Who influences policy and why?

1. Who influences policy and why? • Understanding strategies to influence the policy process Kathryn Oliver kathryn.oliver@manchester.ac.uk @oliver_kathryn

2. Outline • Knowledge brokerage as the ‘answer’ to the EBP ‘problem’ • Approaches to studying KB • Activities of policy actors as a lens • Who are KBs? • How do they influence policy?

3. Evidence-based policy research • Explicitly aims to • increase amount of research used in policy • to ‘upskill’ policy makers • to present joint narratives of how evidence is used in the ‘black box’ of policy Oxman et al. Health Research Policy and Systems 2009 7(Suppl 1):S15

4. Evidence-based policy research i.e. the research Is framed as a “problem” that evidence is not used in research What effect does this framing have? Oxman et al. Health Research Policy and Systems 2009 7(Suppl 1):S15

5. Solutions offered by researchers... Social relations known to affect use of evidence, finding of information, decision-making and many other aspects of policy making

6. KB activities

7. Knowledge brokerage is... A intervention (set of actions) carried out by academic/research-based individuals in an attempt to influence policy processes Policy-makers Academia KB

8. Stumbling block… Policy process models unverified, unvalidated, unhelpful If we don’t understand the policy process, how can we influence it? Oxman et al. Health Research Policy and Systems 2009 7(Suppl 1):S15

9. Questions remain…. WHO influences policy? HOW do they influence policy? & Can we compare [KB] with [strategies used to influence policy] as two sets of activities?

10. NHS North West Regional Director of Public Health (Emma) Heywood, Rochdale & Middleton PCT Bury PCT Manchester PCT Salford PCT Bolton PCT Oldham PCT Directors of Public Health Chair: Alistair Trafford PCY Stockport PCT Ashton Leigh and WIgan Data Chief executive Chairman of board Directors (Finance, Medical, Nursing, HR, Public Health) Non-executive board members

11. Data

12. Influential policy makers 225 network members

13. Data 42 interviews (formal and informal) with academics, policy actors, public health professionals 18 hours observations of public and private meetings Generating accounts of evidence use, policy processes and policy networks

14. Data From these accounts, KB activities identified – and who used them

16. Who are the knowledge brokers? • Within transcripts, identify where • Respondent describes themselves as using one or more KB activities • Describes someone else as using KB activities • Use these data to generate a network

17. KB results NHS Council Public health Universities Size ∝ number of nominations Darkness of line ∝ strength of tie

18. KB results: strong ties only NHS Council Public health Universities Size ∝ number of nominations

19. What does this show us? • People already within policy community act as knowledge brokers • Main KBs appear to be NHS and council managers • Self-nominations common

21. Does the concept help us to understand the policy process? • Roles not played by academics or researchers • Exchange or brokering of knowledge part of policy process • Focusing just on this aspect risks ignoring • Wider strategies used to influence policy • Policy makers’ conceptual understanding of policy process

22. KB as part of policy entrepreneurship framework

23. Creating and managing key organisations [The Commissioning Programme Board] manages business on behalf of the Chief Execs...everybody knows how business is done....But I would say that because I invented it. NHS manager_10 If my job is just to make stuff happen and get the correct outcome from meetings..., you know, collate the evidence, you have the discussions outside the meeting, you see who's with you, you think about how to present the case, you... it's one of those things of “never going into a meeting with a proposal without knowing exactly how it's going to come out of the meeting”….. That sounds terribly manipulative but to me it's about momentum NHS manager_9

24. Deciding the topic and detail of the policy Me and Alistair, we were trying to get sentences into [a key economic document] for about a year. Basically what would happen would be the document as would be written would occasionally manage to get to my desk at which I would put in various sentences which would ... some would get pruned out some would get in. Or you’d be constantly writing to Alistair about the arguments so he felt that he had sufficient strength behind him to be able to say “This is it, this is the case”. Public health intelligence_1

25. [Alistair] would exercise a certain degree of leeway in interpreting ...those instructions [from the DPH], but nonetheless in general...he wouldn't want, to substitute their own professional judgment because he isn't himself a public health professional... he's a doer and an implementer. ...So when he's got that policy, erm that lead he, the he kind of really takes it on and runs with it DPH_10 ....Alistair’s almost the acceptable face of mad DPHs, isn't he really. Managerial translation, I'll have a chat with him behind the scenes Council officer _6 NHS manager_10 = Alistair Managing other people

