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Using policy theories to interpret public health case studies: the example of a minimum unit price for alcohol

By James Nicholls and Paul Cairney, for the University of Stirling MPH and MPP programmes.

There are strong links between the study of public health and public policy. For example, public health scholars often draw on policy theories to help explain (often low amounts of) policy change to foster population health or reduce health inequalities. Studies include a general focus on public health strategies (such as HiAP) or specific policy instruments (such as a ban on smoking in public places). While public health scholars may seek to evaluate or influence policy, policy theories tend to focus on explaining processes and outcomes.

To demonstrate these links, we present:

  1. A long-read blog post to (a) use an initial description of a key alcohol policy instrument (minimum unit pricing, adopted by the Scottish Government but not the UK Government) to (b) describe the application of policy concepts and theories and reflect on the empirical and practical implications. We then added some examples of further reading.
  2. A 45 minute podcast to describe and explain these developments (click below or scroll to the end)

Minimum Unit Pricing in Scotland: background and development

Minimum Unit Pricing for alcohol was introduced in Scotland in 2018. In 2012, the UK Government had also announced plans to introduce MUP, but within a year dopped the policy following intense industry pressure. What do these two journeys tell us about policy processes?

When MUP was first proposed by Scottish Health Action on Alcohol Problems in 2007, it was a novel policy idea. Public health advocates had long argued that raising the price of alcohol could help tackle harmful consumption. However, conventional tax increases were not always passed onto consumers, so would not necessarily raise prices in the shops (and the Scottish Government did not have such taxation powers). MUP appeared to present a neat solution to this problem. It quickly became a prominent policy goal of public health advocates in Scotland and across the UK, while gaining increasing attention, and support, from the global alcohol policy community.

In 2008, the UK Minister for Health, Dawn Primarolo, had commissioned researchers at the University of Sheffield to look into links between alcohol pricing and harm. The Sheffield team developed economic models to analysis the predicted impact of different systems. MUP was included, and the ‘Sheffield Model’ would go on to play a decisive role in developing the case for the policy.

What problem would MUP help to solve?

Descriptions of the policy problem often differed in relation to each government. In the mid-2000s, alcohol harm had become a political problem for the UK government. Increasing consumption, alongside changes to the night-time economy, had started to gain widespread media attention. In 2004, just as a major liberalisation of the licensing system was underway in England, news stories began documenting the apparent horrors of ‘Binge Britain’: focusing on public drunkenness and disorder, but also growing rates of liver disease and alcohol-related hospital admissions.

In 2004, influential papers such as the Daily Mail began to target New Labour alcohol policy

Politicians began to respond, and the issue became especially useful for the Conservatives who were developing a narrative that Britain was ‘broken’ under New Labour. Labour’s liberalising reforms of alcohol licensing could conveniently be linked to this political framing. The newly formed Alcohol Health Alliance, a coalition set up under the leadership of Professor Sir Ian Gilmore, was also putting pressure on the UK Government to introduce stricter controls. In Scotland, while much of the debate on alcohol focused on crime and disorder, Scottish advocates were focused on framing the problem as one of public health. Emerging evidence showed that Scotland had dramatically higher rates of alcohol-related illness and death than the rest of Europe – a situation strikingly captured in a chart published in the Lancet.

Source: Leon, D. and McCambridge, J. (2006). Liver cirrhosis mortality rates in Britain from 1950 to 2002: an analysis of routine data. Lancet 367

The notion that Scotland faced an especially acute public health problem with alcohol was supported by key figures in the increasingly powerful Scottish National Party (in government since 2007), which, around this time, had developed working relationships with Alcohol Focus Scotland and other advocacy groups.

What happened next?

