Public health policy: assumptions and expectations

Rather misleadingly, this very draft paper is called The Politics of Evidence-based ‘Health in All Policies’. It’s for Integrating Science and Politics for Public Health, convened by Patrick Fafard and Adèle Cassola at the Global Strategy Lab.

The most interesting section, for me, is the attempt to sense check the following list of assumptions/ expectations that I associate with public health studies of public policy. Unless stated otherwise, this list is based on literature reviews and documentary analysis underpinning studies of tobacco policy and prevention policy (Cairney and St Denny, 2020), as well as more impressionistic reflections from peer-reviewing many papers on this topic and attending relevant conferences (usually to speak to practitioners about the politics of EBPM). I am relying primarily on (a) the sense, often described in qualitative research, of a ‘saturation point’ to feel confident that more research will not unearth more categories, than (b) counting the frequency of term-use in each category, or (c) network analysis to identify the nature of a self-defined public health profession or community. As such, the focus is on the assumptions that scholars in this field often seem to take for granted, and often do not feel the need to explain. Its purpose is logical and conditional: if these are the assumptions, these are the expectations.

On that basis, I present a common public health narrative of the policy problem, how to understand it, and the processes necessary to address it:

• Focus on preventing ill health rather than treating it when it becomes too severe.
• Distinguish between types of prevention: primary (focus on the whole population to stop a problem occurring by investing early and/or modifying the social or physical environment); secondary (focus on at-risk groups to identify a problem at a very early stage to minimise harm); tertiary (focus on affected groups to stop a problem getting worse)
• Focus on the social determinants of health inequalities, defined by the WHO (2019) 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’.
• Promote ‘upstream’ measures designed to influence the health of the whole population (or health inequalities) rather than ‘downstream’ measures targeting individuals (although we discussed some debate/ confusion about the meaning of upstream).
• Use scientific evidence to identify the nature of problems and most effective solutions.
• Define scientific evidence in a particular way, such as in relation to a ‘hierarchy’ in which (a) the systematic review of randomised control trials often represents the gold standard, and (b) systems modelling plays a key role. Or, in fewer cases, challenge that hierarchy energetically.
• Promote major policymaking reforms, including a focus on holistic or joined-up government, since the responsibility for health improvement goes well beyond health departments.  Prevention (or preventive policymaking) is a classic term, and ‘health in all policies’ (HIAP) is currently a key term.
• Focus strongly on the role of industry as ‘vested interests’ causing public health problems (the ‘commercial determinants of health’) and, often, the lack of political will to regulate commercial activity.
• Treat public health and prevention as a form of social protection (new category after PHE). Often, actors describe a moral imperative to intervene (in which case, the opposite argument relates to individual responsibility and opposition to the ‘nanny state’ – see also Cairney et al, 2012 on ‘secular morality’).
• Use tobacco control as a model for other specific issues (e.g. alcohol use, obesity, salt) and the prevention agenda more generally (Studlar and Cairney, 2019).
• Focus on identifying policy changes that represent a ‘win-win’ scenario in which all parties benefit from the policy outcome (in terms of their health), rather than identifying political winners and losers from the policy choice itself (new category – Baum et al, 2014).

Such assumptions underpin expectations for the role of government, and provide a frame of reference for assessing the overall direction of policy (such as for ‘prevention’). Please let me know if there is a big missing category, or one of them doesn’t seem quite right.

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):

This is definitely okay and in no way terrifying and/or highly problematic (from The Times) pic.twitter.com/Ozev1Ts0c6

— James Ball (@jamesrbuk) December 13, 2016

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.

 

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).

Great launch for new @EU_H2020 project #IMAJINE led by @AberUni in Brussels today. @AU_IGHPP 1/2 pic.twitter.com/7MLDksfLUB

— Michael Woods (@WoodsZzp) January 18, 2017

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

 

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:

cairney-offshoot-troubled-families-ebpm-5-9-16

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.

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, 13^th June 2016.

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:

https://paulcairney.wordpress.com/prevention/

 

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…

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Two myths about the politics of inequality in Scotland

The first obvious myth about Scotland is that it is a land of milk and honey inhabited by a left-wing population that demands equality at all costs – or, even, that its financial advantage combines with consistently social democratic policies to reduce socio-economic inequalities to a level far below the rest of the UK.

In fact, Scotland’s social attitudes are more subtly left-wing, its devolved policies often diverge more in headline than substance, and – crucially – its record on inequalities does not match the rhetoric, of a social democratic Scotland, that we heard so often during the referendum campaign. For example, the Christie Commission, which set the Scottish Government’s new inequality 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.

