JRSM > Volume 96, Number 4 > Pp. 194-196

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Evidence-based policy and practice: riding for a fall?

David J Hunter PhD FRCP(Edin)  

School for Health, Wolfson Research Institute, University of Durham Queen's Campus, University Boulevard, Thornaby, Stockton on Tees TS17 6BH, UK

E-mail: d.j.hunter{at}durham.ac.uk

	INTRODUCTION

TOP INTRODUCTION GETTING EVIDENCE INTO POLICY... THE DISCONNECT BETWEEN EVIDENCE... THE PLACE OF EVIDENCE... CONCLUSION REFERENCES

 
Hard on the heels of evidence-based medicine (EBM) comes evidence-based policy and practice (EBPP). At all levels in healthcare systems there is a hunger for better knowledge to inform policy and practice. Is this yet another of the fashions and fads that continually beset the National Health Service, or does EBPP mark a development that could fundamentally change the way in which health policy is made and implemented?

There are good reasons to be sceptical about some of the claims made for EBPP. Rudolf Klein¹ has written about ‘the new scientism’ with its promise that greater knowledge will reduce uncertainty and release us from the dirty business of political decision-making. A forlorn hope, he indicates. Coming from a different perspective, Gore Vidal has written: ‘it is the spirit of the age to believe that any fact, however suspect, is superior to any imaginative exercise, no matter how true’. Policy-making and management are often creative activities that fly in the face of the ‘evidence’. In the past, the application of EBPP has been the exception rather than the rule. Even where evidence exists in favour of change, to achieve that change remains a challenge. Too little attention has been paid to implementation and the factors that govern its success or failure. The position in clinical medicine is similar.

Despite these doubts, the prevailing view today is that evidence-based policy should temper, if not replace, opinion-based policy. In this paper I comment on three features—the challenge posed by getting evidence into policy and practice; the disconnect between the evidence base and policy reality; and the place of evidence in policy.

	GETTING EVIDENCE INTO POLICY AND PRACTICE

TOP INTRODUCTION GETTING EVIDENCE INTO POLICY... THE DISCONNECT BETWEEN EVIDENCE... THE PLACE OF EVIDENCE... CONCLUSION REFERENCES

 
If EBM is any guide to the likely fate of EBPP, then we have to consider the ‘evidential paradox’. Despite the evangelism for EBM and the ‘EBM industrial complex’ put in place to accompany it, there is widespread scepticism concerning its impact on practice. To complicate matters, in all policy domains public and lobbying groups express increasing scepticism about ‘expert’ authority. Whether the issue is food safety, MMR vaccinations or female sexual disorders, public trust in scientists is on the decline. (Sometimes, indeed, a lack of trust seems a rational response—especially when the evidence comes from industry-funded research.)

Other barriers to evidence-based policy and practice have their origins in the nature of the policy process itself and in the management practice of healthcare. They include:

• The complexity of the evidence and arcane disputes over its methodological basis and rigour
  
• The intricacies of the policy process and the attempt to balance competing interests and perhaps reconcile the irreconcilable
  
• The influence of political priorities when a government asserts it has a mandate from the electorate to drive through certain changes
  
• Ideological acceptability even to a government that proclaims it is ideology-free
  
• The multiple, and possibly contradictory, goals of policy-makers and managers
  
• Tacit knowledge valued over and above research evidence perceived as irrelevant, out-of-date or inapplicable to local circumstances
  
• Lack of consensus about the evidence: whose opinions count—the expert's or the public's?
  
• Practicability
  
• The curse of the temporal challenge, whereby the time required to generate evidence exceeds the time policy-makers and managers are willing to wait before taking action
  
• The play of power
  
• The reality of pressure group politics whereby some issues rise up the political agenda and others slip down, or off
  
• The absence of a culture of EBPP—a case of he who does, knows.
  

Sometimes, also, an expressed desire for evidence is simply an excuse for inaction. This would seem to be so in respect of much public health, where interventions to tackle health inequalities and health improvements are subject to rules of evidence that are not applied to the rest of the NHS. As the World Health Organization points out,² the problem is not lack of evidence but lack of political will.

	THE DISCONNECT BETWEEN EVIDENCE AND POLICY

TOP INTRODUCTION GETTING EVIDENCE INTO POLICY... THE DISCONNECT BETWEEN EVIDENCE... THE PLACE OF EVIDENCE... CONCLUSION REFERENCES

 
EBPP, like EBM, subscribes to a rational, linear model of how research and evidence are acted upon. It goes something like this. Policy ideas give rise to policy development and implementation and, at the end of the process, policy evaluation is undertaken to determine the success or otherwise of the policy. Unfortunately, the reality is more complex and messy. Essentially, policy formation and its implementation is a cyclical process whereby the various stages from start to finish are subject to critical evaluation and evidence-gathering. Modifications are made continuously according to what the evidence reveals. Even then, the evidence may not always impact on policy, or its influence may be overshadowed by other factors deemed more important.