The SNP first announced that it would support MUP in 2008, but it did not implement this change until 2018. There are two key reasons for the delay:

  1. Its minority government did not achieve enough parliamentary support to pass legislation. It then formed a majority government in 2011, and its legislation to bring MUP into law was passed in 2012.  
  2. Court action took years to resolve. The alcohol industry, which is historically powerful in Scotland, was vehemently opposed. A coalition of industry bodies, led by the Scotch Whisky Association, took the Scottish Government to court in an attempt to prove the policy was illegal. Ultimately, this process would take years, and conclude in rulings by the European Court of Justice (2016), Scottish Court of Session Inner House (2016), and UK Supreme Court (2017) which found in favour of the Scottish Government.

In England, to the surprise of many people, the Coalition Government announced in March 2012 that it too would introduce MUP, specifically to reduce binge drinking and public disorder. This different framing was potentially problematic, however, since the available evidence suggested (and subsequent evaluation has confirmed) that MUP would have only a small impact on crime. Nonetheless, health advocates were happy,  with one stating that ‘I do not mind too much how it was framed. What I mind about is how it measures up’.

Once again, the alcohol industry swung into action, launching a campaign led by the Wine and Spirits Trade Association, asking ‘Why should moderate drinkers pay more?’

This public campaign was accompanied by intense behind-the-scenes lobbying, aided by the fact that the leadership of industry groups had close ties to Government and that the All-Party Parliamentary Group on Beer had the largest membership of any APPG in Westminster. The industry campaign made much of the fact there was little evidence to suggest MUP would reduce crime, but also argued strongly that the modelling produced by Sheffield University was not valid evidence in the first place. A year after the adopting the policy, the UK Government announced a U-turn and MUP was dropped.

How can we use policy theories and concepts to interpret these dynamics?

Here are some examples of using policy theories and concepts as a lens to interpret these developments.

1. What was the impact of evidence in the case for policy change?

While public health researchers often expect (or at least promote) ‘evidence based’ policymaking, insights from research identify three main reasons why policymakers do not make evidence-based choices:

First, many political actors (including policymakers) have many different ideas about what counts as good evidence.

The assessment, promotion, and use of evidence is highly contested, and never speaks for itself.

Second, policymakers have to ignore almost all evidence to make choices.

They address ‘bounded rationality’ by using two cognitive shortcuts: ‘rational’ measures set goals and identify trusted sources, while ‘irrational’ measures use gut instinct, emotions, and firmly held beliefs.

Third, policymakers do not control the policy process.

There is no centralised and orderly policy cycle. Rather, policymaking involves policymakers and influencers spread across many authoritative ‘venues’, with each venue having its own rules, networks, and ways of thinking.

In that context, policy theories identify the importance of contestation between policy actors, and describe the development of policy problems, and how evidence fits in. Approaches include:

The study of framing

The acceptability of a policy solution will often depend on how the problem is described. Policymakers use evidence to reduce uncertainty, or a lack of information around problems and how to solve them. However, politics is about exercising power to reduce ambiguity, or the ability to interpret the same problem in different ways.

By suggesting MUP would solve problems around crime, the UK Government made it easier for opponents to claim the policy wasn’t evidence-based. In Scotland, policymakers and advocates focused on health, where the evidence was stronger. In addition, the SNP’s approach fitted within a wider political independence frame, in which more autonomy meant more innovation.

The Narrative Policy Framework

Policy actors tell stories to appeal to the beliefs (or exploit the cognitive shortcuts) of their audiences. A narrative contains a setting (the policy problem), characters (such as the villain who caused it, or the victim of its effects), plot (e.g. a heroic journey to solve the problem), and moral (e.g. the solution to the problem).

Supporters of MUP tended to tell the story that there was an urgent public health  crisis, caused largely by the alcohol industry, and with many victims, but that higher alcohol prices pointed to one way out of this hole. Meanwhile opponents told the story of an overbearing ‘nanny state’, whose victims – ordinary, moderate drinkers – should be left alone by government.

Social Construction and Policy Design

Policymakers make strategic and emotional choices, to identify ‘good’ populations deserving of government help, and ‘bad’ populations deserving punishment or little help. These judgements inform policy design (government policies and practices) and provide positive or dispiriting signals to citizens.

