Sandbags not swords: a manifesto for better policy-making

What’s the point of health policy?

This long read explores an answer, but starts with the statement being used not as a question but as an exclamation of exasperation. My world for over a decade was health policy, both in Whitehall departments and external think-tankery. I joined because I was fascinated by the opportunity to try and apply new thinking to old problems. I left at a point when policy seemed to create more problems than it solved, and that this was widely acknowledged not only by those subject to the latest proclamation, but by those involved in making it too. The holy grail for policy (used as a short-hand to mean the role of national policy-making) — and in turn for policymakers — was to cause minimal harm, to do nothing, to be pointless.

Personally I couldn’t cope with this profound lack of agency (I now work for a social enterprise). But neither could I admit that policy was pointless, that there wasn’t a noble role for policy to play in making the jobs of those working in health care and wider public service easier, not harder. When the (admittedly rather dull) annals of 21st century policymaking come to be written, the role of national policy in responding to the current challenges facing health and health care will be seen to be shockingly rubbish. Endless distraction of reorganisation. Dishonesty as to the scale of the problem. Blithe dismissal of the role of non-health care policy in dictating health outcomes. Initiativitis (and its unhappy bedfellows, duplication, confusion and burnout) taken to new heights. The endless quest to find a plausible line to take to awkward questions blinding us from the fact they’re questions we should have asked ourselves. Does it have to be this way?

This would be a short piece if I thought it did. But let’s frame the challenge in the right way. All too often when bemoaning policy’s woes we heap blame on our politicians, our media, or if we’re feeling particularly bitter, our public. This is a cul-de-sac. An intellectual indulgence not worth the time. They’re not going anywhere, let’s not pretend otherwise. The task isn’t to try and take politicians out of policymaking. Instead the task is to construct a set of strategies which work within the real-world, warts and all. It may not be classically pure, think of it as policy-street fighting, but it can work.

Evaluate like a baker

So let’s start at the end: how do we know if we’ve achieved policy nirvana? How do we know if it’s worked? To answer this let’s talk baking — and let’s put in an advance apology for the number of metaphors deployed in this piece. A good loaf is one which uses the right ingredients, in the right proportions, baked to the right method. Crucially it’s the cumulative impact of the different ingredients coming together that results in a good end-product.

And so it is with policymaking: when trying to influence the overall results of a complex system what matters is not the specific impact of a specific policy, but rather the cumulative impact of different policies, and how those policies interact with other factors. Our standard model of evaluating policies is equivalent to working out how a loaf tastes by sampling the flour alone — not irrelevant, but not particularly helpful either. Failing to think about the cumulative impact matters: the independent review into care provided at University Hospitals of Morecambe Bay NHS Foundation Trust between 2004 and 2013 found mothers and babies died unnecessarily as a result of a ‘lethal mix’ of factors. Part, but by no means all, of this was due to the cumulative pressures upon the organisation by national policy which skewed the hospital’s priorities with deadly results. Each of those policy areas would have had a willing and likely highly able team of policymakers behind it thinking about the impact of their part of the picture. No one was looking at the overall. If anything is different now it’s not immediately apparent.

Build coastal defences

With a focus on the cumulative, the joins and interactions between different policies matter just as much as the main substance of the policy. This is counter-cultural to policymakers, but particularly to politicians. As characterised by Jon Coles, architect of the wildly successful improvements to London schools in the 2000s, politicians seek policies to use as swords to strike down dragons: there is a problem, here is my solution, all will be well again.

It’s just a shame that such straight-forward linear processes don’t really exist. Problems requiring action by national policy will likely have gained their national salience by their difficulty in being addressed by other levels of government administration. By default such problems are likely to have multiple causes, each requiring a different solution, and be likely to mutate when prodded in ways you could never have expected. To use the parlance, these problems are wicked, not tame, unlikely to ever be solved completely, just made better or worse.

The complex world we inhabit laughs at swords and such pre-school models of how change happens. In its place we need to think of policies in terms of sandbags — the careful assembly of a range of interventions, locked together to achieve the overall effect. Such coherence is not a panacea, but does help maximise the impact of whatever resources we have at our disposal.

