government action ineffectively. Our initial shock and enthusiasm for policy change translates into disenchantment with yet another ‘too difficult’ problem.

The UK Government’s Social Mobility and Child Poverty Commission has released new research on the life chances of the British population. It identifies a “’glass floor’ in British society” to reject the idea that people get on in life through hard work and merit. Instead, mediocre and lazy children in the right family will do better than bright and hardworking children in the wrong family.

This is horrible paraphrasing of the report, but you get the idea about how most people might notice the report in a hurry, have their beliefs about the lack of a British meritocracy reinforced, then complain that the government is doing enough about it. There wasn’t quite a public outcry (far from it), but you might be forgiven for thinking that the report gives the government plenty of reason to do something. The big question is: will it do anything new with the information?

I wouldn’t rule it out, but would exercise this note of caution: reports like this don’t speak for themselves or give governments a clear impetus to act. Instead, they form part of a larger pattern in this area (of socio-economic inequalities policy), in which we can speak with much more certainty about the size of the problem than (a) its cause, (b) how we should respond, and (c) who exactly should respond.

The size of the problem

The size of the problem is quantified well (it’s not a simple task to measure cognitive ability, class backgrounds and life chances like this) and easy to understand. For example, the commission’s press release states that:

‘Less able, better-off kids are 35% more likely to become high earners than bright poor kids … children from more advantaged social backgrounds who are assessed at age 5 as having low cognitive ability are nonetheless significantly more likely to become high earners than their high ability peers in lower income households. Children from high income backgrounds who show signs of low academic ability at age 5 are 35% more likely to be high earners as adults than children from poorer families who show early signs of high ability’.

The cause of the problem

This is when things get a bit trickier, because although the chair of the commission, Alan Milburn, describes ‘a social scandal that all too often demography is still destiny in Britain’, the commission is not entirely clear on who or what caused it. There is not one simple message about a single villain. Instead, there are at least two, and both stories are not crystal clear.

First, the author of the report, Dr Abigail McKnight, links the outcomes to the behaviour of certain parents:

“The fact that middle class families are successful in hoarding the best opportunities in the education system and in the labour market is a real barrier to the upward social mobility of less advantaged children.”

The keyword there is ‘hoarding’, which suggests inappropriately selfish behaviour. Yet, the chair of the commission, Alan Milburn, is keen not to blame parents: ‘No one should criticise parents for doing their best for their children. That’s what we all want’.

Instead, Milburn sort of blames the government for its current lack of proportionate action: ‘The government should make its core mission the levelling of the playing field so that every child in the country has an equal opportunity to go as far as their abilities can take them’.

The result is a mixed view about the cause of the problem – perhaps it’s the fault of some hoarding parents (the especially rich ones sending their kids to private schools, getting tutors and securing internships for their children) and not so much others (the ones using their own skills to secure a spot for their child in a good state school) – and maybe the solution is to give other parents some of these skills to ‘level the playing field’ a bit.

The realistic solution

This is when things get even trickier, because the report seems to call for the government to do far more than it will, while giving it the ability to say that it is already doing as much as it should.

In the ‘far more than it will’ column is the call to reduce socio-economic inequalities (through wealth and income redistribution?), remove differences in quality between schools, and remove class-based barriers to University admissions.

In the ‘sort of doing it already’ column is the call for the state to intervene early in people’s lives to, in effect, train disadvantaged parents in how to give their children things like ‘soft skills’ related to forming networks and spotting opportunities.

The ultimate complication

The final, and perhaps trickiest, obstacle is about working out who is in charge of taking the next step, to drive this new policy agenda forward. The final paragraph of the main report is instructive:

‘If politicians are serious about their expressed desire to increase social mobility in the UK they will need to address barriers that are preventing less advantaged children from reaching their full potential and remove barriers that block downward mobility’.

It doesn’t say who the politicians are – perhaps for good reason. In areas such as social and economic inequality, it is increasingly difficult to know who is responsible for policy progress. If it’s mainly about economic redistribution, you can call for action from central government – but, let’s be honest, this won’t get you very far. If it’s mainly about training and encouraging ‘soft skills’ like ‘resilience’, central government might produce a broad strategy document, but its localism agenda suggests that it expects local public bodies to take responsibility for social outcomes.

The overall message is that it takes us seconds to understand the problem and call for government action, but a lot longer to decide what we want them to do, and longer still to find the people likely to do it. By that time, our attention will probably have shifted elsewhere, until the next report comes out and we do it all over again. Maybe this time will be different.

 

 

 

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

Many of us may have a broad idea about how to make good, ‘progressive’, social policy. Or, we might find a lot of agreement on a collection of (albeit often-vague) terms to describe a philosophy of policy and policymaking.

This may relate to a drive to reduce inequalities, and perhaps the costs of public services, by getting to the ‘root cause’ of problems, or encouraging a focus on the ‘assets’ of individuals, encouraging people to participate and ‘co-produce’ their public services, and developing the ability of local communities to tailor national policies to their areas.

