Lessons from policy theories for the pursuit of equity in health, education and gender policy

By Paul Cairney, Emily St.Denny, Sean Kippin, Heather Mitchell

This post first appeared on the Policy & Politics blog. It summarizes an article published in Policy & Politics.

Could policy theories help to understand and facilitate the pursuit of equity (or reduction of unfair inequalities)?

We are producing a series of literature reviews to help answer that question, beginning with the study of equity policy and policymaking in health, education, and gender research.

Each field has a broadly similar focus.  Most equity researchers challenge the ‘neoliberal’ approaches to policy that favour low state action in favour of individual responsibility and market forces.   They seek ‘social justice’ approaches, favouring far greater state intervention to address the social and economic causes of unfair inequalities, via redistributive or regulatory measures. They seek policymaking reforms to reflect the fact that most determinants of inequalities are not contained to one policy sector and cannot be solved in policy ‘silos’. Rather, equity policy initiatives should be mainstreamed via collaboration across (and outside of) government. Each field also projects a profound sense of disenchantment with limited progress, including a tendency to describe a too-large gap between their aspirations and actual policy outcomes. They describe high certainty about what needs to happen, but low confidence that equity advocates have the means to achieve it (or to persuade powerful politicians to change course).

Policy theories could offer some practical insights for equity research, but not always offer the lessons that some advocates seek. In particular, health equity researchers seek to translate insights on policy processes into a playbook for action, such as to frame policy problems to generate more attention to inequalities, secure high-level commitment to radical change, and improve the coherence of cross-cutting policy measures. Yet, policy theories are more likely to identify the dominance of unhelpful policy frames, the rarity of radical change, and the strong rationale for uncoordinated policymaking across a large number of venues. Rather than fostering technical fixes with a playbook, they encourage more engagement with the inescapable dilemmas and trade-offs inherent to policy choice. This focus on contestation (such as when defining and addressing policy problems) is more of a feature of education and gender equity research.

While we ask what policy theories have to offer other disciplines, in fact the most useful lessons emerge from cross-disciplinary insights. They highlight two very different approaches to transformational political change. One offers the attractive but misleading option of radical change through non-radical action, by mainstreaming equity initiatives into current arrangements and using a toolbox to make continuous progress. Yet, each review highlights a tendency for radical aims to be co-opted and often used to bolster the rules and practices that protect the status quo. The other offers radical change through overtly political action, fostering continuous contestation to keep the issue high on the policy agenda and challenge co-option. There is no clear step-by-step playbook for this option, since political action in complex policymaking systems is necessarily uncertain and often unrewarding. Still, insights from policy theories and equity research shows that grappling with these challenges is inescapable.

Ultimately, we conclude that advocates of profound social transformation are wasting each other’s time if they seek short-cuts and technical fixes to enduring political problems. Supporters of policy equity should be cautious about any attempt to turn a transformational political project into a technical process containing a ‘toolbox’ or ‘playbook’.

You can read the original research in Policy & Politics:

Paul Cairney, Emily St.Denny, Sean Kippin, and Heather Mitchell (2022) ‘Lessons from policy theories for the pursuit of equity in health, education, and gender policy’, Policy and Politics https://doi.org/10.1332/030557321X16487239616498

This article is an output of the IMAJINE project, which focuses on addressing inequalities across Europe.

The future of public health policymaking after COVID-19: lessons from Health in All Policies

Behold Paul’s attempt to make our faces the same size

Paul Cairney, Emily St Denny, Heather Mitchell 

This post summarises new research on the health equity strategy Health in All Policies. As our previous post suggests, it is common to hope that a major event will create a ‘window of opportunity’ for such strategies to flourish, but the current COVID-19 experience suggests otherwise. If so, what do HIAP studies tell us about how to respond, and do they offer any hope for future strategies? The full report is on Open Research Europe, accompanied by a brief interview on its contribution to the Horizon 2020 project – IMAJINE – on spatial justice.