This set of problems receives only sporadic political attention, but there is some potential for a lack of progress on inequalities to frame the next Scottish Parliament election (if the constitutional question does not continue to dominate).

For example, high levels of inequality in school educational attainment, linked to income and poverty, and discussed at length by Dani Garavelli, have prompted Mandy Rhodes to argue that ‘Scotland’s record on closing the attainment gap is all but failing’, others to argue that ‘Scotland’s educational apartheid’ is ‘is Scotland’s greatest national disgrace’ (Alex Massie) that ‘shames the nation’ (Kevin McKenna), and John McDermott (backed by evidence from Lucy Hunter Blackburn) to argue that these inequalities are reinforced by Scotland’s free University tuition policy. The middle classes are more likely to do better at school, go to University, and leave with no debt than their working class peers. In other words, the claim is that the Scottish Government is either failing to solve the problem of inequality or making it worse – a charge that would be dynamite if the constitution did not dominate political attention so consistently for so long.*

Yet, this conclusion has produced a second, equally problematic, myth: our obsession with Scottish independence has set back the inequalities agenda for years. This story has two main elements. First, the SNP government has taken its eye off the ball because it has been able to entertain its independence obsession, at the cost of paying attention to substantive social policy, without having to worry about the effect of its governing record on its popularity: inequality has worsened but its position remains strong while it can blame Westminster for any problem. Second, there is a simple solution to educational and other inequalities in Scotland – we just need to be driven by the evidence of success (for example, in other countries) and find the political will and leadership necessary to make tough decisions and stick to them.

Both of these points can be dismissed easily. First, maybe we don’t pay much attention to relevant policies, but the Scottish Government and Parliament do. In fact, there is unusually high agreement between parties on the need for the ‘decisive shift to prevention’ prompted by the Christie Commission, accepted wholeheartedly in government, and overseen by the Finance Committee. Further, when people do pay attention – when there is party political electoral competition and public attention to policy – it undermines long term policy strategies. Bursts of attention to political issues tend to produce rushed solutions to the wrong problem – more money goes to acute hospital care to reduce waiting times or to local authorities to boost teacher numbers and reduce class sizes, taking money away from the policies designed to reduce inequalities in the long term.

Second, the key problem that we need to face, if we want to go beyond simply shaming the nation’s or the government’s record, is that we don’t know what the evidence is and what policy should be. No politician or political commentator likes to admit that they can see a huge problem but don’t have a clue about how to solve it – yet, that is the problem we face. The simple solutions of media commentators are untested and their success rests largely on assertion rather than evidence. Or, when experts are called upon to settle the matter, you find that equally eminent scholars support contradictory solutions.

My new research with Emily St Denny shows just how far this problem goes. Even if there is cross-party agreement on the need to act, no one quite knows how to do it: how to define ‘prevention’ policies, gather evidence of ‘best practice’ (from home and abroad), turn the evidence into policies that can be ‘scaled up’ across the country, and demonstrate success for long term projects in a way that helps them compete for funding with high profile and popular quick fixes. What seems like an academic discussion about the nature of evidence and the mechanics of policy delivery is actually an issue at the core of the inequality debate. We show how foolish it would be to assume that the problem can be solved by attention and political will.

The latest version of this paper is here: Cairney 2015 EBPM and best practice 22.4.15 . It underpins a talk I gave to the Scottish Government today, and an academic-practitioner workshop tomorrow, bringing together the Government, Parliament, academics, and policy practitioners, to discuss how to move on from the broad commitment to reduce inequalities to actual projects with demonstrable success.

*This is also an issue that @chrisdeerin has been discussing for some time, partly to bash the Nats and partly to advocate learning from projects such as the ‘London Challenge‘. This is a broader topic – policy learning and transfer – that needs additional discussion. I discuss it (albeit tangentially) in some separate posts – such as  on theory – and in a previous paper looking at the transfer of prevention policies.

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

 

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

This post also appears on the ESRC website

The Scottish Centre on Constitutional Change does not simply examine the potential for a major event, Scottish independence, to have a major impact on Scottish politics. It also focuses on policymaking, which often exhibits stability and continuity despite major events. For example, the idea of evidence based policymaking (EBPM) represents a broad aim that the Scottish Government would pursue regardless of its constitutional status. The Scottish Government is also likely to continue its focus on a ‘decisive shift to prevention’ – to pursue ‘early interventions’ in people’s lives and address potential social problems before they produce high demand for acute, responsive public services – because the broad idea generates wide party political and public sector support.

