Tackling wicked problems through street-level diplomacy: the case of antimicrobial stewardship in Northern Europe

Antimicrobial resistance (AMR) can be considered a wicked problem because the phenomenon is characterised by multiple, interdependent factors, functioning within ostensibly intractable dynamics. Collaborative or networked governance is often seen as the most appropriate approach to address wicked problems, and there is often scepticism regarding the scalability of micro-level local solutions contributing to neglect in the literature of the role that street-level actors play. Our study focuses on AMR stewardship practices in Northern Europe (Netherlands, Sweden and England), a region which has been relatively successful in controlling antibiotic use in healthcare. We conducted purposively sampled, theoretically-informed, qualitative interviews to explore stewards' practice as policy actors – how they carried out their tasks, worked with others, and dealt with tensions in their role. Using abductive analysis, we demonstrate that participants pursued sustained engagement with antibiotic prescribers and sought creative ways of working with, rather than against, embedded professional values. They deployed deliberative and diplomatic relational practices to build trust. Street-level diplomacy offers a theoretical framework for understanding how policy actors can work in the context of wicked problems. Street-level diplomats operate, with high levels of discretion, within complex, adaptive systems utilising their relational skills to build dynamic forms of influence amongst those implementing policies that have direct impact on citizens and services users. This provides a pragmatic analytical route through the extremes of romanticised calls for ‘collaboration’ to solve wicked problems or critical perspectives that suggest that wicked problems are intractable.