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EDITORIALS: Sally Macintyre Evidence based policy making BMJ 2003; 326: 5-6 [Full text]

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A Modest Proposal

Woody Caan   (7 January 2003)

Evidence based clinical governance - who cares?

Usiakimi Igbaseimokumo   (9 February 2003)

Evidence based policy making

Alexander E Limentani   (2 March 2003)

Also still needed: a consistent metric for quantifying health inequalities

Allan Low   (13 January 2004)

A Modest Proposal 7 January 2003
Woody Caan, Professor of Public Health Department of Public and Family Health, APU, Chelmsford, Essex CM1 1LL. Send response to journal: Re: A Modest Proposal	Macintyre (1) has made a valuable contribution to future health outcomes research, by clarifying the urgent policy need to incorporate measures of health inequalities when assessing overall health improvement. To convince a largely (99.6% vs 0.4%) indifferent research community, I suggest a modest demonstration project. This project should not appear radically new, but rather build on existing knowledge, for a clearly defined population, subject to major socio-economic inequalities, and for whom policy makers have identified several potential, sharply-focused interventions. Above all, individuals within the socially heterogeneous population should present with an unambiguous clinical outcome. Illicit use of drugs like heroin, methadone and cocaine present a widespread challenge to both policy makers and public health professionals, with a key problem in evaluating different interventions being the need to place individual “outcomes” within some wider societal context (2). Both individual users and those who live close alongside them are at risk. Used between the ages of 15 – 25, these substances are strongly associated with a downward socio-economic trajectory (3). There is a contextual relationship between the risk of drug-related harm and the experience of social capital and solidarity (4). In 2001, the UK government decided on an Action Plan to Prevent Drug-Related Deaths, climaxing in 2003 with a specified package of interventions. Crucially, an interdisciplinary group has been developing a “specialist register of drug related deaths in the UK” (5). Most public health professionals would acknowledge death as a pretty unambiguous clinical outcome. Over time, a significant reduction in the drug-related deaths among the most disadvantaged young people (say, those in care, or the homeless, or youth offenders, or residents in the least desirable postcodes… ). A modest extension of the established register would enable a realistic demonstration of the impact of national policy on an area of manifest health inequalities. Will implementing the Action Plan save the life of an illiterate 15 year old runaway squatting in a derelict Glasgow flat, or only the more cherished children of parliamentarians in Westminster ? Woody Caan, professor of public health. Department of Public and Family Health, APU, Chelmsford CM1 1LL. 1 Macintyre S. Evidence based policy making. BMJ 2003; 326: 5-6. 2 Sindelar JL, Fiellin DA. Innovations in treatment for drug abuse: solutions to a public health problem. Annu Rev Public Health 2001; 22: 249-272. 3 Economic and Social Research Council. Disconnected Youth ? Young people, the “underclass” and social exclusion. Youth, Citizenship and Social Change Research Briefing 2002; 6: 3. 4 Caan W. Adolescent drug use and health: problems other than dependence. In: Caan W, de Belleroche J (eds) Drink, Drugs and Dependence. From science to clinical practice. London: Routledge, 2002; 145-170. 5 Ghodse H, Oyefeso A, Corkery J, Baldacchino A (eds). Drug-Related Mortality: perspectives across Europe. London: European Collaborating Centres in Addiction Studies, 2002. Competing interests:   In the words of Jonathan Swift (1729): "I profess, in the sincerity of my heart, that I have not the least personal interest in endeavouring to promote this necessary work, having no other motive than the publick good of my country, by advancing our trade, providing for infants, relieving the poor, and giving some pleasure to the rich."
Evidence based clinical governance - who cares? 9 February 2003
