Exploring the Economic Dimensions of Complexity: A Post-Positivist Evaluation of Diabetes Policy and Governance

The Evidence-Based Policy movement has become increasingly attendant to issues of complexity, with “realist” and “theories of change” methodologies now established. Yet there is scope to develop the field in this regard: economic evaluation remains firmly neoclassical despite significant criticisms of the framework. Frank Fischer has argued persuasively that issues of choice and efficiency are too normatively contested to reduce down to monetary measurement (Fischer and Forester, 1993). Furthermore, evaluations typically focus on specific polices or interventions: there is scope to develop methods to address evaluative questions of governance, concerning the arrangements through which policies are developed and delivered (Torfing et al., 2012). The present paper develops an innovative approach to evaluation by combining postpositivist “frame” analysis with heterodox political economy. The challenge of governance is conceptualised as one of facilitating coordination, a concept central to political economy. By analysing and contrasting stakeholder “frames” at different levels of governance, it is possible to establish whether and to what extent coordination is occurring. This is applied in a case study of diabetes, following the passage of the Health and Social Care Act (2012). The empirical research included thirty interviews with diabetes stakeholders between January 2012 and March 2015, spanning public health, primary care and secondary care. Stakeholders were asked for their appraisals of policy and governance, using the SWOT interview technique. Strengths and opportunities included the potential opened up for joined-up working across local authority departments and patient-centred care in general practices. Yet constrained resources, the Quality and Outcomes Framework and the purchaser-provider split were widely viewed as problematic to the successful delivery of diabetes services. The paper ends with a brief discussion of Sustainability and Transformation Plans (STPs), based on the research.