Policymaking is about turning these broad aims into specific policies. In our paper, we set out a framework to think this process through, from identifying an aim, to using evidence to inform the selection of projects to fund and support. Some specific policies may differ under a devolved or independent Scotland, but the thought process stays the same.

First, we set out our aims. A clear definition of prevention and a set of detailed aims aids engagement with the public and the government’s policymaking partners. It helps produce a common set of expectations. It helps maximise the ability of a government to identify the most relevant evidence, when it seeks to learn from pilot projects and international experience.

This is difficult to do with ‘prevention’, which can mean anything from inoculating a whole population against a virus, to providing ‘crisis intervention’ to a small group. It can mean providing education and support or regulating behaviour. It is about identifying the root causes of problems, which is easier for many diseases than ‘wicked’ social problems. It is about how ‘decisive’ you want to be in a short space of time, and how you want to balance aims, such as between reducing inequalities or costs (at least when you can’t do both).

The Scottish Government addresses this problem through the National Performance Framework, which provides broad strategic objectives combined with a set of measures to gauge the success of prevention (and other) policies. It then invites local authorities, in partnership with public bodies, the voluntary and private sector, and service users – through Community Planning Partnerships – to produce Single Outcome Agreements which describe how these objectives will be met in each local area (there are 32).

In this sense, the Scottish Government has two broad aims: to pursue prevention projects and to make policy in a particular way, summed up in terms like ‘co-production’. Prevention policy results from Scottish Government direction, coupled with local plans produced in partnership with a range of participants. These aims can reinforce each other, when cooperation produces a high commitment to co-produced objectives, and/or undermine each other, when a proliferation of plans produces a wide range of meanings of prevention.

Second, we seek evidence to help clarify our aims and inform our decisions. Evidence can be drawn from past experience, pilot projects in our own country or policies pursued in others. The Scottish Government has an interesting double-role: to identify what evidence is relevant, based on its own aims; and, to translate evidence into lessons that are relevant to other participants. A commitment to co-production creates a commitment to  understand what drives local policymakers and what information is relevant to them, given the constraints they face (including budget and time) and what drives them to act. It also prompts us to focus as much on the evidence of successful delivery arrangements as successful policy interventions. This is a fundamental issue when we seek to learn lessons from other projects: are we learning about the policy solution or the way in which the solution is understood and used, more or less competently, in particular areas?

Third, we use our judgement. The identification of ‘success’ is a political judgement based on our aims and beliefs. Many projects quickly develop good reputations based on these, rather than ‘scientific’, criteria. We outline a framework to ensure that a sufficient amount of relevant evidence is gathered before a project is deemed successful. However, many projects may not live up to this minimum standard, particularly if we want to learn quickly to address pressing problems. Consequently, evidence-gathering is no substitute for political choice based on limited evidence – and that choice may vary markedly across 32 local areas. This is evidence-based policymaking for the real world.

The full paper, to be presented to the Scottish Government on the 24th February, is here: Cairney St Denny Prevention Paper 21.2.14

Preventative Spending and the ‘Scottish Policy Style’

‘Preventative spending’ and ‘prevention’ describe a broad aim to reduce public service costs (and ‘demand’) by addressing policy problems at an early stage; 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 problems – related to crime and anti-social behaviour, ill health and unhealthy behaviour, low educational attainment, unemployment (and, most recently, anti-environmental behaviour) – by addressing them at source, before they become too severe and relatively expensive. This aim may be timeless, and relate to previous policies directed at identifying the root causes of social problems – such as poverty, social exclusion, and poor accommodation. It has also received more recent attention during an ‘age of austerity’ in which governments seek to reduce spending and/ or redirect spending to other areas (to address key demographic shifts such as an ageing population, which affect service demand in other areas).

Prevention has some potential to generate widespread consensus – to bring together groups on the ‘left’, seeking to reduce poverty, and groups on the ‘right’, seeking to reduce economic inactivity and the costs of public services. It can also be linked to other ‘valence’ issues, such as (a) the need for ‘joined up’ or ‘holistic’ government in which we foster cooperation between, and secure a common aim for, departments, public bodies and stakeholders at several levels of government; and, (b) a shift from short, often misleading, targets as proxies for policy aims, to more meaningful long term outcomes.