Talk like a theatre impresario

But swords are so appealing and speech-ready, particularly when Ministers may not be in the job long enough to see more than a couple of their policies come to pass. In contrast trying to convince a Minister to go on Newsnight talking about the need for a broad-based range of actions to best suit a complex adaptive system isn’t an appealing prospect. What you require is multiple stories, none of them wrong, but tailored to what people want to hear — coined by former obesity advisor to Boris Johnson as Mayor of London, Harry Rutter as the need for a ‘Front of House’ story, as well as the back-room detail. Addressing childhood obesity is likely to take 20 years of concerted, connected action on a plethora of fronts; but that the story you tell is about breastfeeding friendly stickers in cafes.

I have upmost sympathy for politicians requiring the Front of House, it’s the fuel they need to run; and good policy provides it without neglecting the complexity behind the scenes.

Test like Deming

And at the same time don’t try and play the game of giving Ministers things they don’t want to say. ‘I’ve decided I was wrong’, is one; ‘we’ve spent quite a lot of money on something which didn’t work’ is another. This is when politics and the art and science of service improvement mix like oil and water. Our knowledge of improvement, built on William Deming and other luminaries, is based on rapid testing cycles, learning as much from failure as success, and creating ‘psychologically safe’ cultures where individuals can show vulnerability and question openly. None of this is particularly Today programme friendly. Although we might occasionally pretend otherwise, we want our politicians to show certainty and control, not to admit doubt. When Estelle, now Baroness, Morris decided she ‘wasn’t up to the job’ as Education Secretary she was widely praised for her courage in saying so, but far fewer people called for her to stay in the government.

Squaring the circle involves not backing Ministers into a corner. Genuine testing and learning is fundamental, but only if you create space to fail. The approach to announcing pilots (and their many synonyms) in health is to do so with maximum fanfare, especially if there are pots of money attached. Great headlines on the day, but any chance of failure and risk-taking goes out of the window; they’ve been announced, they have to succeed. For the London schools challenge, they took a different approach — deliberately not making any fuss about the start of new things they wanted to test, and waiting until they were certain before issuing the press release.

Be HR not HQ

Which brings us back to the policymaking psyche. I spent a year at HM Treasury; didn’t overly like it, nor particularly good at it either. What stayed with me was the postcode: SW1A 2HQ. Working for the team tracking Department of Health spending this resonated. It appeared there were two options as to how to manage relations with the Department: HQ (we’re in charge, it’s our money really, what can you do for us?), or HR (we’re a supporting service, we provide your money, what can we do to help you get the biggest bang for your buck?).

When you fill a building with incredibly smart ambitious people keen to make their mark, you can guess which becomes the dominant model. But it’s the HR role which should be the model not only for the Treasury, but for all health policy. Health care is a business delivered by hundreds of thousands of people, most with a strong professional identity, many exceptionally highly trained, interacting with people often in a distressed, vulnerable, angry, unhappy, frustrated state. Working in health and care entails a working life confronting things that human nature programmes people to avoid — such as infection, suffering and death. For national policy to adopt a default position that it’s in charge, that it’s able to tell people what to do, is naïve and simply wrong. As is often evident when performance targets are removed, you might get people to do something they disagree with for a period of time, but not sustainably.

Policy works when it understands the motivations, expertise and needs of those delivering services, and seeks to support not judge. The London Schools Challenge succeeded in large part by dropping a focus on naming and shaming, in place of tapping into a feeling of moral purpose among those involved in the programme. This is not a prescription for removing accountability, but the need for national policy to presume that those working locally are far more likely to have better information and insight than they do, and to respond accordingly. This implies more focus on development and capability building than assessment. And it requires putting the HQ to HR shift in flashing neon lights; after decades of expecting to be told what to do, policymakers need to make it very clear if they’re not going to do that — and then live by their words.

And so what?

What’s the prize for doing this? We have no money. We’re not likely to have any more any time soon. Policy can be constructive — it can contribute to happier societies, saved lives, and support when all seems lost. In short, it can help, and can do so within the messy real world it inhabits. Policymakers are not heart surgeons; the real world impact of what we do can seem distant, intangible, abstract. However the cost of not having better policy is felt by some of the most vulnerable in society. It’s time for health policymaking — and policymakers — to reclaim its credibility.

Rich Taunt is part of Kaleidoscope Health and Care. Rich worked for the UK Government between 2005 and 2014, mostly at the Department of Health.