COVID-19 should have prompted governments to treat health improvement as fundamental to public policy

Many had made strong rhetorical commitments to public health strategies focused on preventing a pandemic of non-communicable diseases (NCDs). To do so, they would address the ‘social determinants’ of health and health inequalities, defined by the WHO as ‘the unfair and avoidable differences in health status’ that are ‘shaped by the distribution of money, power and resources’ and ‘the conditions in which people are born, grow, live, work and age’.

COVID-19 reinforces the impact of the social determinants of health. Health inequalities result from factors such as income and social and environmental conditions, which influence people’s ability to protect and improve their health. COVID-19 had a visibly disproportionate impact on people with (a) underlying health conditions associated with NCDs, and (b) less ability to live and work safely.

Yet, the opposite happened. The COVID-19 response side-lined health improvement

Health departments postponed health improvement strategies and moved resources to health protection.

This experience shows that the evidence does not speak for itself

The evidence on social determinants is clear to public health specialists, but the idea of social determinants is less well known or convincing to policymakers.

It also challenges the idea that the logic of health improvement is irresistible

Health in All Policies (HIAP) is the main vehicle for health improvement policymaking, underpinned by: a commitment to health equity by addressing the social determinants of health; the recognition that the most useful health policies are not controlled by health departments; the need for collaboration across (and outside) government; and, the search for high level political commitment to health improvement.

Its logic is undeniable to HIAP advocates, but not policymakers. A government’s public commitment to HIAP does not lead inevitably to the roll-out of a fully-formed HIAP model. There is a major gap between the idea of HIAP and its implementation. It is difficult to generate HIAP momentum, and it can be lost at any time.

Instead, we need to generate more realistic lessons from health improvement and promotion policy

However, most HIAP research does not provide these lessons. Most HIAP research combines:

1. functional logic (here is what we need)
2. programme logic (here is what we think we need to do to achieve it), and
3. hope.

Policy theory-informed empirical studies of policymaking could help produce a more realistic agenda, but very few HIAP studies seem to exploit their insights.

To that end, this review identifies lessons from studies of HIAP and policymaking

It summarises a systematic qualitative review of HIAP research. It includes 113 articles (2011-2020) that refer to policymaking theories or concepts while discussing HIAP.

We produced these conclusions from pre-COVID-19 studies of HIAP and policymaking, but our new policymaking context – and its ironic impact on HIAP – is impossible to ignore.

It suggests that HIAP advocates produced a 7-point playbook for the wrong game

The seven most common pieces of advice add up to a plausible but incomplete strategy:

1. adopt a HIAP model and toolkit
2. raise HIAP awareness and support in government
3. seek win-win solutions with partners
4. avoid the perception of ‘health imperialism’ when fostering intersectoral action
5. find HIAP policy champions and entrepreneurs
6. use HIAP to support the use of health impact assessments (HIAs)
7. challenge the traditional cost-benefit analysis approach to valuing HIAP.

Yet, two emerging pieces of advice highlight the limits to the current playbook and the search for its replacement:

1. treat HIAP as a continuous commitment to collaboration and health equity, not a uniform model; and,
2. address the contradictions between HIAP aims.

As a result, most country studies report a major, unexpected, and disappointing gap between HIAP commitment and actual outcomes

These general findings are apparent in almost all relevant studies. They stand out in the ‘best case’ examples where: (a) there is high political commitment and strategic action (such as South Australia), or (b) political and economic conditions are conducive to HIAP (such as Nordic countries).

These studies show that the HIAP playbook has unanticipated results, such as when the win-win strategy leads to  HIAP advocates giving ground but receiving little in return.

HIAP strategies to challenge the status quo are also overshadowed by more important factors, including (a) a far higher commitment to existing healthcare policies and the core business of government, and (b) state retrenchment. Additional studies of decentralised HIAP models find major gaps between (a) national strategic commitment (backed by national legislation) and (b) municipal government progress.

