Intended for healthcare professionals


In search of social equipoise

BMJ 2013; 347 doi: (Published 04 July 2013) Cite this as: BMJ 2013;347:f4016
  1. M Petticrew, professor ,
  2. M McKee, professor ,
  3. K Lock, senior lecturer ,
  4. J Green, professor ,
  5. G Phillips, research fellow
  1. 1Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
  1. Correspondence to: M Petticrew mark.petticrew{at}
  • Accepted 1 May 2013

A failure to acknowledge uncertainty about the effectiveness of social interventions is a major barrier to evidence based public policy making. M Petticrew and colleagues argue that we need to develop and apply the concept of social equipoise

Randomised controlled trials are common in medicine but less so in other fields. However, the use of trials in medicine is helped by an open acknowledgment of uncertainty about effectiveness—that is, clinical equipoise. In theory the same should also apply to social interventions (such as public policies), but no concept of “social equipoise” exists. This makes it politically difficult for policy makers to acknowledge uncertainty and to conduct evaluations. The development of “social equipoise” may help foster a greater culture of evaluation outside medicine. This may be particularly important in England now that public health has moved from the control of primary care trusts to local authorities, which are influenced by party politics.

Equipoise and the role of randomised trials

The randomised controlled trial is often described as the “gold standard” for evaluating clinical interventions,1 and its use has increasingly been advocated in other sectors such as international development and social policy.2 Although its roots are in the social sciences rather than medicine, it is rare for it to be used to evaluate innovations in public policy.3 For example, the number of randomised trials identified by the Campbell Collaboration, covering education, social welfare, crime, and justice, is a small fraction of the number in the Cochrane Collaboration, with its focus on health.4 The reasons for this are the subject of debate but include perceptions that trials are costly and pose practical and ethical difficulties. One recent report for the UK’s Cabinet Office challenged several such arguments and included another possible explanation: that policy makers often think that they already know the answer.4 However, it …

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