Conclusion: Revisiting the Prevention Puzzle

Prevention is the ultimate example of a policy problem with an intuitively appealing, but ultimately elusive, solution. There is a profound gap between policymaker expectations and policy outcomes. Governments describe a high commitment to radical changes in prevention policy and preventive policymaking, but fail to deliver. We reject the idea that this puzzle can be explained primarily with reference to insincere politics or low political will. The danger with such conclusions is that they encourage a cycle of failure. Each new generation of policymakers will think that it will perform differently, and make a difference, simply because it exhibits high and sincere commitment. Or, each new generation of advocates will think that they just have to get the evidence, strategy, and language right, to inspire politicians to make the kinds of ‘evidence-based’ decisions whose value they take for granted. Advocates will struggle to understand their failure to close an ‘evidence–policy gap’, and policymakers will fall into the same basic trap that we describe in this chapter. Instead, our explanation helps policymakers and practitioners solve the puzzle of prevention policy by facing up to its ever-present challenges.

Prevention and Criminal Justice

First, we describe the general issues that governments face when pursuing social and criminal justice policies in a multi-centric environment. Both governments manage the same tensions between relatively punitive and individual versus supportive and population-wide measures to reduce crime, as part of an overall cross-cutting focus on prevention and early intervention. Second, we identify the historic policymaking strategies that UK governments have used to combine social policy and criminal justice policy, often with reference to target populations who—according to several UK ministers—do not pay their fair share to society and do not deserve state help. Third, we show how such trends influence preventive policies in specific areas such as drugs policy, in which the UK still reserves responsibility for drugs classification. Fourth, we use this UK context to identify the extent to which Scottish policy has a greater emphasis of social over criminal justice. To do so, we use the case study of a window of opportunity for a public health approach to serious violence. We focus on Scotland as the relatively innovative government on this issue, to provide context for initial analysis of the UK government’s proposed policy shift.

Which Government’s Policy Style is More Conducive to Prevention?

We have demonstrated that many governments face the same ‘prevention puzzle’, caused partly by universal drivers associated with multi-centric policymaking. Further, they face contradictory pressures to share power for pragmatic reasons or centralize power to seem in control. However, what if policymakers in different political systems try to solve these dilemmas in fundamentally different ways? For example, are some systems more conducive to long-term planning and more likely to facilitate central governments trying to ‘let go’ and encourage localism? This question is often central to comparative political studies involving the UK. The UK’s Westminster model often represents the archetype of a ‘majoritarian’ democracy with a top-down policymaking style and adversarial political culture. Lijphart contrasts it with ‘consensus’ democracy characterized by coalition-building between parties and political culture built on ‘inclusiveness, bargaining and compromise’. In theory, this distinction could guide our analysis of UK and Scottish preventive policymaking, since some ‘architects of devolution’ envisaged ‘new Scottish politics’ as the antidote to ‘old Westminster’, to produce a consensus democracy with greater emphasis on pragmatic policymaking. However, their reputations are inaccurate caricatures that provide a misleading way to compare UK and Scottish prevention policy.

Early Intervention for ‘Troubled Families’

Early intervention in the lives of families and children is a central part of the prevention agenda. However, there is little consensus on the ways in which to do it, based on the framing of target populations, timing of intervention, extent of state involvement in family life, and evidence for the success of each intervention. To frame this analysis we ask: (1) Was there a distinctive ‘window of opportunity’ for the introduction of the troubled families programme in the UK? (2) How does each government socially construct target populations, and what is the effect on policy design? (3) To what extent has each government relied on local authorities and partnerships to deliver its national agenda, and what outcomes or practices have ‘emerged’ from local activity? To help answer these questions, we consider the meaning of ‘families policy’ to help understand who has responsibility for it, trace three main elements of their policy histories, and gauge the extent to which UK policy already represented divergence from the past and from Scottish policy.

Prevention Policy and Public Health

Health policy is the traditional home of prevention policies. Public health is at the heart of policies designed to improve population health, and perhaps reduce health inequalities, often through changes in behaviour at an early age. Public health policy tends to be a hub for advocates of EBPM. In theory, healthcare and public health are symbiotic, particularly if early public health interventions reduce demand for acute healthcare. However, in practice, public health is an exemplar of the wide gap between expectations for ‘evidence-based’ prevention policy and actual outcomes. To demonstrate, first, we apply our theoretical approach, outlined in Chapters 1 to 3, to present a broad examination of health policy and the role of prevention within it, considering what a window of opportunity for prevention policy within a complex system means in relation to health and public health policy. Second, we show that the UK and Scottish governments have described different policy styles, but faced and addressed the ambiguity and complexity of preventive health policy in similar ways. Third, our comparison of broad prevention versus specific tobacco policies shows why substantive policy change is more apparent in the latter: there is a clearer definition of the policy problem, a more supportive environment for meaningful policy change, and more windows of opportunity for specific policy changes. These three conditions are not yet fulfilled in the broader prevention agenda.

