Meet the local policy workers: Implementation of health promotion guidelines in Denmark
| DOI | 10.1177/0952076716683568 |
| Author | Camilla L Wimmelmann,Anja MB Jensen,Signild Vallgårda |
| Date | 01 January 2018 |
| Published date | 01 January 2018 |
| Subject Matter | Articles |
Public Policy and Administration
2018, Vol. 33(1) 66–87
! The Author(s) 2016
Meet the local policy
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workers: Implementation
DOI: 10.1177/0952076716683568
journals.sagepub.com/home/ppa
of health promotion
guidelines in Denmark
Camilla L Wimmelmann,
Signild Vallga˚rda and Anja MB Jensen
Section of Health Services Research, University of Copenhagen,
Denmark
Abstract
Reporting on an interview and observation-based study in Danish municipalities, this
article deals with local policy workers and takes it’s departure in the great variation we
observed in implementation of centrally issued health promotion guidelines. We pre-
sent five types of local policy workers, each of whom we found typified a specific way of
reasoning and implementing the guidelines. This typology illustrates the diversity found
within a group of local policy workers and helps explain the variability reported in most
studies on policy/guideline implementation. On the level of individuals, variation in
implementation is often explained by the implementers’ perceptions of need for, and
potential benefits of the policy, self-efficacy and skill proficiency. We add ‘professionally
related experiences’ as another explanation. We introduce the concepts of translation
and hinterland to understand how and why people in the same positions receiving the
same set of guidelines implement them differently and suggest that local policy workers’
professionally related experiences affect the frames in which they translate the guide-
lines and decide upon the strategies of implementation. As such, this article illustrates a
residual order of implementation practice: the unruly and elusive part of public policy
implementation, ordered only partly by the centrally issued policies.
Keywords
Guidelines,
health
promotion,
implementation,
local
policy
workers,
public
administration
Corresponding author:
Camilla L Wimmelmann, Section of Health Services Research, University of Copenhagen, Øster
Farigmagsgade 5B, Building 10, 1014 Copenhagen K, Denmark.
Email: cwi@sund.ku.dk
Wimmelmann et al.
67
Introduction
This article deals with the local implementation of centrally issued public policies
by taking the national Danish health promotion guidelines as a case. In so doing, it
focuses on the people who are presupposed to implement the guidelines locally –
namely, the local policy workers, defined as the people working with the local
government’s strategy, implementing and assigning the local priorities and mana-
ging as well as shaping the local services. In this article, we put a face on the local
policy workers and illustrate how the implementation of public health guidelines is
shaped by the policy workers’ professionally related experiences.
In public policy, and especially within the field of public health, guidelines are
abundantly issued by central governments to streamline or standardise the local
authorities’ practices (Rod and Høybye, 2015) according to an often evidence-
based routine or sound practice. Thus, we regard guidelines as a policy in the
following. Inherent in the use of guidelines as a form of regulation (Timmermans
and Epstein, 2010) is the premise of a linear knowledge-to-action process (Hjelmar
and Møller, 2015). This premise is a matter of a rather straightforward and top-
down mechanistic and apolitical process of implementation in which the local
policy workers are expected to carry out the guidelines as formulated and endorsed
by those in authority such as politicians – reflecting the belief that local policy
workers are neutral conduits through which guidelines flow intact and unmediated
(Kingfisher, 2013). As such, regulation by the use of guidelines adheres to a
‘technocratic idea of rational policy’ (Jenkins, 2007), even though scholars decades
ago showed that such rational models of policy-making were ‘not effective in prac-
tice, nor convincing in theory’ (Parsons, 1995: 468). Yet the premise of regulation
by the use of guidelines greatly resembles the belief in ‘rational policy’ processes
and practices (Cairney, 2009; Hjelmar and Møller, 2015; Jenkins, 2007; Markussen
and Wackers, 2015).
Inspired by the seminal work of Michael Lipsky (1980), a range of scholars have
shown that the actions of the local policy workers very often diverge from the
stated policies (May and Winter, 2009). Lipsky (1980) illustrated how so-called
‘street-level-bureaucrats’ adapted the objectives of social policies to suit their cli-
ents’ or their own preferences, and concluded that policy implementation, in the
end, comes down to the people who actually implement it. This strand of academic
work is grounded in a constructionist view of social reality, presenting public policy
as a (discursive) construct that turns on multiple interpretations (Fischer, 2003),
and shows how ideals of basic societal goals, pursued by policy-making, often
conflict in policy implementation (Stone, 2002).