Some studies acknowledge the need to use policymaking research to produce new ways to encourage and evaluate HIAP success

Studies of South Australia situate HIAP in a complex policymaking system in which the link between policy activity and outcomes is not linear.  

Studies of Nordic HIAP show that a commitment to municipal responsibility and stakeholder collaboration rules out the adoption of a national uniform HIAP model.

However, most studies do not use policymaking research effectively or appropriately

Almost all HIAP studies only scratch the surface of policymaking research (while some try to synthesise its insights, but at the cost of clarity).

Most HIAP studies use policy theories to:

1. produce practical advice (such as to learn from ‘policy entrepreneurs’), or
2. supplement their programme logic (to describe what they think causes policy change and better health outcomes).

Most policy theories were not designed for this purpose.

Policymaking research helps primarily to explain the HIAP ‘implementation gap’

Its main lesson is that policy outcomes are beyond the control of policymakers and HIAP advocates. This explanation does not show how to close implementation gaps.

Its practical lessons come from critical reflection on dilemmas and politics, not the reinvention of a playbook

It prompts advocates to:

• Treat HIAP as a political project, not a technical exercise or puzzle to be solved.
• Re-examine the likely impact of a focus on intersectoral action and collaboration, to recognise the impact of imbalances of power and the logic of policy specialisation.
• Revisit the meaning-in-practice of the vague aims that they take for granted without explaining, such as co-production, policy learning, and organisational learning.
• Engage with key trade-offs, such as between a desire for uniform outcomes (to produce health equity) but acceptance of major variations in HIAP policy and policymaking.
• Avoid reinventing phrases or strategies when facing obstacles to health improvement.

We describe these points in more detail here:

Our Open Research Europe article (peer reviewed) The future of public health policymaking… (europa.eu)

Paul summarises the key points as part of a HIAP panel: Health in All Policies in times of COVID-19

ORE blog on the wider context of this work: forthcoming

Case studies: healthcare, public health, mental health #POLU9SP

This is the second 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.

Most aspects of health policy have been devolved since 1999, and many were devolved before 1999, so we can generate a relatively long term picture of policy change/ divergence in three key areas: healthcare, mental health, and public health. We can then revisit the idea of prevention and inequalities raised in the first lecture.

Healthcare

The NHS has always been a little bit different in Scotland, which enjoyed administrative devolution – through the Scottish Office (a UK Government Department) – before 1999 and maintained its own links with professional groups.

Scotland has traditionally trained a disproportionate number of UK doctors and maintained an unusually high presence of Royal Colleges. This greater medical presence boosted the Scottish Office’s policymaking image as ‘professionalised’, or more likely to pursue policies favoured by the medical profession than the UK’s Department of Health. For example, it appeared to be less supportive of reforms based on the ‘marketisation’ of the NHS.

Devolution turbo boosted this sense of Scottish policy difference (see the Greer and Jarman discussion).

For example, while the UK Labour Government furthered the ‘internal market’ established by its Conservative predecessors, the Labour-led Scottish Government seemed to dismantle it (for example, there are no Foundation hospitals). It also bought (and effectively renationalised) a private hospital, which had a symbolic importance way above its practical effect.

Since 2007, the SNP-led Scottish Government – often supported publicly by UK-wide groups such as the British Medical Association (and nursing and allied health professions) – has gone big on this difference between Scottish and UK Government policies, criticising the marketization of the NHS in England and expressing, at every opportunity, the desire to maintain the sort of NHS portrayed by Danny Boyle at the Olympics opening ceremony.

This broad approach is generally supported, at least implicitly, by the important political parties in Scotland (the SNP is competing with a centre-left Labour Party and the Conservatives are less important). It is also supported by a medical profession and a public that, in practice, tends to be more committed to the NHS (in other words, opinion polls may not always show a stark difference in attitudes, but there is not the same fear in Scotland, as in the South-East of England, that doctors and patients might defect to the private sector if the NHS is not up to scratch).

