I was presenting at a health conference about how ideas and innovations spread, when a Director of Public Health vividly brought home the challenges involved. He did so by answering a question about whether or not to introduce a payment reward scheme for people who successfully lose weight and maintain a healthy BMI. He answered that he wasn’t sure what the research had to say about such an approach and therefore declined to answer. I was almost speechless. My response was to pose a (deliberately provocative) question: would the use of public funds to reward people for changing their poor health habits pass the Front Page of the Paper test?
He was viewing the question through the default lens of a scientifically-trained, logical and rational mind, one which applies such cartesian logic in a specific domain in which the scientific method has been responsible for amazing improvements in human health and life expectancy. One in which evidence of what works and the need to manage risk rightly take cetnre stage. His immediate thought was to consult the evidence, just like the economist who answers the question about a four-day working week in terms of productivity and not wellbeing. Mine was to instinctively zoom out and view the question through the eyes of fellow citizens. How might they might see the morality of such an approach? ‘Your tax pounds, hard at work’. He seemed to have no thought for the irrational or the human side beyond the efficacy of such an approach.
Might not some people, for instance, be tempted to put on weight simply to be able to lose it again and thus claim the financial reward? Particularly if money is tight. Great on paper, particularly if your economics training teaches that everyone is an emotionless, rational utility-maximiser. Might not some people, having lost the weight and claimed the reward (akin to reaching the 8-week quit target for smokers), put it all back on again? Do you claim the reward a second time, a third, a fourth? Unless we unpack why people do what they do, seeking and then addressing the underpinning issues, whether eating too much, smoking, drug or alcohol abuse, shopping or debt, and so on, things will never change. This is why habit change is so difficult. Sure, just stop the undesired behaviour. Start a new one. Of course, these can help, but financial rewards or other such ‘carrots’ are only ever sticking plasters over much deeper wounds. We need to understand what is causing the wound in the first place.
And so it is that the scientific method, appropriately used in assessing the efficacy of new treatments and medicines, is also applied to all other aspects of health. It is a manifestation of the expression ‘to a hammer, every problem looks like a nail’. The challenge we face is in figuring out the context within which we are operating and whether such analysis is helpful, as it is in addressing complicated challenges. When, however, we are approaching complex challenges – such as obesity – we must beware the unintended consequences. Otherwise known as the ‘fixes that fail’ archetype, this is what happens when we act as though cause and effect relationships apply to a situation that is actually complex. In complexity relationships are emergent and we must act accordingly. This, at its heart, is why innovation can’t simply be taken from one test-bed vanguard pilot site and scaled across the rest of the country. To attempt to do so is to fail to account for context.
We might think of spread as the way ideas, practice, rumours, stories, products and the like are passed from person to person across society’s social networks. When a group is constituted as a network, there is a particular pattern of ties that connects the people involved. Connection has to do with who is connected to whom (the network structure), and contagion pertains to what, if anything, flows across these ties (the network function). One fundamental determinant of flow is the tendency of human beings to influence and copy one another, meaning that each and every one of these ties offers opportunities to influence and be influenced. This is the power of social norms. Since everything we do or say tends to ripple through our social network, it’s been found that we are influenced by those in our networks up to three degrees of separation. Since most people have about 11 close friends in their ‘core discussion network’, at three degrees of separation that’s 1,331 people who are influencing you. One of those 1331 people runs a marathon, the odds improve that you will as well. Each unhappy friend deceases the likelihood of your happiness by 7%.
Scale is often seen as a subset of spread, in that it is really about the extent to which something new has penetrated a particular market or cohort of the target audience. Beloved of silicon valley and tech start-ups, as apps and the internet make scale a more viable proposition than ever before. The idea that designing or building something once and delivering it multiple times can achieve economies of scale is misguided at best when we are dealing with complex social issues.
It is also a word combined into that most ubiquitous of phrases, ‘impact at scale’. Clearly, the need to evidence the results of an endeavour can be useful in demonstrating efficiency and effectiveness in some situations. This is less helpful when we are working in complexity and consequences can’t with any reliability be predicted. Often I think we say ‘impact’ when we mean change. Or when, more likely, we are desperately seeking evidence that what we have done wasn’t a total waste of someone else’s money and that something useful – beneficial – arose form our best efforts. By extension, ‘-at scale’ amplifies this hope through the notion that these benefits were far-reaching, thus implicitly signalling value for money. The effectiveness of impact and the economy of scale. Reinforcing linear thinking, given economy is the cost of inputs, efficiency is the cost of turning them into outputs and effectiveness is the results they achieve. Of course, it’s hard for anyone – employee, commissioner, CEO – to admit that since they are working in complexity it is almost impossible to predict the outcomes of their endeavours and thus disingenuous to claim the credit for them. They need, instead, more nuanced ways of exploring and evidencing the difference they are making in the world.