In some cases we might focus on the idea of ‘wellbeing’, to develop meaningful outcomes-based (and generally non-monetary) measures of improvement, or ‘early intervention’ and ‘prevention’, in which we address the root causes of problems by tailoring public service interventions to meet needs at the earliest point of a person’s life, rather than addressing problems as they become acute. Some of this policy may be universal, but we might also recognise that some people can be usefully targeted as ‘higher risk’ or in greater need of support.

We might also focus on the importance of employment and economic activity, as a key part of a drive to improve people’s mental health or wellbeing by encouraging them to participate (when possible) in society and develop meaningful social networks.

So far, so good. At this level of generality, this collection of ideas might generate cross party support. For those on the ‘left’, it offers a sense of social justice and reduction of inequalities. For those on the ‘right’, it offers the potential to reduce public service costs and shrink some parts of the state.

Yet, this agreement is often illusory, with the potential to break down dramatically when people turn a broad agenda into concrete policies and draw on additional ideas about, for example, the types of groups that deserve the state’s ‘benefits and burdens’.

There is an episode of The Simpsons which sums up this potential (albeit it’s totally made up and the example is to do with environmentalism): Lisa Simpson and Monty Burns agree on the nature of the problem, and both seem to be well intentioned, but they come up with fantastically different ideas about the practical solution (and how we should treat other animals).

To a large extent, this similarity and difference can be found in the mix of UK and Scottish Government policy and policymaking. If you look at key documents, they now talk in an almost-identical language, focusing on root causes, inequalities, public health, parity between mental and physical health, the importance of employability and employment, the assets-base of individuals, co-production, early intervention, the benefits of localism over central direction, and the need for central government to share policymaking responsibility with local government, public bodies, and a wide range of actors in the third and private sector. They are both making choices that often raise profound questions about the ethics of state intervention into the lives of individuals and families. They also both make the right ‘noises’ about the benefits and risks of state intervention, and this kind of language would, I think, be welcomed broadly across the public sector and in social policy circles.

Yet, what comes next is a different matter. The Scottish Government has cultivated a reputation for taking the Lisa Simpson approach, generating a sense of benevolent state intervention and making sure that its interventions receive fairly wide ‘ownership’ in key parts of the public sector – albeit while generating some dissent in key issues, such as on public health measures (most notably, a minimum unit price of alcohol) and the state guardianship of children (most notably, the idea of a ‘named’ person for each Scottish child). a regular feature of interviews with England-based interviewees is that they look fondly to Scotland and its social policies.

The UK Government, on the other hand, often looks like the Monty Burns character, by producing controversial policies on, for example, major welfare retrenchment, reducing entitlement to benefits related to unemployment, particularly for people with recognised disabilities (but based in part on the importance of employment to wellbeing) and a Troubled Families programme which is often described as punitive and stigmatising (but based in part on the principle of early intervention and the identification of the root causes of social problems).

In other words, the same basic principles can be used in a way that produces profoundly different policies.

Part of our current work is to try to explain why those differences in policy and policymaking, by the UK and Scottish Governments, might arise, and what their effects may be. It is too simple to state that the differences relate to the political parties in office: the SNP in Scotland and the Conservatives in the UK, largely because we are talking about long term trends that transcend parties. Other possible explanations include:

• Their division of responsibilities. The UK Government still has responsibility for hot button issues such as welfare reform and employment. It still takes the ‘hard choices’ that tend to divide people politically, and produce highly visible winners and losers.
• Their consultation and ‘governance’ processes. The Scottish Government has a reputation for inclusive and consensual policymaking (between governments and interest groups), which could relate generally to a policymaking ‘culture’ but does relate specifically to the scale of its task (its responsibilities are limited, and it is small enough for policymakers to form often-meaningful personal relationships with participants). It also has a reputation for a ‘governance’ style that values partnership with the public sector, and a relatively high acceptance of long term measures of success, compared to the UK Government which often combines a focus on ‘localism’ with short term targets and performance management to maintain central control and accountability.
• The broader ways in which they characterise and treat ‘target populations’. We should resist the tendency to think that, in terms of political culture, Scotland is the home to left wing social democracy while England is increasingly right wing, intolerant and small state. The social attitudes surveys do not support this dichotomy of image. Yet, if we can detect a level of political competition based on these broad categories (in other words, Scottish parties may be more likely to compete using ‘left wing’ language), we might identify a tendency by their respective governments to articulate the same broad policies in very different ways.

With Emily St Denny, I am looking at these issues in a number of ways, albeit focusing primarily on the study of Scotland as part of the broader work of the Centre on Constitutional Change, and I can provide further links to these studies as we go along. Current examples include:

• Our earlier work on defining ‘prevention’ and ‘early intervention’
• My current paper on mental health policy