Public health

Scotland won the race to ban smoking in public places and is currently trying to introduce a minimum unit price for alcohol. It has also placed particular emphasis on the wider determinants of health and made the right noises about the balance between public health and acute care. However, there are also major similarities in Scottish and UK Government approaches. For example, the UK tops the European league table on comprehensive tobacco control (and England/ Wales beat Scotland to ban smoking in cars with children).

Mental health

To some extent, early Scottish Governments developed an international reputation for innovation in some areas relating to wellbeing. It also reformed mental health and capacity legislation in a relatively quick and smooth way – at least compared to the UK Labour Government, which had a major stand-off with virtually all mental health advocacy groups on psychiatric-based reforms. Part of the difference relates to the size of Scotland and its government’s responsibilities which can produce a distinctive policy style; it often has the ability to coordinate cross-cutting policy, in consultation with stakeholders, in a more personal way. However, this is a field in which there tend to be often-similar policies beyond the Sun-style headlines.

The bigger picture of continuity: a tax funded service

These Scottish-UK differences should be seen in the context of a shared history and some major similarities. Both NHS systems are primarily tax-funded and free at the point of use, with the exception of some charges in England (which should not be exaggerated – for example, 89% of prescriptions in England are tax-funded). Both governments have sought to assure the public in similar ways by, for example, maintaining high profile targets on waiting times. Both systems face similar organisational pressures, such as the balance between a public demand for local hospitals and medical demand for centralised services. Both governments face similar demographic changes which put pressure on services. Both have similarly healthy (or unhealthy) populations.

The bigger picture of prevention and health inequality

Although the Scottish Government pursues an agenda on prevention to reduce service demand and health inequalities, many other policies based on the idea of universal provision have the potential to exacerbate inequalities.

For example, a real rise in spending (cash spending adjusted with the GDP deflator) on health policy of 68% from 2000-11 did not have a major effect on health inequalities (Cairney and McGarvey, 2013: 229). Instead, Scottish Governments tended to use the money in areas such as acute care to, for example, maintain high profile waiting list (non-emergency operations) and waiting times (A&E) targets which did not have a health inequalities component (Cairney, 2011: 177-9). It has also phased out several charges, such on prescriptions and eye tests, which increase spending without decreasing inequalities (particularly since the lowest paid already qualified for exemptions for charges).

It has pursued strongly a public health strategy geared, in part, towards reducing health inequalities, but with the same tendency as in the UK for healthcare to come first. This process includes interesting overlaps in aims and outcomes, such as in tobacco control where smoking is addressed strongly partly because it represents the single biggest element of health inequalities, but most initiatives do not necessarily reduce inequalities in smoking.

Further Reading

I discuss these issues in more depth in Scottish Politics and The Scottish Political System Since Devolution. See also this draft chapter on prevention and health policy by the Scottish and UK Governments

 

Vote Yes to Save the NHS?

Well, what do I know? I thought that the Yes campaign argument – independence is the only way to protect the Scottish NHS – wouldn’t gain much traction. Instead, it is getting a lot of attention, perhaps at the expense of the currency issue, and is described as this week’s ‘key battleground’ by the Guardian and BBC – partly because concern for the NHS appears to prompt a rise in support for Scottish independence. No campaigners have become increasingly agitated about this claim – I have read a gazillion tweets about NHS ‘lies’, and Malcolm Chisholm MSP describes the ‘the biggest lie of the Referendum campaign’ and ‘the biggest political lie of all my years in politics’.

So, what are the issues involved and what explains the direction of the debate so far?

I described this campaign as surprising because health policy has been devolved since 1999. Under devolution, over the last 15 years, the Scottish Government has been responsible for using a devolved budget that has generally been large, allowing it to develop or maintain distinctive health policies without much interference from the UK Government – including a rejection of the ‘internal market’ strategy pursued with great vigour in England.