Our aim is to examine how that agenda (a) plays out in Scotland, which has developed its own ‘policy style’; and (b) how it overlaps with current debates on constitutional change. Compared to the other ESRC Scotland projects, our topic is less sensitive to a changing constitution – the preventative spending agenda has already begun. However, it is not immune to that wider debate: more devolution, or independence, would extend Scottish Government responsibilities in relevant fields such as social security and welfare policy; and, the case can be made for independence to foster joined up government (or, reduce overlaps in government responsibilities for cross-cutting issues).

A Scottish Government Approach to ‘Universal’ Issues?

Any country’s prevention agenda would face common obstacles:

Defining and ‘Owning’ the Problem. Prevention is a vague term associated with many different aims (such as to reduce service costs or increase quality of life in a population). It is difficult to know what prevention policy would look like and how to measure its success in a meaningful way (particularly since government policy may be one of multiple causes of shifts in outcomes such as inequality). Its ability to gather wide support is a double-edged sword, since it brings together people with very different aims (and some groups will have unrealistic aims). One could have ostensibly the same policy for decades, but pursued with different choices, about the level and type of intervention, and about the main driver (such as reducing inequality or long term costs). This vagueness makes it difficult to secure stakeholder ‘ownership’ – or their support may only be for particular aspects of policy.

Shifting the Balance of Power. Prevention may require a challenge to existing services, and produce opposition from groups with reasonable concerns. It may require some governments to give up their powers unilaterally, such as local authorities when they accept binding shared aims with unelected bodies, or central governments devolving powers in a meaningful way.

Short term Costs versus Long Term Gains – undermines Long Term Commitment? A shift in resources may be designed to produce better outcomes over decades, which may be difficult to measure, at the risk of highly visible costs in the short term. These costs may be financial (invest for the long term in the same way you would invest in capital) and/ or political (when existing visible services are sacrificed for longer term aims). A visible party political imperative (parties competing for office every 5 years may seek short term measures of success or failure) may combine with visible effects on public services (and their employees) and the less visible issues such as intergenerational equality, to disrupt long term policies.

Normative. In some areas, early intervention may be criticised as excessive intervention (such as in tobacco and alcohol control – or the extreme example of preventative detention).

Wicked. We are dealing with areas that often seem intractable, or too big/ connected to be amenable to a simple/ workable solution.

Policy Transfer and Learning. What works in one issue or place may not work in another.

Policymaking. Any policy is subject to the usual constraints regarding uncertainty (for example, about how policy will influence social behaviour), the potential for unintended consequences, and the need for sustained leadership and partnership.

The Scottish Government may address these issues using a ‘Scottish Policy Style’, regarding:

1. The way in which it works with stakeholders to produce common policy aims.
2. The way in which it seeks to implement policy.

To some extent, it has a reputation for closer cooperation with stakeholders and building policy delivery on trust in implementing bodies (when compared to the UK Government). Its consultation approach may be used to gather information and foster group ‘ownership’. Its approach to implementation may be suited to a shift from short term targets to long term outcomes. It may continue to exploit advantages in relation to its size, with smaller government departments more able to make links across government, and senior policymakers more able to from personal networks with members of key stakeholder and delivery bodies. On the other hand, reputations can be misleading and based on snapshots in time. Early cooperation may have been based on a ‘honeymoon’ period of devolution and a favourable economic context. Further, not all Scottish Governments have pursued ‘bottom up’ and long term approaches to policy implementation.

Emily St Denny (@EmilyStDenny) and I are interested in how these issues play out in practice, examining:

• The academic literature on preventative spending in theory and practice
• Written statements on prevention in Scotland – reports by the Scottish Government, Scottish Parliament and related bodies such as the Improvement Service and CIPFA
• Interviews with practitioners – Government, Parliament, local government, NHS.

A lot of this work is part of a larger collaboration with colleagues in the ESRC Scottish Centre for Constitutional Change, including:

• with Michael Keating and Malcolm Harvey (@MalcH) at Aberdeen to link these issues to broader, comparative, studies of policymaking, examining the potential for learning from other, relevant, political systems and policies.
• with the three Davids in Economics (Bell, Comerford, Eiser) at Stirling to examine how the progress of such policies can be tracked using outcome measures, and how meaningful it is to say that government policy helped cause those outcomes.
• with Kirstein Rummery (@KirsteinRummery) and Craig McAngus (@craigmcangus) to examine particular aspects of inequality and unequal outcomes in areas such as age and gender