The world of Policy and the Salzburg Statement

With his recent elevation to Taoiseach, something Leo Varadkar (who was supposed to work with me when I did a locum in Tallaght in May 2007… but he was occupied with some election or other) said in the late 1990s got a fair bit of coverage. This was to the effect that as a doctor you can help a few people, but as Minister for Health you can help millions. While at first glance this seems like a truism, it has for some reason got under my skin. There are various reasons for this, not all of which I will get into. Perhaps I am jealous of a road not travelled! (I am pretty confident I am not)

In a way it sums up a particular seduction – the seduction of the World of Policy. Get interested in any field – from the natural world to technology to medicine indeed – and sooner or later the siren song of policy will be heard. Wouldn’t it be great to Make A Difference not just on the piecemeal, day-to-day way, but on a grander scale? Increasingly I think not. Clearly someone needs to formulate policy and to think about things on a broad scale – but they should do so without illusions and with a certain humility. People have a habit of behaving in a way that the enlightened policy makers don’t foresee.  The circuit of conferences and “networking” can become an echo chamber of self congratulation. Doing good, perhaps, is best done on a smaller scale.

These thoughts are occasioned by reading about the Salzburg Statement. This is something I heartily approve of – a call for action to ensure all children enjoy the right to play in a nature rich space within ten minutes of their home.  The statement is made up of eight key actions:

Eight actions to transform cities for children

  1. Ensure children of all ages, backgrounds, income, and abilities have equitable access to nature and play regularly and in meaningful ways to promote good health and wellbeing.

  2. Embed nature in everyday places used by children, such as schools, backyards, parks, playgrounds and city streets, to make the city into a natural outdoor classroom.

  3. Involve children in designing and planning natural spaces for recreation, education, inspiration and health, to give them ownership and pride in their local communities, schools and parks

  4. Build curiosity, wonder, and care for nature in children (for example by greening school grounds and involving children with community gardens).

  5. Protect natural features across cityscapes and create an equitably distributed network of accessible green and nature-rich spaces that all generations can reach on foot.

  6. Connect cities with the broader ecosystems in which they are embedded, creating corridors for people, plants and animals to move safely across the city and into its surroundings.

  7. Establish more urban conservation areas to increase access to nature and connect cities to the broader protected area network.

  8. Work together through cross sectoral and multi-level partnerships to build an inclusive culture of health in cities.

 

There’s nothing there I would disagree with, though as with all these kind of interventions I would like more robust dissection of what, say, Item 3 would mean in practice.

I am always a little wary of dressing up worthy activity in the mantle of Health. What Resting a case for nature on the vagaries of purported health benefits can be a dangerous and debunkable game – especially with the media. This visual  handily shows how media can seize on single studies to generate headlines:statins.png

One can easily imagine a Katie Hopkins-ish journalist seizing on the inevitable ambiguities of research to “debunk” the claims for health benefits of nature.

I should state very clearly I have no reason to think that the Salzburg Statement is a wonderful initiative I look forward to hearing more of. But I am a little wary of the siren call of the World of Policy.

Evidence based medicine and evidence based policy

There was a fair bit of media coverage of the finding that teenage-pregnancy-prevention programmes using simulated babies are associated with an increased rather than decreased teenage pregnancy rate. Some of the media discussion focused on the role of evidence in public policy.

Via Twitter, I came across this article on evidence-based policy by Howard White in The Independent

Evidence-based medicine has transformed medical practice. TheCochrane Library has published more than 6,000 studies summarising high quality evidence for health interventions. Notable cases include breast screening, which used to be recommended for women from the age of 40 until the evidence showed that the number of false positives recorded was in fact doing more harm than good. The risks from unnecessary surgery were greater than the often small benefits from early treatment forbreast cancer.

Hormone replacement therapy (HRT) is another example. It was routinely used to reduce heart disease, but then became far less common when evidence showed adverse effects. There is now a more nuanced understanding of which women will benefit from HRT and which will not.

Prior to Cochrane, doctors based their advice on out-of-date knowledge, personal experience and the influence of drug reps. Today, doctors have access to evidence-based guidelines. Decisions on what the NHS can and should fund are informed by the advice of the National Institute for Health Clinical Excellence after a review of the evidence.

So why can’t we do the same for social and economic policy?

For those who are interested, I engaged (or am engaging) in a twitter exchange on this with Howard White, whose replies have been very gracious. As in so many of these exchanges I suspect that we agree on more than we disagree on (and possibly agree on everything with a difference in emphasis)

Of course policy should be based on evidence, where available. This not only seems extremely reasonable and  rational – it is eminently reasonable and rational. I also write as an admirer of the Cochrane Collaboration.

However, I always feel a sense of caution when clinical concepts are introduced into political discourse. The best definitions of EBM always include the word “judicious”, as here

“Evidence-based medicine is the conscientious explicit and judicious use of current best evidence in making decisions about the care of individual patients.”

Judicious is key – judgment and reflection are required. Does this body of evidence apply to my patient, this individual person in front of me, or does it not? As I wrote on another point:

it is one thing to have an evidence base for a specific therapy in medical practice, quite another for a specific intervention in society itself.

My review of Helen Pearson’s The Life Project is still to be published, when it does I will perhaps write a little more on “evidence-based policy”, a concept which began to enjoy great vogue in the 1990s.What Pearson’s book shows, however, is that the devil can cite evidence for his own purpose; “evidence” can be wielded with agendas.

Obviously the Campbell Collaboration aims to address this, by being transparent about the evidence used and the methodology used to synthesise it.

A further point is that evidence-based policy tends to presuppose consensus on the ends of policy  – and emphasise technocratic means of getting there. Thereby the focus on specific interventions, rather than any wider sense of not merely social goals but of social meaning. Of course, this very much in keeping with a time in which we are all supposed to be beyond “grand narratives” – which is of course itself a “grand narrative.” I would suggest that many recent events in politics around the world are best understood as testing this notion to destruction.

Bringing it all back to a question I asked a while ago about the best kind of evidence for health informatics innovations, perhaps what this illustrates is that the way we do evidence now tends to be to focus on specific interventions and, as far as possible, measure their effects as specific interventions and without reference to an overall system. Indeed, this is obviously necessary for assessing therapies and treatments. But is it necessarily missing something when it comes to a system?