Though Lipsky’s work concerned the discretion used by those directly engaged
in policy delivery on the frontline, other studies (e.g. Brewer, 2005; Freeman, 2006;
Kingfisher, 2013) have likewise shown that local policy workers influence the poli-
cies; they interpret and reformulate the policies when they put them into practice.
Actually, as Kingfisher (2013: 62, emphasis in original) claims, ‘in the business of
taking up and doing social policy, those [local policy workers] are key: they are the
means by which policy practices and the ideas informing them are materialised and
68
Public Policy and Administration 33(1)
sustained’. As a result, centrally issued public (health) policies and guidelines are
not merely implemented but rather made through the everyday practices of the
local policy workers (Freeman, 2006; Freeman and Maybin, 2011; Jenkins, 2007;
Kingfisher, 2013). In other words, the local policy workers are very influential in
regard to the actual realisation of centrally issued public health guidelines and thus
in terms of the services provided to citizens.
The empirical findings of these studies stress the importance of methodologies
that emphasise studies of local policy workers’ roles. Such approaches with an
explicit interest in what happens ‘on the ground’ have greater explanatory potential
(Hupe, 2014; Hupe and Hill, 2016). Our ‘advanced implementation study’ (Hupe,
2014) treats the intentions of the guideline (makers) as only one among a range of
variables explaining the implementation variation. In so doing, we emphasise that
local policy workers are not merely ‘local policy workers’; they are people – they are
human individuals whose actions are, like everyone else’s, guided by unarticulated
and embodied understandings rather than expressed rules and prerogatives
(Freeman and Sturdy, 2014; Kingfisher, 2013; Taylor, 1995). Yet the local policy
workers, as implementers of public health guidelines, have been handled as
a homogeneous group of people (such as ‘the civil service’, ‘street-level bureau-
crats’, etc.) in most studies, implying that the knowledge we have of those people is
limited – in fact, we know ‘surprisingly little’ (Freeman et al., 2011: 128; Wagenaar,
2004: 643).
The aim of this paper originates from an empirically based curiosity. While
studying how the Danish national set of centrally issued health promotion guide-
lines was enacted locally in the Danish municipalities, the variation we saw in how
the guidelines were implemented could not be (fully) explained by ‘traditionally’
suggested modifying implementation factors, such as organisational structure, per-
ceived need and agency or financial resources (Durlak and DuPre, 2008;
McConnell, 2015). Focusing on the level of individuals, variation in implementa-
tion has primarily been explained by the implementers’ perceptions of need for and
potential benefits of the policy (Winter, 2003); self-efficacy and skill proficiency
(Durlak and DuPre, 2008); self-interest (Maynard-Moody and Musheno, 2000)
and ‘policy accumulation’: that public professionals often are confronted with
(a series of) policy changes, intended to refine, replace or complement other policies
which results in professionals having a certain predisposition towards policies in
general (van Engen et al., 2016). However, in general, and as Steijn et al. (2012: 4)
argue, at the level of individuals ‘public administration has historically looked
primarily at the content of public policies and discretion issues for explaining the
implementers’ willingness to implement public policies, [but] it seems that this does
not provide the full picture.’
The closer we looked at the moments in which decisions pertaining to the guide-
lines were made, the more the guidelines dissolved into a multiplicity of logics and
strivings for different goals. In some of those moments, the guidelines related to the
centrally issued guidelines in nothing but name. In analysing the variation in the
implementation of the guidelines, we noticed the significance of the policy workers’
Wimmelmann et al.
69
professionally related experiences for how they put the guidelines into practice. The
term ‘professionally related experiences’ should not be confused with professional
‘skills’ or ‘capabilities’ as are handled in literature on ‘professions’ and ‘profession-
alism’. Rather, we have constructed this term to grasp the concrete experiences/
situations that the local policy workers have encountered in their professional lives
and which have formed the local policy workers’ attitudes and...
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