Environmental and Systemic Effects on Prevention Policy

Policy actors may combine cognition and emotion to simplify their choices, or turn a complex problem into a small number of issues and objectives. However, they do so in an environment that remains complex and affects the impact of any policy. Policymakers try to deliver policy in environments containing many policymakers and influencers spread across many levels and types of government, operating in many organizations and networks with their own rules and language, and responding in different ways to relevant socio-economic conditions and events. Or, policymaking takes place in a ‘complex system’ that can amplify or dampen policymaker energy, and policy outcomes can ‘emerge’ at local levels, often despite central government attempts to control them. Consequently, it is relatively straightforward to identify central government policies, as collections of statements of intent and policy instruments, but difficult to predict or track their effects. Instead, policy theories and concepts help us understand the impact of choice in a ‘multi-centric’ policymaking environment.

Prevention and Mental Health Policy

In health and public health policy in general, the conditions to support prevention policy are not yet apparent. Attention is low or fleeting, ambiguity is high, and debates on the meaning and application of prevention policies are wide. A supportive policymaking environment, producing regular windows of opportunity for specific policy changes, is difficult to identify. Such problems are accentuated when prevention and public health meet mental health. Recently, there have been meaningful calls for greater attention and resources to mental health policy, to pursue ‘parity’ between mental and physical health, and to stress the need for ‘public mental health’ to play a larger part in the public health agenda. However, this agenda remains in its infancy following decades of relative neglect, low public and policymaker attention, and uncertainty about what public mental health means (beyond the vague aim to promote mental well-being and prevent mental illness). At the same time, other policy agendas may undermine these fragile developments, such as when employment policy reforms affect the ability of people with mental ill health to receive social security benefits. In that context, we show that a firm and sincere commitment to public health and mental health is not enough to guarantee the success of preventive mental health initiatives.

The Scottish Government’s Decisive Shift to Prevention

The Scottish Government faces the same ‘prevention puzzle’ as the UK government, but often argues that it deals with it in different ways. Some of this potential distinctiveness relates to a Scottish ‘policy style’ or ‘approach’, in which it encourages relatively consensual policy consultation and delivery. However, as Chapter 4 suggests, a lot of the ‘Scottish approach’ is aspirational. Further, many policymaking differences relate to the size of the Scottish Government, its responsibilities, and the scale of its task. If we account for such differences, the Scottish and UK governments often seem to respond in similar ways to the dilemmas posed by multi-centric policymaking and Westminster-style accountability. In the absence of clear and systematic differences between them, we need to produce empirical analysis of how each government: (a) makes sense of prevention policy, and (b) produces models of preventive policymaking. In that context, the Scottish Government experience provides a rich source of case study evidence on how governments address policy problems, and how territorial governments act while operating within wider multi-level systems.

Prevention Policy in the UK

This chapter zooms out to identify the overall ‘weight’ of post-war initiatives, under the general banner of UK prevention policy, across multiple policy areas. Many UK governments have faced the same basic prevention puzzle, and the vague idea of prevention policy has risen up and fallen down the UK government policy agenda for most of the post-war era. However, there was a step-change of activity from 1997. The newly elected and self-styled New Labour government, led by Prime Minister Tony Blair, identified something akin to a ‘window of opportunity’ for major changes in policy and policymaking. Compared to its predecessors, it used the language of prevention more frequently, and was far more likely to describe it as a vehicle to address socio-economic inequalities, join up government, and pursue ‘evidence-based policy’. Initially, we find in its social construction of target populations some shift of emphasis from personal responsibility to structural causes of poor outcomes. Yet, we also detect a growing frustration with limited progress and more explicit moral judgements of target populations over time, prompting a more centralized approach to policymaking and a greater focus on ‘problem’ families towards the end of New Labour’s era of government. Most of this prevention agenda continued under the Conservative–Liberal Democrat Coalition government from 2010 to 2015, albeit with a greater focus on the economy, employability, ‘troubled families’, and individual responsibility.

Prevention Policy as the Ultimate ‘Wicked’ Problem

This book shows how to analyse, and seek to solve, the most enduring, puzzling, and important problems in public policy. Policy scholars often begin by relating such problems to two broad questions: why does policymaker attention and action seem disproportionate to the size of policy problems, and why is there such a gap between their policy aims and outcomes? The answer relates to (a) the limited resources of policymakers, in relation to (b) the complexity of their environments: policymakers only have the ability to pay attention to, and influence, a tiny proportion of their responsibilities, and they engage in a policymaking environment of which they have limited understanding and even less control. This insight resonates particularly in Westminster systems, in which most political debate rests on the idea that ministers are accountable because they can exert central government control. Rather, policymaking systems are complex and ‘multi-centric’ and a focus on the choices of a small number of powerful actors does not help us understand the system as a whole.