Special issue blog series on Transformational Change through Public Policy.
Paul Cairney, Emily St.Denny, Sean Kippin, Heather Mitchell
Could policy theories help to understand and facilitate the pursuit of equity (or reduction of unfair inequalities)? We are producing a series of literature reviews to help answer that question, beginning with the study of equity policy and policymaking in health, education, and gender research, which has just been published in Policy & Politics. Continue reading
FORTHCOMING SPECIAL ISSUE BLOG SERIES ON ‘Beyond Nudge: advancing the state-of-the-art of Behavioural Public Policy & Administration’
Nudge is frequently in the news at the moment. Thaler and Sunstein coined the term to describe the way in which governments could use small policy interventions (like an advert, a sign, or a letter) to ‘nudge’ people into changing their behaviour for the better, both for themselves and for society at large. Experts in nudge (so called behavioural scientists) have been busy during the current pandemic advising the government on the best way of getting people to follow coronavirus health advice whether it be washing your hands while singing happy birthday or staying at home to save the NHS.
We already know however that many people do not do what they are told. In my recent article in Policy & Politics, I describe how scholars working in public health draw on the notion of fatalism to explain the intractability of citizens who ignore their doctors’ advice. A fatalist mindset inclines some people to believe that their fortunes are, in the strongest sense of the word, predetermined or at least heavily constrained by forces beyond their control. People who believe their lives are characterised by luck, powerlessness and impenetrable complexity tend to respond poorly to authoritative advice. Three types of fatalism are of particular relevance to nudge. Continue reading
Jon Glasby and Rosemary Littlechild
An extended version of this post was originally published on 4 October 2016 in the Policy Briefing section of Discover Society which is provided in collaboration with the journal Policy & Politics. The original post is available at http://discoversociety.org/2016/10/04/policy-briefing-who-knows-best-understanding-older-peoples-experience-of-emergency-hospital-admission/.
Every year, the NHS experiences more than 2 million unplanned hospital admissions for people over 65 (accounting for 68 per cent of hospital emergency bed days and the use of more than 51,000 acute beds at any one time). With an ageing population and a challenging financial context, such pressures show no sign of abating – and the NHS is having to find ways of reducing emergency hospital admissions (in situations where care can be provided as effectively elsewhere). Often, the assumption in policy and media debates seems to be that potentially large numbers of older people are admitted to hospital without really needing the services provided there, but because there is nowhere else for them to go or because other services are not operating effectively. Continue reading
By Mhairi Mackenzie, Chik Collins, John Connolly, Gerard McCartney, Mick Doyle
We know from decades of international research that power, politics and specific social and economic policies have a fundamental role in creating health. These factors contribute very significantly to the gradient we see across income groups in terms of life expectancy and more general wellbeing.
However, many health policy researchers have identified how policies which claim to be about reducing health inequalities seldom squarely address these fundamental determinants of health. Instead, policies have a distinct tendency to focus on changing the behaviours of (mainly) poor people. The message is often that people smoke too much, drink too much or don’t make the best use of services that are available to them. These messages do not give proper consideration to why particular health damaging behaviours occur in particular places or why health is worse in certain places even in the absence of these behaviours. Even those policies which do start with a broader analysis of the problem of disparities in health are subject to lifestyle drift when it comes to putting policy into practice. Although policy documents may state that the causes of poor health or inequalities in health are to do with poverty and deprivation, the interventions which actually operate on the ground focus much less (if at all) on changing people’s material circumstances and rather more on trying to change behaviours (which are in fact heavily shaped by material circumstances).
In light of the above, it is unsurprising that research in different countries also shows that when policy makers and practitioners talk about how health is created they tend not to give due regard to these known fundamental causes. Again, the emphasis is on explanations that focus on individual lifestyles. Behavioural interventions aimed at changing the lives of poor individuals clearly have a powerful draw on the attention of policy makers. The reasons for this preference are many and varied and include the desire for quick policy wins over longer term action and the seductive appeal of short and simplistic causal pathways to health, in preference to having to deal, intellectually and practically, with the longer and more complex pathways which are actually at work.
Another reason, however, for the hardiness of the behavioural intervention as a policy tool – despite its apparent lack of success in addressing the problem – is that it fits within a broader contemporary political narrative. That narrative tells us that individuals are responsible for making and breaking their own life chances. Consequently, their health and social outcomes lie overwhelmingly in their own hands. There is, in this view, ‘no such thing as society’, or at least no wider societal determinants which individuals can’t be expected to just over-ride through their personal choices and individual acts of will. In this narrative the state’s role is to ‘nudge’, ‘activate’ or mandate individuals to do the right thing rather than to challenge fundamentally the existing power relations within society.
This kind of thinking is part of the wider set of discourses, policies and practices associated with neoliberalism. These provide both the context in which, and the mechanisms through which, the lives of some communities have become in many ways much more difficult since the 1980s – and their existence and identity much more marginalised. Research tells us that it is this fundamental part of the story of how poor health is created that is largely missing from the discourse of those in policy and practice.
