Tag Archives: Prevention

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):

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.


Leave a comment

Filed under Evidence Based Policymaking (EBPM), Prevention policy, Public health, public policy

The theory and practice of evidence-based policy transfer: can we learn how to reduce territorial inequalities?

I am now part of a large EU-funded Horizon2020 project called IMAJINE (Integrative Mechanisms for Addressing Spatial Justice and Territorial Inequalities in Europe), which begins in January 2017. It is led by Professor Michael Woods at Aberystwyth University and has a dozen partners across the EU. I’ll be leading one work package in partnership with Professor Michael Keating.


The aim in our ‘work package’ is deceptively simple: generate evidence to identify how EU countries try to reduce territorial inequalities, see who is the most successful, and recommend the transfer of that success to other countries.

Life is not that simple, though, is it?! If it were, we’d know for sure what ‘territorial inequalities’ are, what causes them, what governments are willing to do to reduce them, and if they’ll succeed if they really try.

Instead, here are some of the problems you encounter along the way, including an inability to identify:

  • What policies are designed explicitly to reduce inequalities. Instead, we piece together many intentions, actions, instruments, and outputs, in many levels and types of government, and call it ‘policy’.
  • The link between ‘policy’ and policy outcomes, because many factors interact to produce those outcomes.
  • Success. Even if we could solve the methodological problems, to separate cause and effect, we face a political problem about choosing measures to evaluate and report success.
  • Good ways to transfer successful policies. A policy is not like a #gbbo cake, in which you can produce a great product and give out the recipe. In that scenario, you can assume that we all have the same aims (we all want cake, and of course chocolate is the best), starting point (basically the same shops and kitchens), and language to describe the task (use loads of sugar and cocoa). In policy, governments describe and seek to solve similar-looking problems in very different ways and, if they look elsewhere for lessons, those insights have to be relevant to their context (and the evidence-gathering process has to fit their idea of good governance). They also ‘transfer’ some policies while maintaining their own, and a key finding from our previous work is that governments simultaneously pursue policies to reduce inequalities and undermine their inequality-reducing policies.

So, academics like me tend to spend their time highlighting problems, explaining why such processes are not ‘evidence-based’, and identifying all the things that will go wrong from your perspective if you think policymaking and policy transfer can ever be straightforward.

Yet, policymakers do not have this luxury to identify problems, find them interesting, then go home. Instead, they have to make decisions in the face of ambiguity (what problem are they trying to solve?), uncertainty (evidence will help, but always be limited), and limited time.

So, academics like me are now focused increasingly on trying to help address the problems we raise. On the plus side, it prompts us to speak with policymakers from start to finish, to try to understand what evidence they’re interested in and how they’ll use it. On the less positive side (at least if you are a purist about research), it might prompt all sorts of compromises about how to combine research and policy advice if you want policymakers to use your evidence (on, for example, the line between science and advice, and the blurry boundaries between evidence and advice). If you are interested, please let me know, or follow the IMAJINE category on this site (and #IMAJINE).

See also:

New EU study looks at gap between rich and poor

New research project examines regional inequalities in Europe

Understanding the transfer of policy failure: bricolage, experimentalism and translation by Diane Stone


Leave a comment

Filed under Evidence Based Policymaking (EBPM), IMAJINE, public policy

We need better descriptions than ‘evidence-based policy’ and ‘policy-based evidence’: the case of UK government ‘troubled families’ policy

Here is the dilemma for ‘evidence-based’ ‘troubled families’ policy: there are many indicators of ‘policy based evidence’ but few (if any) feasible and ‘evidence based’ alternatives.

Viewed from the outside, TF looks like a cynical attempt to produce a quick fix to the London riots, stigmatise vulnerable populations, and hoodwink the public into thinking that the central government is controlling local outcomes and generating success.

Viewed from the inside, it is a pragmatic policy solution, informed by promising evidence which needs to be sold in the right way. For the UK government there may seem to be little alternative to this policy, given the available evidence, the need to do something for the long term and to account for itself in a Westminster system in the short term.

So, in this draft paper, I outline this disconnect between interpretations of ‘evidence based policy’ and ‘policy based evidence’ to help provide some clarity on the pragmatic use of evidence in politics:


See also:

Governments think it’s OK to use bad evidence to make good policy: the case of the UK Government’s ‘troubled families’

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

In each of these posts, I note that it is difficult to know how, for example, social policy scholars should respond to these issues – but that policy studies help us identify a choice between strategies. In general, pragmatic strategies to influence the use of evidence in policy include: framing issues to catch the attention or manipulate policymaker biases, identifying where the ‘action’ is in multi-level policymaking systems, and forming coalitions with like-minded and well-connected actors. In other words, to influence rather than just comment on policy, we need to understand how policymakers would respond to external evaluation. So, a greater understanding the routine motives of policymakers can help produce more effective criticism of its problematic use of evidence. In social policy, there is an acute dilemma about the choice between engagement, to influence and be influenced by policymakers, and detachment to ensure critical distance. If choosing the latter, we need to think harder about how criticism of PBE makes a difference.


Filed under agenda setting, Evidence Based Policymaking (EBPM), Prevention policy, public policy, UK politics and policy

The ‘Scottish Approach to Policy Making’: Implications for Public Service Delivery

The Scottish Government’s former Permanent Secretary Sir Peter Housden (2013) labelled the ‘Scottish Approach to Policymaking’ (SATP) as an alternative to the UK model of government. He described in broad terms the rejection of command-and-control policymaking and many elements of New Public Management driven delivery. Central to this approach is the potentially distinctive way in which it uses evidence to inform policy and policymaking and, therefore, a distinctive approach to leadership and public service delivery. Yet, there are three different models of evidence-driven policy delivery within the Scottish Government, and they compete with the centralist model, associated with democratic accountability, that must endure despite a Scottish Government commitment to its replacement. In this paper, I describe these models, identify their different implications for leadership and public service delivery, and highlight the enduring tensions in public service delivery when governments must pursue very different and potentially contradictory aims. Overall, the SATP may represent a shift from the UK model, but it is not a radical one.

Cairney QMU Leadership and SATP 11.5.16

The paper is to a workshop called ‘Leading Change in Public Services’, at Queen Margaret University, 13th June 2016.


Filed under ESRC Scottish Centre for Constitutional Change, Evidence Based Policymaking (EBPM), public policy, Scottish politics

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

Prevention represents the most important social policy agenda in modern history, but governments do not know how to take it forward. In the name of prevention, the UK and Scottish Governments propose to radically change policy and policymaking across the whole of government. Their simple description 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: a major reduction in socioeconomic equalities by focusing on their ‘root causes’; a solution to unsustainable public spending which is pushing public services to breaking point; and, new forms of localised policymaking, built on community and service user engagement, to restore trust in politics.

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

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

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

Our simple answer is that, when they make a sincere commitment to prevention, they do not know what it means or appreciate scale of their task. They soon find a set of policymaking constraints that will always be present. When they ‘operationalise prevention, they face several fundamental problems in policymaking, 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 resources and intervene in people’s lives; major competition from more salient policy aims regarding the maintenance of 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. Or, more importantly, policymakers may 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.

To follow this work, please see:



Leave a comment

Filed under agenda setting, ESRC Scottish Centre for Constitutional Change, Prevention policy, public policy, Scottish politics, UK politics and policy

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.

  1. 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.

  1. 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?


Leave a comment

Filed under POLU9SP, Scottish politics

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


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