Usiakimi Igbaseimokumo, Consultant Neurosurgeon Hamad Hospital, P.O.Box 3050, Doha, Qatar Send response to journal: Re: Evidence based clinical governance - who cares?	It is increasingly the case that a doctor cannot even ‘cough’ or ‘sneeze’ without being asked to provide the evidence for these natural functions. Yet isn’t it amazing and sometime frightening how many new policies concerning how doctors perform their duties are introduced with little thought much less evidence? I read with great satisfaction Sally Macintyre’s editorial on evidenced based policy making and you wonder who the government asked for advice before the current clinical governance program was introduced. This is supposed to be the epitome of objectivity in quality assurance yet it does not include any means of measuring its effectiveness? The great confusion about what the appraisal component means would have convinced any bystander that it was planned by people who spoke Greek, Hebrew or Latin and is being implemented in English. Every single clinical director had a different view of what appraisal involved and how it was supposed to be implemented. I was in a clinical governance meeting once in London and the discussion arose about a erring registrar whose crime was that he did not share the views of the clinical director on having a multidisciplinary team meeting every week to demonstrate their team spirit. I was mortified that all the clinical director could lament about was that “in the olden days people like this were just frustrated out at the senior registrar hurdle” The superficially and egocentricity of his comment made me wonder again and again why we were attending a course about objective evidence of quality assurance that lacked any inherent means of assessing it’s effectiveness. Surely the first thing any objective planner will do is to define the magnitude of the problem- for instance to what extent current clinical practice defers from expectation and the level of risk patients are exposed to? If not how can one say in ten years if clinical governance has been effective or not and to what extent? Is it perhaps like Bristol that we wish we never knew about the mess? The anaesthetist who blew the whistle in Bristol has had to leave the country ostracised from the system he sort to improve. Just like the registrar alluded to above and Stephen Bolsin,how many other whistle blowers are scapegoats of the system? So are we deliberating avoiding evidence so that our failures may be swept under political jingoism? Competing interests:   None declared
Evidence based policy making 2 March 2003
Alexander E Limentani, Director of Public Health East Kent Coastal PCT, Protea House, New Bridge, Marine Parade, Dover, Kent. CT17 9HQ Send response to journal: Re: Evidence based policy making	Macintyre(1) is right to point out that the evidence base for tackling inequalities in health is lacking. This is paradoxical given the number of studies that have been carried out in recent years(2). However, the evidence base is extensive but not the kind of evidence required for macro-policy making. Scientific studies about particular inequalities and local projects such as smoking cessation, Sure Start, Healthy Schools, describe controlled micro-environments related to individuals, small communities and service interventions. These studies throw little light on policy making to achieve a more equitable health for society as a whole. To think that it would is analogous to expecting the evidence about what makes small businesses flourish to apply to achieving a sound national economy as a whole. Our social science evidence-base, although eloquent on local initiatives, is largely silent about the big picture of what will make a healthy population in the future. The policy to tackle poverty and improve the lot of the worst off in society is a political and moral agenda, which has strength and standing. It does not need an evidence-base for us to know that it is a good thing. We do need more evidence about the effects that different approaches have on the health of the poor and the rest of society. But by its nature society is not a closed, controlled environment and social studies have had little to say about the wider context. If we want to discuss those areas we need to understand better the role of more global influences like vested interests and the cultural, political and spiritual factors that influence what people want. It is important that the lack of evidence-based policy does not stop us taking evidenced-based action at a local level. There are micro- environmental changes that a PCT can influence that will improve the lot of deprived people and will improve local equity of access to services. Enabling small-scale local changes is a good policy and one that we should continue to champion. __________ 1 Macintyre S. Evidence based policy making. BMJ 2003;326:5–6 2 Acheson D. Independent inquiry into inequalities in health: report. London: Stationery Office, 1998. Competing interests:   None declared
Also still needed: a consistent metric for quantifying health inequalities 13 January 2004