Yet, in this ‘age of austerity’, things are beginning to change – allowing the Yes campaign to make three headline grabbing arguments:

1. The UK Government is cutting NHS spending in England, which has a knock-on effect for the Scottish budget via the Barnett formula.

2. The UK Government is pursuing a ‘privatisation’ agenda which, unless you vote Yes, the Scottish Government may be obliged to follow.

3. The right to free healthcare could be written into the constitution of an independent Scotland.

What brings these three arguments together is the idea that staying in the UK means sticking with the austerity agenda – with less money available for public services such as healthcare. The use of one or all of these arguments can be found in almost all of the Yes-friendly newspaper and social media messages so far, including by Lesely Riddoch, Humza Yousaf, Kate Higgins, and Dr Philippa Whitford.

For me, the argument seems exaggerated for three main reasons. First, since devolution, most UK Governments have been keen to boost or maintain funding for the NHS (during good times). In fact, the Scottish Government’s overall budget has risen markedly from 1999 (see the tables at the end).

Second, if there is a No vote, the Scottish Government will continue to spend a budget over which is has very high control. A change in the NHS budget for England does not mean a change in the NHS budget for Scotland. Rather, it affects the overall budget. Therefore, the big question is whether or not the overall Scottish Government budget would rise or fall after a Yes/ No vote. This is a much bigger question that goes beyond the NHS towards, for example, a discussion of Scotland’s fiscal policy, its share of UK debt, and its alternative ideas on austerity.

Third, so far, the ‘privatisation’ agenda in England relates to the use of the private sector to deliver services. The NHS remains tax funded and, in most cases, free at the point of delivery. Further, I can’t see a clear way in which the UK Government could oblige the Scottish Government to follow its lead.* On the contrary – 15 years of devolution has shown us that Scotland can go its own way within the UK.

If so, why does the NHS story have so much traction? Three reasons come to mind:

1. The image of the NHS is so positive and strong that it can prompt regular attention (perhaps more so than education and policing – similar Yes campaigns have received less attention so far). If you talk about privatisation, and the fate of the NHS under the Conservative Party, you can tap into fears about the loss of an institution that is cherished in Scotland (compare with John McTernan’s praise of competition).

2. The survey question, to demonstrate the impact of NHS concerns on a Yes vote, is a wee bit leading: Does the prospect of an increased role of the private sector in the NHS in England having an adverse effect on the Scottish budget which funds NHS Scotland make you likely or unlikely to vote for an independent Scotland in the referendum? Indeed, I am surprised that only 46% said that it made them likely to vote Yes (35% No, 18% undecided).

3. The UK Labour Party has picked a bad time to warn voters in England that the NHS is in crisis, and treated by the Conservative-led government as ‘another utility to be broken up and privatised’. It has prompted the Yes campaign to suggest that its concerns are shared by the most important party (in Scotland) involved in the No campaign*:

It was also a point made repeatedly by Cabinet Secretary Alex Neil in his Scottish Parliament statement on the 19th August. This comes at a time when the NHS in England is described regularly as in crisis or near ‘collapse’. For every one story suggesting that the NHS budget in Scotland continues to rise, you may find several arguing that the NHS budget in England has been ‘clawed back’ (e.g. here, here and here).

Overall, the ‘save our NHS’ message is simple and could yet be effective. Who knew?

*UPDATE. 9.9.14. One response to this post is that ‘privatisation’ may result from a forthcoming trade agreement between the US and EU –  the ‘Transatlantic Trade and Investment Partnership’, designed to allow EU companies  to compete in the US market, and vice versa. The prospect of TTIP has prompted a lot of attention to the potential for US companies to strong-arm their way into the NHS. The argument is strongest in the UK, with a relatively large market for private companies and tendered services. The argument goes that, if a government puts a service out to tender, private companies have the right to compete. Then, people argue that, if the NHS is not exempt, private companies have an assured place in the market – and can sue if they find any obstructions to their involvement in a free market. Then, the argument goes, if the UK does not exempt its NHS, Scotland cannot exempt its NHS (it is not the EU member state). This prompts the prospect of US companies suing to gain a share of the Scottish NHS market. From what I can tell, the argument is almost entirely speculative, based on little or no legal advice and little or no comparable experiences. It has also been rejected by European Commission’s chief negotiator.

