By Chris Hatton
I’ve been reading an extraordinarily interesting book recently by Katherine Smith*. The central strand of the book is to explore, through detailed case studies, why and how some areas of public health evidence (notably tobacco control) have ‘successfully’ made their way into government legislation and public health policy, whereas other areas with equally compelling public health evidence (notably the social determinants of health inequalities) have not translated into legislation and public policy.
I can’t do justice to the subtleties of her argument here, but my simple misrepresentation of it is that evidence is only one component in the service of an ‘idea’. For this idea to translate into any form of public policy requires a whole series of conditions to be in place. Katherine Smith argues that for public health these conditions include:
- The idea having to be consistent with (and/or presented in ways that make them seem to be consistent with) larger institutional ideas (or meta-narratives) held across governments such as a medical model of health rather than a social model of health or that promoting economic growth as the primary objective of government.
- Having broad coalitions (e.g. lobbying and pressure groups, NGOs, policymakers, journalists, academics) with an agreed idea and central programme.
- Being able to articulate a positive policy alternative as a result of the idea, rather than simply using the idea to critique existing arrangements.
- Having an already existing institutional structure within government and other agencies within which the idea can be readily embedded.
Katherine Smith presents a detailed case study concerning tobacco control, arguing that the evidence was used to support an effective, broad-based coalition with an agreed idea (to reduce smoking through targeted tobacco control measures) and a willingness to engage in argument with opponents of tobacco control. This had positive proposals, underpinned by arguments that tobacco control would yield economic benefits (for example in the reduction of healthcare costs associated with passive smoking). ‘Downstream’ tobacco control measures such as smoking cessation could be readily placed within a medical model and within existing institutional structures (as a part of the NHS), and even smoking bans in public places did not require a social model of health (which would require ‘upstream’ approaches to reducing social inequalities in taking up smoking in the first place). In Katherine Smith’s terms, tobacco control’s (partial)’success’ was partly due to its being able to flex itself from a critical idea to an institutionally acceptable idea.
In contrast, health inequalities evidence and ideas have generally fared less well in terms of translation into legislation and government policy. This is partly because they are insistent on a social model of health and they cut across all aspects of government departments and policy/service delivery structures. Health inequalities proponents have also not managed to form broad-based coalitions with an agreed programme of positive alternatives, instead offering a series of fragmented critiques of current arrangements. Only those elements of these ideas that can be transmuted through institutional filters make it through to policy in any form (for example psychological therapies for people with mental health problems, framed in terms of improving economic productivity and focused on ‘downstream’ delivery through health services rather than working on the ‘upstream’ conditions that increase the chances of mental health problems in the first place). In Katherine Smith’s terms, these ideas that challenge existing arrangements without offering positive alternatives are critical ideas.
There are also some ideas that are so flexible that they can be made to fit almost any set of government priorities – Katherine Smith calls these chameleonic ideas.
Finally, there is a recognition that very, very occasionally, charismatic ideas are possible. These are ideas that overturn or fundamentally change the institutional ideas or meta-narratives so completely that they replace them with the new set of charismatic ideas that themselves then become institutional.
When I was reading this book, I was struck by how useful this framework might be for understanding the strategic and tactical dilemmas of the independent living movement in translating the independent living idea into meaningful changes in legislation, policy and practice.
First, it suggests that if the independent living idea is to remain solely critical of existing arrangements without offering a positive alternative, it is unlikely to gain any traction on legislation, policy and practice.
Second, it presents a dilemma about whether the independent living movement intends to hold out as a charismatic idea, with long odds against success but with the prize being to overturn institutional meta-narratives and institutional structures to create a new sense of ‘this is just the way things are’. Alternatively, can the independent living movement retain its integrity and reach its goals if it is ‘flexed’ to try and accommodate to institutional ideas and structures (and if so, which elements can be flexed, and how far)?
Third, whatever the agreed solution to the dilemma presented above, there needs to be a broad-based coalition with agreed objectives and articulation of a positive alternative policy vision, and clear arguments to mobilise against critics of independent living.
Under the previous government, it could be argued that a lot of the conditions for successful translation of independent living ideas into legislation, policy and practice were in place (e.g. the Equality Act, the DRC, ODI, Equality 2025, supporting for user led organisations). The current government is clearly a much more difficult environment, not only economically but in the dismantling of the elements of a broad-based independent living coalition with any presence inside government. This suggests that there are tactical decisions to be made about who to engage with in (re)building such a broad-based coalition.
I wouldn’t presume to have any answers to these dilemmas, but I think the ideas set out in Katherine Smith’s book help us to think through the strategy and ultimate goals to make independent living a reality.
*Katherine Smith (2013). Beyond evidence-based policy in public health: The interplay of ideas Palgrave Macmillan: Basingstoke.
About the author
Chris Hatton is an academic at the Centre for Disability Research, Lancaster University, UK, and also currently a Co-Director of Improving Health and Lives, the Learning Disabilities Public Health Observatory, part of Public Health England. His research work over the past 25 years has mainly focused on people with intellectual/learning disabilities, particularly around documenting the inequalities experienced by people with intellectual disabilities and their families and evaluating policies and practices designed to reduce these inequalities. He blogs here in a personal capacity. You can follow Chris on Twitter: @CHRISHATTONCEDR