In our recent Policy & Politics article: working-class discourses of politics, policy and health: ‘I don’t smoke; I don’t drink. The only thing wrong with me is my health’, we wanted to look at how people living in deprived communities – which had felt the brunt of deindustrialisation in the 1980s and had been at the sharp edge of austerity in current times – talked about how politics and policies had impacted on their health, and that of their families and their wider communities. Unlike the messages from policymakers, our sample of participants in the towns of Kilmarnock and Cumnock in East Ayrshire, Scotland, brought vividly to life how it is that power, politics and social and economic policies are indeed a fundamental matter for health – at both an individual and community level.
Here are some of the things our participants told us:
They do not feel at all valued by political elites; on the contrary they are made to feel literally surplus to requirements. An ex-miner told us: ‘I’ve heated their bums wae coal…we’ve served wur cause. If they could dae away wae you noo, they would dae away wae you, because you’re a drain on society…They want me, noo, to work til I’m sixty-seven. I’ve no chance of working to I’m sixty-seven. I’ll no’ see sixty-seven.’ Similarly, another respondent, reflecting on ‘austerity’ and so-called ‘welfare reform’, simply said, “I think they’re trying to kill folk aff”.
They sense that deliberate action was taken by government to destroy the industries on which their communities had depended, and to undermine the strong and more solidaristic community relationships which had prevailed in the past. A respondent from Kilmarnock said: “She [Thatcher] allowed a’ the work to go abroad. And oor factories in Kilmarnock…we had a great town, and it just finished. Factory after factory, well-known brands…employers went. They all went wi’ a feeling o’ sorrow but it didnae help the workers.” Another ex-miner from Cumnock, reflecting on the 1984-85 Miners’ Strike across the UK, said: “looking back you can see the preparation got made. And they really backed the union into a corner … it was to diminish the power of the unions and fragment communities”.
Where ‘negative lifestyles’ exist within these communities, they are seen as closely connected to broader social and political circumstances. Another ex-miner told us how downwardly spiralling morale and behaviours in his community were rooted in changing circumstances: ‘The factories started slimmin doon, cutting workforces. The ability for young people to get into work was becoming limited. We started to see probably drugs in our community for the first time. And probably the excessive drinking was starting to take a hold as well…’ Further, not all of our participants were able to understand their current poor health in terms of their own behavioural decisions – as we indicate in the title of our research paper – one man in poor health summed up this personal conundrum by saying ‘I don’t drink; I don’t smoke – the only thing wrong with me is my health’.
Participants are conscious of current day political strategies to set poor and struggling communities apart from the rest of society. One young woman said: ‘They are using the media…tae bombard folk wi’ … the good old ‘divide and conquer’…it’s like stigmatising full groups at a time. It comes in waves. I mean, the immigrants’ll be due a shot…it’s a’ their fault. It’s like they’re trying to deliberately create this, ‘Everybody that’s on incapacity’s a scrounger.’”
All in all, our research participants provided a vivid articulation of links between politics, policies, deindustrialisation, damage to community fabric and impacts on health. We ask: given the way in which these lay participants’ understandings of health reflect (and enrich) the views of researchers, should our participants and the many who share their stories, actually be the ones educating policy makers and practitioners, rather than being seen as the recipients of perennially failing health education messages? What might be the impact of turning the traditional health education model on its head? How would such a shift in who is doing the educating be received by policy-makers and practitioners?
Mhairi Mackenzie is Professor of Public Policy in the School of Social and Political Sciences at the University of Glasgow. Chik Collins is Professor of Applied Social Science in the School of Media, Culture and Society at the University of the West of Scotland. John Connolly is Senior Lecturer in Public Policy at the University of West of Scotland. Mick Doyle works for the Scottish Community Development Centre. Gerry McCartney works for NHS Health Scotland.
If you enjoyed this blog you may also be interested to read Policy, Politics, Health, and Housing in the UK.
Reposted with kind permission from: http://discoversociety.org/2016/04/05/policy-briefing-how-politics-and-power-create-poor-health-i-think-theyre-trying-to-kill-folk-aff/
The public health field is never short of controversies. On 22nd October 2015, Public Health England (PHE) published a report on Sugar Reduction: The Evidence for Action. The report recommends inter alia, an introduction of a sugar tax of between 10% and 20% on high sugar products such as soft drinks (PHE, 2015b). This has sparked endless debates within the academic and public domains. The vociferous debate sustains when subsequently, the government guarantees that there will be no tax imposition on sugary products, whilst insisting that there are other workable alternatives for tackling health issues, particularly obesity, as a result of overconsumption of products with a large amount of sugar.