For example, opponents of MUP rejected the idea that alcohol harms existed throughout the population. They focused instead on dividing the majority of moderate drinkers from irresponsible minority of binge drinkers, suggesting that MUP would harm the former more than help the latter.

Multi-centric policymaking

This competition to frame policy problems takes place in political systems that contain many ‘centres’, or venues for authoritative choice. Some diffusion of power is by choice, such as to share responsibilities with devolved and local governments. Some is by necessity, since policymakers can only pay attention to a small proportion of their responsibilities, and delegate the rest to unelected actors such as civil servants and public bodies (who often rely on interest groups to process policy).

For example, ‘alcohol policy’ is really a collection of instruments made or influenced by many bodies, including (until Brexit) European organisations deciding on the legality of MUP, UK and Scottish governments, as well as local governments responsible for alcohol licensing. In Scotland, this delegation of powers worked in favour of MUP, since Alcohol Focus Scotland were funded by the Scottish Government to help deliver some of their alcohol policy goals, and giving them more privileged access than would otherwise have been the case.

The role of evidence in MUP

In the case of MUP, similar evidence was available and communicated to policymakers, but used and interpreted differently, in different centres, by the politicians who favoured or opposed MUP.

In Scotland, the promotion, use of, and receptivity to research evidence – on the size of the problem and potential benefit of a new solution – played a key role in increasing political momentum. The forms of evidence were complimentary. The ‘hard’ science on a potentially effective solution seemed authoritative (although few understood the details), and was preceded by easily communicated and digested evidence on a concrete problem:

  1. There was compelling evidence of a public health problem put forward by a well-organised ‘advocacy coalition’ (see below) which focused clearly on health harms. In government, there was strong attention to this evidence, such as the Lancet chart which one civil servant described as ‘look[ing] like the north face of the Eiger’. There were also influential ‘champions’ in Government willing to frame action as supporting the national wellbeing.
  2. Reports from Sheffield University appeared to provide robust evidence that MUP could reduce harm, and advocacy was supported by research from Canada which suggested that similar policies there had been successful elsewhere.

Advocacy in England was also well-organised and influential, but was dealing with a larger – and less supportive – Government machine, and the dominant political frame for alcohol harms remained crime and disorder rather than health.

Debates on MUP modelling exemplify these differences in evidence communication and use. Those in favour appealed to econometric models, but sometimes simplifying their complexity and blurring the distinction between projected outcomes and proof of efficacy. Opponents went the other way and dismissed the modelling as mere speculation. What is striking is the extent to which an incredibly complex, and often poorly understand, set of econometric models – and the ’Sheffield Model’ in particular – came to occupy centre stage in a national policy debate. Katikireddi and colleagues talked about this as an example of evidence as rhetoric:

  1. Support became less about engagement with  the econometric modelling, and more an indicator of general concern about alcohol harm and the power of the industry.
  2. Scepticism was often viewed as the ‘industry position’, and an indicator of scepticism towards public health policy more broadly.

2. Who influences policy change?

Advocacy plays a key role in alcohol policy, with industry and other actors competing with public health groups to define and solve alcohol policy problems. It prompts our attention to policy networks, or the actors who make and influence policy.

According to the Advocacy Coalition Framework:

People engage in politics to turn their beliefs into policy. They form advocacy coalitions with people who share their beliefs, and compete with other coalitions. The action takes place within a subsystem devoted to a policy issue, and a wider policymaking process that provides constraints and opportunities to coalitions. Beliefs about how to interpret policy problems act as a glue to bind actors together within coalitions. If the policy issue is technical and humdrum, there may be room for routine cooperation. If the issue is highly charged, then people romanticise their own cause and demonise their opponents.

MUP became a highly charged focus of contestation between a coalition of public health advocates, who saw themselves as fighting for the wellbeing of the wider community (and who believed fundamentally that government had a duty to promote population health), and a coalition of industry actors who were defending their commercial interests, while depicting public health policies as illiberal and unfair.

