Public management

Toby Lowe and Max French, Newcastle University Business School

 

Complex health problems such as childhood obesity confound traditional ‘scientific’ models of evidence-based policy because the dynamics of complex systems – and not single factors or agents – determine their causation. Recent public health scholarship has argued for the use of complexity-consistent research methods that respond to this conceptual shift to better inform public policy. In this essay we go further, arguing that tackling complexity requires evidence to be created and used, not just in public policy, but throughout the ongoing management of public services and interventions. We present a model of evidence within public management that reflects this view through the dynamic creation and use of evidence by practitioners in social learning systems.

Evidence, public management and obesity

Evidence currently informs public management practice in two ways. Firstly, alongside the rise of evidence-based policy, public management has positioned itself as a discipline of implementation, or evidence-based public management (EBPM). This has involved using metric-based performance management, audit and inspection mechanisms to enforce fidelity to a pre-conceived ‘best practice’, itself assumed to be informed by a reliable body of scientific evidence.

The UK government’s 10-year obesity action plan adopts this model by attempting to regulate the behaviour of public agencies according to best practice. For instance, public bodies are encouraged to adopt Government Buying Standards for food and catering services, while schools are invited to adopt the updated School Food Standards and deliver at least 30 minutes of physical activity for every pupil each day. Public service delivery is considered just once within the strategy, as a commitment to skill up health care professionals to discuss nutrition and bodyweight with families. Even here, however, the intention is to make sure central evidence-based standards are more closely followed.

EBPM fails in the myriad of areas of public and social policy where unambiguous ‘scientific’ evidence is not available and best practice is uncertain. The response within public management has been to adopt forms of outcomes-based public management (OBPM) – including payment by results schemes in commissioning, league table approaches among providers, or results-based accountability in service management. Here, performance incentives are tied to the production of evidence of impact on predefined metrics. For example, the use of payment by results methods in commissioning within the NHS has been expanding since the 2003 NHS Plan, covering 30% of the NHS budget in 2012, and more recently expanding to mental health and community services commissioning.

OBPM differs from EBPM by focusing on the creation of evidence, rather than its utilisation. It is important to note, however, that both approaches adopt the same standards of evidence as traditional evidence-based policy and evidence-based medicine. Both routinely call for ‘objective’ scientific methods like randomised control trials and other experimental methods, while diminishing the validity of personal experience, in-depth qualitative methods, and contextualised evidence.

Dealing with complexity through public management

What both EBPM and OBPM ignore is that all societal outcomes – including public health problems like obesity – are not created by individual policies or service interventions, but emerge through the dynamic and unpredictable interaction of biological factors, personal decision making, multiple service agency interventions, and broader social determinants. Public health outcomes are therefore complex on several grounds:

  • causally, since they emerge through ensembles of interacting mechanisms across multiple nested systems
  • dynamically, since changes in individual, cultural, economic, or technological factors co-evolve dynamically and unpredictably
  • experientially, since individual conditions, preferences and local contexts can vary significantly from person to person.

Policies and interventions must therefore respond to enormous variations between individuals and local contexts, which themselves change unpredictably over time. Yet the model of evidence that underpins and validates EBPM and OBPM is intrinsically at odds with such a world view. The experimental and statistical methods prized within scientific evidence ‘hierarchies’ infer causation from aggregated correlations between variables, and in the process strip away the complexity of lived experience and the contexts with which policies interact to shape outcomes. Experiential knowledge and qualitative insight meanwhile – seen as subjective and unreliable in a scientific model of evidence – become essential in making policies relevant to the varied and rapidly changing contexts into which they are deployed.

Meaningfully addressing complexity requires approaches that adopt a new complexity-friendly public management paradigm. This operates by:

  • increasing the capacity of local actors to adapt to achieve an agreed purpose
  • creating the space for local actors to develop bespoke interventions, based on a deep understanding of client needs and local context
  • creating learning environments for local actors to create and use evidence contextually, and inform judgements within a broader system
  • ensuring this system is healthy – there is a shared purpose, the necessary actors are sufficiently connected, and trusting relationships exist to encourage the sharing of errors and reflective practice.

In recent years, public management practice has demonstrated ways of engaging meaningfully with this paradigm. In public health, quality improvement initiatives have put local actors in charge not just of implementing evidence, but of creating and sharing it. In social care, personal outcomes approaches like Cook and Miller’s Talking Points respond to the variation in causal pathways to effective care by negotiating roles between providers and users in pursuing shared outcomes. In the field of community nursing, the Buurtzorg approach has used small self-managing nursing teams, freed from narrow performance targets, to respond quickly to fast-changing individual needs of their service users, with promising results. Such arrangements bear conceptual similarity to what Bawden describes as ‘critical social learning systems’ – boundary-spanning networks of practitioners committed to open reflection on practice.

The meaning of evidence within a complexity-informed public management

The approach of social learning systems upturns the traditional evidence hierarchy. It makes experiential evidence – and not just objective ‘scientific’ evidence – essential to informing effective service responses. This recalls Michael Lipsky’s conception of ‘street-level bureaucrats’. However, beyond merely re-interpreting evidence-based policy, front-line practitioners become essential in creating locally effective policy by negotiating the balance of scientific and experiential evidence. Since causation in the context of health outcomes cannot be fully understood in the aggregate, the significance of this role in creating and deploying evidence becomes critical in the management of complexity.

Calls have been made in public health for a ‘real’ evidence-based medicine that responds to the lives of service users. While having merit, such ambitions cannot be achieved by treating complex health outcomes like childhood obesity as matters for resolution through policy change alone. The causal, dynamic and experiential complexity of health outcomes can only be resolved by engaging those involved in public management in the creation of locally appropriate evidence. However, this involves a new model of evidence within public management itself, to move beyond the scientific objectivism of both EBPM and OBPM, towards the negotiation of scientific and experiential evidence within social learning systems.

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