Tables at the end

The first and third are from our book. The second is from the Scottish Government’s GERS. These tables are not ideal, but you get the general idea. Spending on the NHS still goes up every year on cash terms, and it has risen markedly in real terms since 1999. However, the Scottish budget has begun to fall in real terms.

*See also: Scottish Labour’s response

We can call Alex Neil a liar. He is lying about the NHS to scare Scotland. #indyref #sp4 pic.twitter.com/TEGmlMhB3i

— Scottish Labour (@ScottishLabour) August 19, 2014

Would Scottish Independence Save the NHS and Keep Education Free?

There have been two quite-surprising messages from the Yes campaign recently: independence is the only way to protect the Scottish NHS, and independence is the only way to keep Scottish compulsory education free. I say ‘surprising’ because both areas have been devolved since 1999 and the Scottish Government has developed or maintained distinctive policies without much interference from the UK Government. It is tempting to conclude that these arguments represent little more than the hype that campaigners feel they have to generate to get attention – and No campaigners have generally been dismissive of these claims. Beyond the hype, what is the argument in each case?

In health, there are two arguments. First, the UK Government is cutting (or will cut) NHS spending in England, which has a knock-on effect for the Scottish budget. The Scottish Government would either have to cut Scottish NHS spending or find the money from another service (as in higher education, if UK spending falls when it charges fees). Second, the UK Government is pursuing a ‘privatisation’ agenda, which is anathema in Scotland. Yet, so far, this relates largely to the use of the private sector to deliver services. The NHS remains tax funded and, in most cases, free at the point of delivery.

In education, the argument from Teachers for Yes seems to be: if you vote Yes, you can stop funding nuclear weapons and give education greater priority in the budget. This can be used to fund education directly – teachers, buildings, equipment – and indirectly, by reducing poverty and, therefore, reducing inequalities in education outcomes (or, for example, spending more on childcare and pre-school services). Independence would also give the opportunity to enshrine a right to education in a written constitution. The press release contrasts this vision with a UK future of austerity, with reduced spending on education in England having a knock-on effect on Scotland.

There is a more sophisticated case that could be made by the Yes campaign, which could go something like this:

• our priority is to reduce inequality
• at the heart of health and education inequality is income inequality
• only independence gives us the levers to introduce a more progressive tax and benefits system and reduce income inequality.
• This might be boosted by the desire of many to reduce spending on areas such as defence and, for some, to increase taxation.

Or, it could simply argue that everything is connected; that a tax and benefits system underpins all efforts to ‘join up’ the delivery and funding of public services. Some of that argument is in the Scottish Government’s White Paper.

However, I don’t think that the Yes campaign is making that sophisticated case. Or, at least, I haven’t yet seen it. Instead, the focus is on the idea that staying in the UK means sticking with the austerity agenda – and less money for public services such as health and education. What it doesn’t address is that the austerity agenda would be faced by an independent Scottish Government as much as a devolved one. What it doesn’t address is that, under devolution, the Scottish Government has been responsible for using a devolved budget that has generally been very large and has only now begun to shrink – and that, if UK austerity really does start to ‘bite’, a devolved Scottish Government will have some scope to borrow and tax to offset the effect (although I qualify that statement here). Consequently, it is too easy to dismiss. While it might have an effect on some voters inclined to vote Yes, it is also vulnerable to ridicule and could easily backfire.

See also: a discussion of the Barnett formula, which underpins a lot of this debate