3. Was there a ‘window of opportunity’ for MUP?

Policy theories – including Punctuated Equilibrium Theory – describe a tendency for policy change to be minor in most cases and major in few. Paradigmatic policy change is rare and may take place over decades, as in the case of UK tobacco control where many different policy instruments changed from the 1980s. Therefore, a major change in one instrument could represent a sea-change overall or a modest adjustment to the overall approach.

Multiple Streams Analysis is a popular way to describe the adoption of a new policy solution such as MUP. It describes disorderly policymaking, in which attention to a policy problem does not produce the inevitable development, implementation, and evaluation of solutions. Rather, these ‘stages’ should be seen as separate ‘streams’.  A ‘window of opportunity’ for policy change occurs when the three ‘streams’ come together:

  • Problem stream. There is high attention to one way to define a policy problem.
  • Policy stream. A technically and politically feasible solution already exists (and is often pushed by a ‘policy entrepreneur’ with the resources and networks to exploit opportunities).
  • Politics stream. Policymakers have the motive and opportunity to choose that solution.

However, these windows open and close, often quickly, and often without producing policy change.

This approach can help to interpret different developments in relation to Scottish and UK governments:

Problem stream

  • The Scottish Government paid high attention to public health crises, including the role of high alcohol consumption.
  • The UK government paid often-high attention to alcohol’s role in crime and anti-social behaviour (‘Binge Britain’ and ‘Broken Britain’)

Policy stream

  • In Scotland, MUP connected strongly to the dominant framing, offering a technically feasible solution that became politically feasible in 2011.
  • The UK Prime Minister David Cameron’s made a surprising bid to adopt MUP in 2012, but ministers were divided on its technical feasibility (to address the problem they described) and its political feasibility seemed to be more about distracting from other crises than public health.

Politics stream

  • The Scottish Government was highly motivated to adopt MUP. MUP was a flagship policy for the SNP; an opportunity to prove its independent credentials, and to be seen to address a national public health problem. It had the opportunity from 2011, then faced interest group opposition that delayed implementation.
  • The Coalition Government was ideologically more committed to defending commercial interests, and to framing alcohol harms as one of individual (rather than corporate) responsibility. It took less than a year for the alcohol industry to successfully push for a UK government U-turn.

As a result, MUP became policy (eventually) in Scotland, but the window closed (without resolution) in England.

Further Reading

Nicholls, J. and Greenaway, J. (2015) ‘What is the problem?: Evidence, politics and alcohol policy in England and Wales, 2010–2014’, Drugs: Education, Prevention and Policy 22.2  https://doi.org/10.3109/09687637.2014.993923

Butler, S., Elmeland, K., Nicholls, J. and Thom, B. (2017) Alcohol, power and public health: a comparative study of alcohol policy. Routledge.

Fitzgerald, N. and Angus, C. (2015) Four nations: how evidence–based are alcohol policies and programmes across the UK?

Holden, C. and Hawkins, B. (2013) ‘Whisky gloss’: the alcohol industry, devolution and policy communities in Scotland. Public Policy and Administration, 28(3), pp.253-273.

Paul Cairney and Donley Studlar (2014) ‘Public Health Policy in the United Kingdom: After the War on Tobacco, Is a War on Alcohol Brewing?’ World Medical and Health Policy6, 3, 308-323 PDF

Niamh Fitzgerald and Paul Cairney (2022) ‘National objectives, local policymaking: public health efforts to translate national legislation into local policy in Scottish alcohol licensing’, Evidence and Policyhttps://doi.org/10.1332/174426421X16397418342227PDF

Podcast

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Using policy theories to interpret public health case studies: the example of a minimum unit price for alcohol Understanding Public Policy (in 1000 and 500 words)

