John Boswell, Paul Cairney, and Emily St Denny examine agencies with responsibility for preventive health policy in Australia, New Zealand, and England. They find that building and maintaining legitimacy for such agencies may come at the expense of quick progress or radical action in service of the prevention agenda.
Most public health advocates bemoan the current balance of resources in health spending and attention. They complain that far too much money is wasted on acute services, when people are already sick, rather than on preventive measures, which stop them getting sick in the first place. The problem—in this view—is low political will to do what is necessary: divert resources away from the high-profile services which dominate media attention (e.g. hospital waiting times) and towards difficult policy initiatives that might bring government into conflict with ideological commitments (think, ‘the nanny state’) and powerful industry interests (especially Big Tobacco, Big Alcohol, Big Food). The solution, in this view, is to offer bold leadership, to coordinate action, and provide a bulwark against political interference.
One particular formula, which advocates have promoted in recent times, has been an executive agency devoted to public health and prevention. Executive agencies are dedicated bodies which enjoy operational autonomy from government departments and (usually) direct access to the executive. They are integrated within government (to help coordinate policymaking functions) but operate sufficiently autonomously to ensure that their objectives are not necessarily affected by changing political context and elected policymakers’ fluctuating attention. The hope among public health advocates is that executive agencies with responsibility for preventive health can provide that missing leadership and political will. They are akin to the caricature of bold warriors, speaking truth to power fearlessly, challenging vested interests, and facing down public opposition for the sake of the greater good.
However, agencification is not a simple solution for the preventive health movement. In fact, the evidence suggests that most executive agencies falter and fail. In our research, we explore the actual effect of attempts to ‘institutionalise’ the prevention agenda in practice. We compare the trajectories of recently established agencies with responsibility for preventive health in Australia, New Zealand, and England.
We find that these agencies struggle to provide the sort of bold advocacy expected of them. On the one hand, being bold and brash brings the risk of generating too much conflict with powerful interests inside and outside government. In the Australian case, for instance, the newly formed agency made powerful enemies with the food and alcohol lobby, and failed to be seen as sufficiently useful to win bipartisan political support. It was little surprise it was de-funded within months of Tony Abbott’s Coalition government taking office.
On the other hand, being too timid also brings risks. The New Zealand agency ended up courting controversy for the opposite reason—seen as too close to industry interests and the concerns of the ruling government. The agency survives but with its reputation as an advocate for preventive health severely diminished (although recent developments, after we conducted our research, suggest this may change).
Instead, it was in the English case that we observed agency officials best managing this tension. They did so by foregrounding the relatively uncontroversial benefits that public health could provide, and backgrounding their more challenging prevention work. One official we spoke to even described himself as a ‘prevention ninja’. He argued that, rather than providing outright leadership for preventive health, it was more profitable to pursue this agenda by stealth, building and leveraging good will with other powerful actors:
So, for example, what would be the point of doing something which upset the NHS, if you want them to deliver some evidence-based interventions which are likely to have an impact on public health? So we’ve got to play canny. It’s about using our relationships.
The implications of these reflections are important. We confirm that creating agencies cannot solve the prevention problem, as the viability of agencies depends on a complex configuration of factors which shift over time. We learn that such agencies may actually serve this agenda better by emphasising technical public health programmes and sneaking prevention in the back door rather than by offering the allegedly ‘bold’ advocacy many envisage. Building and maintaining widespread legitimacy for such agencies, and their work, may come at the expense of quick progress or radical action. However, it ensures that agencies can walk before they try to run.
Note: the above draws on the authors’ published work in Social Science & Medicine.
Paul Cairney is Professor of Politics and Public Policy at the University of Stirling.