Borrowing from the Nudging Theory, tax is seen as a ‘shove’, capable of prevailing the ‘upstream approach’ in public health (policy approach that can affect large populations, such as economic disincentives) through the preventative route (Local Government Association, 2013). This blog post seeks to explore whether the government should reconsider its initial decision not to impose a taxation on sugary products. It will take stock of the evidence that links sugar with obesity, and consider the success of a sugar tax in various countries in addressing the population’s health. It then goes on to explore the power of taxation in changing people’s behaviour and the potential benefit of such a measure on the NHS, before considering whether the tax on sugary products can address the failure of the Public Health Responsibility Deal between the government and the food industry. Continue reading
Policy & Politics talking public health in Milan last month with Editorial Advisory Board member Katherine Smith
In a session jointly sponsored by Policy & Politics and the University of Glasgow Social and Public Health Sciences Unit, leading international experts explored how public health professionals perceive the role of the alcohol, tobacco and food industries in shaping public policy. . The international panel of speakers, appearing at the 8th European Public Health Conference which took place in Milan on 14-17 October was chaired by Professor Oliver Razum, Dean of the School of Public Health at Bielefeld University, Germany. It included Professor Nicholas Freudenberg of City University New York, Dr Lori Dorfman from the Berkeley Media Studies Group and the University of California, Berkeley, School of Public Health, Dr Benjamin Hawkins from the London School of Hygiene and Tropical Medicine, Dr Heide Weishaar from the MRC/CSO Social and Public Health Sciences Unit, University of Glasgow and Policy & Politics’ Editorial Advisory Board member Dr Kat Smith from the Global Public Health Unit, University of Edinburgh. The session was organised by Heide and Kat along with Dr Shona Hilton of the MRC/CSO Social and Public Health Sciences Unit, University of Glasgow. This blog sums up the issues discussed and sets out an agenda for future research in this area.
One of the few indisputable truths in life is that we will all, eventually, die but what we will die of, and at what age, is changing across the world, with non-communicable diseases (NCDs) increasingly accounting for excessive morbidity and mortality burdens. The growing prevalence of NCDs is triggering substantial policy concern, evident, for example, in the 2011 UN high level meeting on NCDs. Yet, it is clear there are very different ways of thinking about this ‘epidemiological transition’: it has been framed, on the one hand, as a consequence of the choices that individuals make and, on the other, as a consequence of the strategies Continue reading
Ellen Stewart (University of Edinburgh, UK) discusses her article “A mutual NHS? The emergence of distinctive public involvement policy in a devolved Scotland“
In the last twelve months’ heated debates about the SNP’s evolving role in UK politics, there has been far too little focus on their record North of the border, where they have now been in Government for almost two full terms (first as a minority government from 2007-2011, and then, beating the odds of the electoral system, with an unexpected majority since 2011). The UK media has only occasionally engaged with this record in government, and these efforts have often been haphazard potted histories, shifting between judging Scotland’s policies or its outcomes, and between comparing them to the other countries of the UK, or to the pre-recession past.
The difficulty of discussing devolved policy in a measured fashion is not new, although it is certainly heightened in the current political climate. In 2011, when I sat down to write what was eventually published in Policy & Politics as ‘A mutual NHS: the emergence of distinctive public involvement policy in a devolved Scotland’, I was trying to pin down some substance behind the pervasive rhetoric of ‘mutuality’ in the Scottish NHS. Much academic analysis of the ‘distinctiveness’ of Scottish health policy has relied on data from interviews with politicians, civil servants Continue reading
by Mara Tognetti, Professor of Health Policy at Milan-Bicocca University, Italy
The research project “The community takes care of Huntington’s Disease” – piloted by the Observatory and Methods for Health at the Department of Sociology and Social Research of Milan-Bicocca University and directed by the present author – has conducted free interviews to learn about how health workers and relatives find the task of assisting people with Huntington’s Disease (HD). This is an incurable neuro-degenerative genetic complaint which sets in during the prime of the individual’s life cycle and puts paid to the social and physical existence of patient and family. It places social relations under enormous strain and completely disrupts family, working and social life.
For this reason, and because no kind of therapy yet exists to retard or halt progression, the challenge is both to search for an effective cure and to find ways, from the outset, of supporting those who shoulder the burden: the patient, the family and the health workers.
The research aimed to provide a picture of family needs and difficulties in looking after an HD sufferer. We particularly looked at how caregivers perceive their own requirement for time off for themselves, on the Continue reading
Jonathan Wistow, Lena Dominelli, Katie Oven, Christine Dunn, and Sarah Curtis, from Durham University, discuss their latest article from EPSRC-funded research, “The role of formal and informal networks in supporting older people’s care during extreme weather events”. This article is now available on fast track.
Climate change and demographic projections point, respectively, to more frequent occurrences of extreme weather and an ageing population. Taken together these provide new dynamics to which health and social care systems need to respond. Firstly, demographic change will lead to a growth in the population group that relies most on services within health and social care systems. Secondly, the increased frequency of extreme weather events can have serious effects on the services, buildings, communication routes and utilities that are important for health and social care of older people.
This article is an output from an Engineering and Physical Sciences Research Council funded research project under the Adaptation and Resilience in the Context of Change programme, called Built Infrastructure for Older People in Conditions of Climate Change. The project brought together a team of researchers from different disciplines to understand how Continue reading