By James Nicholls and Paul Cairney, for the University of Stirling MPH and MPP programmes. There are strong links between the study of public health and public policy. For example, public health scholars often draw on policy theories to help explain (often low amounts of) policy change to foster population health or reduce health inequalities. Studies include a general focus on public health strategies (such as HiAP) or specific policy instruments (such as a ban on smoking in public places). While public health scholars may seek to evaluate or influence policy, policy theories tend to focus on explaining processes and outcomes,. To demonstrate these links, we present this podcast and blog post to (1) use an initial description of a key alcohol policy instrument (minimum unit pricing in Scotland) to (2) describe the application of policy concepts and theories and reflect on the empirical and practical implications.  Using policy theories to interpret public health case studies: the example of a minimum unit price for alcohol | Paul Cairney: Politics & Public Policy (wordpress.com)
  1. Using policy theories to interpret public health case studies: the example of a minimum unit price for alcohol
  2. Policy in 500 Words: policymaking environments and their consequences
  3. Policy in 500 Words: bounded rationality and its consequences
  4. Policy in 500 Words: evolutionary theory
  5. Policy in 500 Words: The Advocacy Coalition Framework

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Filed under 1000 words, 750 word policy analysis, agenda setting, alcohol, alcohol policy, podcast, Public health, public policy, Scottish politics, Social change, UK politics and policy

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

In policy studies, we talk about the rare occasions when some problems or policy solutions ‘take off’ suddenly or when an ‘idea’s time seems to come’. Indeed, one aim of Kingdon’s ‘multiple streams analysis’ is to show us that ideas come and go, only to be adopted if the time is right: when attention to a problem is high, a well-thought-out idea exists, and policymakers have the motive and opportunity to adopt it. Only then will policy change in a meaningful way.

If only life were so simple. Instead, look again at that word ‘idea’. It means at least two things: a specific policy solution to a clearly defined problem, or a potentially useful but vague way of thinking about a complex and perhaps intractable (or, at least, ‘wicked’) problem. If it is the latter, the ‘window of opportunity’ may not produce the sort of policy change we might expect. Instead, we may see a groundswell of attention to, and support for, a policy solution that is very difficult to ‘operationalise’. We may find that everyone agrees on the broad solution, but no-one agrees on the detail, and we spend years making very little progress.

This is the danger with several potential solutions which highlight the possibility of addressing: the fall-out from austerity and reduced budgets; the need to reduce demand for acute public services by addressing socio-economic problems at an early stage; the need to ‘join up’ a range of government responsibilities; and, a desire to move away from unhelpful short term targets towards more long term and meaningful measures of policy success. Several solutions are currently in good currency, including: the social investment model, the wellbeing agenda, prevention (or preventative spending) and early intervention.

In each case, there may be a window of opportunity to promote such solutions, but the following obstacles arise:

  • Each example represents an idea, or way of thinking about things like public expenditure, that could either underpin new ways of thinking within government, become faddish before being rejected, or provide a gloss to justify decisions already made.
  • If the former, it could take decades for this way of thinking to become ‘institutionalised’, turned into ‘standard operating procedures’ and detailed rules to coordinate action across the public sector (suggesting that it requires meaningful, sustained cross-party support).
  • During this time, governments will still face hard choices about which areas are worthy of the most investment. In each case, the aim is vague, the evidence is often weak, it is difficult to compare the return from investments in different public services, and the process has a tendency to revert to a political exercise to determine priorities. In the face of uncertainty, policymakers may revert to tried and trusted rules to make decisions, and reject the more risky, new approach, with uncertain measures and outcomes.
  • The budget process is, in many ways, separate from a focus on social investment, activity and outcomes – largely because it remains an exercise to guarantee spending on established services and departments, or to reduce spending on some services at the margins.
  • There is a level of unpredictability in politics that makes such long term investment problematic – particularly when investment in one area, with quiet winners, comes at the expense of another service, with vocal losers (as demonstrated by any move to close a local hospital, rural school or university department). A tension between long term central planning and short term electoral issues often produces incremental and non-strategic changes, in which services receive ‘disinvestment’ and are allowed to wither.