Allan Low, freelance health economist Bowser Hill Farm, NE17 7AY Send response to journal: Re: Also still needed: a consistent metric for quantifying health inequalities	Macintyre's editorial about the dearth of assessments of the impact of interventions on health inequalities (1) rightly emphasises the importance of monitoring the impacts of programmes and using routine statistics to assess differential effects on different socio-economic groups. A problem with this, that she did not mention, is the lack of attention the UK government has paid to the issue of quantifiying health inequalities. Without an accepted and consistent health inequalities metric, meaningful comparisons of change over time across social groups, regions, PCTs, and types of illness cannot be made and much of the “doing something” experience will not inform impact assessment. This lack of attention to the measuring of health inequalities is manifest in three inconsistencies between government stated policy on inequalities and the construction of targets and "monitoring indicators". As Macintyre says the government professes to be concerned with socioeconomic inequalities in health. Yet of their two headline health inequality targets, one does not measure socioeconomic inequalities in health and is constructed without reference to socioeconomic factors (life expectancy), while the other does measure socioeconomic inequality in health and is constructed with reference to socioeconomic factors (infant mortality). Similarly, the national health inequality indicators recently published in "Tackling health inequalities: a programme for action" are a mixture of those constructed with and without reference to socioeconomic factors. For example indicators which do measure socioeconomic inequality and are specified with reference to a socioeconomic factor include: a. Accidents: Rate of decline in road accident casualties in the 88 Neighbourhood Renewal Fund areas, compared with the rate of decline in England as a whole. b. Diet: Proportion of people consuming five or more portions of fruit and vegetables per day in the lowest quintile of household income distribution compared with the other quintiles. c. Smoking prevalence: Trends in prevalence in manual groups compared to the population as a whole. Indicators which do not measure socioeconomic inequality and are not specified with reference to a socioeconomic factor include: a. Influenza vaccinations: Average percentage uptake for the 20% of PCTs with the lowest uptake compared to the national average. b. Teenage conceptions: Average rate for the 20% "top-tier" local authorities with the highest under-18 conception rates, compared to the national average. c. Mortality from the major killer diseases: Age-standardised death rates per 100,000 population for the major killer diseases (cancer, circulatory diseases), ages under 75 for the 20% of areas with the highest rates compared to the national average. The second inconsistency between government policy and quantification of targets and indicators relates to statements by the Minister for Public Health and government advisors about "the importance of not just considering the two extreme ends of the spectrum when examining (inequalities in) life expectancy, but the gradient across the whole population" (2). Yet targets and indicators are set in terms of the 20% worst and the average, or one social group and the rest, or social class I and V. The third inconsistency relates to the requirement that PCTs take the lead in addressing health inequalities and that they demonstrate "measurable progress" in reducing local inequalities over the next three years under the Department of Health priorities and planning framework. Yet the only assistance with assessing progress locally on offer so far is the "basket" of 70 indicators. As Bull and Hamer(3)have pointed out, these indicators will only be useful for assessing and tracking health inequalities if differential data are gathered by area or socioeconomic group and changes in variations across groups are assessed. No accompanying guidance on how to use these data to construct summary measures of socioeconomic inequalities in health are provided. The Relative Index of Inequality (RII) is a summary measurers of socioeconmic inequalities in health which does examine the gradient across whole populations, which can be simply calculated with a spreadsheet and which has been shown to be applicable at PCT level, using routine data sources. (4) Macintyre's call for the design of routine statistics to assess and compare socioeconomic inequalities in health should be combined with a call to adopt a standard metric such as the RII or equivalent that is consistent and is also compatible with policy objectives. References: (1) Macintyre S. Evidence based policy making: impact on health inequalities still needs to be assessed. BMJ 2003; 326:5-6. (2) Wanless D. Securing good health for the whole population: population health trends. HM Treasury, 2003. (3) Bull J, Hamer L. Closing the gap: setting local targets to reduce health inequalities. London: Health Development Agency, 2001. (4) Low A, Low A and Fleming M. Health equity assessment across Sunderland: moving from profiling to measurement. Health Development Unit Discussion Paper no.1. Sunderland, 2003. Competing interests: None declared