26. Me, Alistair and Evan, we’re running this place, in the core group... we know where power centres are, we know how far to nudge, we know how to attach an idea to [his chief exec}... that’ll make her look good in AGMA Chief Execs. Council Officer_6 We can’t just sit in an office and dream things up... I think a lot of people forget that that’s how things work in the real world, is through relationships and it does take time to build relationships, to build trust, and so you know, reorganisations that lose lots of people mean you just have to start all over again because that is how it, that is how the world works, that’s how you get things done. DPH_8 [Alistair’s] connectedness is indisput...you know his capacity to take, the information that he gets from the DPHs to influence... right across the AGMA structures...and that sort of work and relationship with a very wide range of officers where he keeps his fingers on the pulse that’s... is very very powerful. DPH_10 Using relationships

27. Example: alcohol MUP • Creation of GM Health Commission • Had to take action on alcohol as key priority area • Alistair managed papers for meeting • Alistair, Evan and Sam (policy managers) identified MUP as a possible policy • Identified experts to attach to policy • Drew up policy papers • Identified executives to present and champion policy • Persuaded local and regional senior figures to endorse the policy • Policy considered successful because GM now much more visible • Individuals involved had greater credibility • Bargaining position with Westminster strengthened.

28. Knowledge ≠ evidence Evidence is used as part of a negotiated political strategy I'll get a confident view from the DPH when she's in her own space, that it's an evidence-based intervention, that it's adding value... [Then] other senior views coming through around “[is this] giving bang for the buck” and so forth so then the confidence of the DPH not coming through in the same way ...in fact knowing which side her bread's buttered and shutting up. And then in the end the person who made the decision ...was the leader of the council who came up with his own elegant solution, which was “we'll continue to give it to the under-16s because that's a political winner, we'll do a little bit of targeted stuff for means-tested” ...after all the heat and noise from the evidence-based experts.. Council officer_6

29. Understanding and using relationships vital Even within acadaemia, if you said... oh I searched the evidence and so on, if you want the answer to something, usually what you do is you email somebody you know, and say “What about this?” and they’ll connect back to you with people…You could argue it's a way of quickly getting to the evidence cos all you're trying to do is use your contacts to try and find someone who knows about the issue that you're interested in (Clinical academic)

30. Message or messenger? Individuals’ characteristics (credibility, likeability, trustworthiness) influenced how messages were received [The individual] with the responsibility for this piece of work erm is somebody who erm has had a very very longstanding interest in [the area] but at the same time, [their] manner can antagonise some people. So there was that, I think, something about the messenger.....The messenger kind of clouded the message... (Board member, NHS)

31. Insiders and outsiders: qualitative descriptions • Core group of actors involved in all stages of policy • Some actors were not influential - did not want to be, did not have skills, had wrong characteristics • Key characteristics included: being ‘sensible’, ‘credible’, being ‘on message’ i.e. endorsed by other influential people • Being able to identify, create, maintain & finally exploit relationships as a strategy to influence policy

32. Revisiting the KB concept Academia Policy-makers KB

33. Revisiting the KB concept

34. Conclusions • KB activities can and do influence policy... • ...but only when used by the right people as part of a wider ‘toolkit’ of strategies • Very difficult to do effectively if not embedded in policy community • “Message” content is not as important as “messenger” characteristics • Current approaches to ‘tackling’ EBP are likely to fail unless actor- and relational factors are taken into account • Effective leadership and mobilisation of the policy machinery is dependent on an ability to make and exploit relationships beyond those associated with knowledge production and translation

35. Implications Proposing the ‘solution’ of KB to the ‘problem’ of EBP risks ignoring (the importance of) day-to-day activities of policy makers While important to help policy makers find and use evidence, literature does not acknowledge the fact that there are already individuals using KB activities Identifying these actors and describing their strategies / activities used to influence policy illuminates components of the policy process itself Focus on empirical descriptions sheds new light on the policy process and questions utility of current research foci in EBP Implies that to be influential, researchers should consider adopting a pro-active approach to make & exploit links with influential actors, using practical targeted messages

36. So what? • Assumptions that policy makers do not use evidence & require help from generalist researchers are challenged • Should we continue to focus on knowledge brokerage and transfer as a means of researchers influencing policy?… or • Does the policy entrepreneurship framework of activities offer a new way of understanding policy processes? • Does this imply that researchers who wish to influence policy need to create their own relationships and ties with relevant actors?

37. Funded by DG Research, European Commission • Thanks to Frank de Vocht, Annemarie Money & Martin Everett http://www.ccsr.ac.uk/mitchell/ Mitchell Centre for Social Network Analysis Oliver K, de Vocht F, Money M, Everett M (2013) Who runs public health? A mixed-methods study combining network and qualitative analyses. Journal of Public Health (epub 5th April) Oliver K, Everett M, Verma A, de Vocht F (2012) The human factor: reorganisations in health policy. Health Policy 106:6 Oliver K, Lorenc T, Innvaer S (under review) New Directions in Evidence-Based Policy Research. Public Administration Oliver K, Money A, Everett M, de Vocht F. (under review) How to make friends and influence policy. Social Science and Medicine