To some extent, these issues may be addressed well during regular interactions between governments and their ‘social partners’, such as when governments, business and unions get together to produce something akin to a framework in which other policy decisions are made. In that sense, group-government relations represent a form of ‘institutional memory’. Governments and politicians come and go, but group-government relations represent a sense of continuity. This could be the main way to keep social investment on government agendas, as a salient topic or, perhaps more powerfully, as a way of thinking that is taken for granted and questioned rarely, even when new parties enter office.

Yet, there are problems with this ‘corporatist’ aim if it refers to government-wide group-government relations, since policy networks tend to develop on a ‘sectoral and subsectoral’ scale. Governments tend to deal with complex government by breaking it down into manageable chunks. Consequently, for example, medical and teaching unions could engage as one of many trades unions in concert with business, but they tend to speak mostly to education and health departments, in areas with minimal union-business links. Further, such groups tend to be more concerned with the targets and priorities identified at sectoral levels. They may like the idea of soft targets and long term, more meaningful, outcome measures, but have to address short term targets; they may pay attention to cross-sectoral aims when they can, but focus most of their attention on particular fields and priorities specific to their work.

The Scottish Government case

The issues I described are not unique to one government. Yet, some governments also face distinctive problems. For example, in Scotland, as part of the UK, there are specific issues around the links between policy instruments, shared responsibility, and joined up thinking:

  • The Scottish Government remains part of a UK process in which monetary and fiscal policies are determined largely by the Treasury, with the Scottish Government’s primary role to spend and invest.
  • Its position raises awkward questions about the consistency of policies, when spending decisions based on a ‘universalism’ narrative cannot be linked directly to the idea that redistribution should be achieved through taxation. The Scottish Government may be overseeing a spending regime that favours the wealthy and middle classes (universal free services with no means testing) as long as taxation is not sufficiently redistributive.
  • These issues have not become acute since devolution, partly because the Scottish Government budget has been high, and the independence agenda has postponed some difficult debates on new budget priorities. However, they are likely to become more pressing as budgets fall and organisations compete for scarcer resources.

Current issues: more powers, more accountability?

These issues are important right now, because the Smith Commission is currently considering the devolution of further powers to the Scottish Parliament/ Government:

  • A focus on policies such as ‘prevention’ should prompt us to consider how to align priorities and powers. The parallel is with economic policy, in which a key concern relates to the alignment of fiscal powers with monetary union. With prevention, we should ask what’ more powers’ would be used for. For example, would the Scottish Government seek to address health and education inequalities by addressing income inequalities? If so, what powers could be devolved to address this issue without undermining that broader question of macroeconomic coherence?
  • A focus on shared powers raises new issues about accountability. As things stand, accountability is already a problem in relation to outcomes based measures and the devolution of policies to local public bodies. In a ‘Westminster’ style system, we are used to the idea of government accountability to the public via ministers accounting to Parliament, or directly via elections. Yet, if the responsibility for outcomes is further devolved, and outcomes measures span multiple elections, how can we hold governments to account in a meaningful way? Or, as importantly, if elected policymakers still feel bound by these short-term accountability mechanisms, how can we possibly expect them to commit to policies with short term costs, with pay-offs that may only begin to show fruit after they have retired from office?
  • These issues are further exacerbated by a shared powers model, in which we don’t know where UK government responsibility ends and Scottish Government responsibility begins.

This sort of discussion may prompt us to re-examine the idea of a ‘window of opportunity’ for change, at least when we are discussing vague solutions to complex problems. A window may produce a broad change in policymaker commitment to a policy solution, but that event may only represent the beginning of a long, drawn out process of policy change. We often talk about ‘policy entrepreneurs’ lying in wait to present their pet solutions when the time is right – but, in this case, ‘solution’ may be a rather misleading description of a broad agenda, in which everyone can agree on the aims, but not the objectives.

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Filed under ESRC Scottish Centre for Constitutional Change, Evidence Based Policymaking (EBPM), Public health, public policy, Scottish independence, Scottish politics, UK politics and policy