Of course, much policy research or evidence need not directly result in change or have an instrumental impact on future developments. According to the ‘enlightenment’ or ‘infiltration’ view of research and evidence, the task is not always to provide hard data for the purposes of engineering change but sometimes to provide ideas and arguments that will challenge the assumptions of policy-makers and managers. In this way, evidence can help create a constituency for change and set a context for policy.

The messiness of the policy process suggests that evidence is only one ingredient among many in the mix. Others equally if not more important are experience, judgment, resources and values. Achieving an optimal balance between these is the art of successful policy-making and management practice.

	THE PLACE OF EVIDENCE IN POLICY

TOP INTRODUCTION GETTING EVIDENCE INTO POLICY... THE DISCONNECT BETWEEN EVIDENCE... THE PLACE OF EVIDENCE... CONCLUSION REFERENCES

 
To overcome the perceived disconnect between the evidence base and practice, various observers have devised checklists of criteria by which EBPP might be realized. One such attempt³ includes the following:

• Policy should be supported by systematic, empirical evidence
  
• It should be supported by cogent argument
  
• The scale of likely health benefit should be assessed and stated
  
• The fit with existing or proposed government policy should be clarified
  
• Consideration of the possibility that the policy might do harm
  
• Ease of implementation
  
• Cost of implementation.
  

The key point underpinning such pleas is that all new policies should be accompanied by a statement of the evidence consulted in their preparation. In this way, the danger of ‘factoids’ would be avoided whereby policy is developed and enacted on the basis of assumptions or speculations that through their constant repetition become truisms.⁴

It would be nice to think our policy-making masters and mistresses could be persuaded to behave more responsibly and in an evidence-based way. But while they are happy to preach the evidence-based mantra to others, they seldom practise what they preach. This suggests a need to be circumspect about how far we can make a seemingly irrational process more rational. Perhaps the focus needs to shift from the construction of an evidence base that is remote or isolated from the real world of policy and practice, so that more attention can be devoted to how policy is conceived, crafted and implemented.

	CONCLUSION

TOP INTRODUCTION GETTING EVIDENCE INTO POLICY... THE DISCONNECT BETWEEN EVIDENCE... THE PLACE OF EVIDENCE... CONCLUSION REFERENCES

 
If EBPP is to become something other than a passing fad then more attention must be paid to research and evidence applicable in the real world rather than an ideal world. If asked for an example of successful EBPP, the Government might reasonably point to the Sure Start programme, aimed at breaking the cycle of poverty by giving preschool children a better chance in life; this has been evidence-based both in conception and in implementation, with ongoing evaluation and refinement of policy as the initiative unfolds.

Perhaps most crucially, what this reality-check calls for is a new relationship between the research community and the worlds of policy and practice. Too often, the research agenda is driven by researchers and not by the endusers: policy-makers and managers might pay closer attention to the evidence base if they took a more active part in its construction and were consulted more about their concerns and needs. One difficulty is the pressure on academic researchers to publish in esoteric peer-reviewed journals, driven by the increasingly dysfunctional Research Assessment Exercise. To produce material in a format that policy-makers and managers might actually read is a second-order spare-time activity that counts for little in academic terms.

The prospects for a new relationship seem remote. Compounding the problem is the fact that skills in research differ from the skills required to illuminate research findings or translate them into policy. Occasionally researchers are able to cross this divide, but many others dismiss such work as beyond their scope, distasteful, unimportant to their careers, or contrary to their employers' expectations.

Research findings and the evidence they inform will never represent a passport to better policy and practice. We cannot avoid or ignore the complexity and incompleteness of policy. The purists engaged in gathering evidence and intent upon improving the way policy is made and implemented might do worse than heed the words of John Maynard Keynes:

‘There is nothing a government hates more than to be well-informed, for it makes the process of arriving at decisions much more complicated and difficult.’

Amen to that!

	REFERENCES

TOP INTRODUCTION GETTING EVIDENCE INTO POLICY... THE DISCONNECT BETWEEN EVIDENCE... THE PLACE OF EVIDENCE... CONCLUSION REFERENCES

 

1. Klein R. The NHS and the new scientism: solution or delusion? Quart J Med1996; 89:85 -7

2. World Health Organization. The World Health Report 2002: Reducing Risks, Promoting Healthy Life. WHO: Geneva,2002

3. Macintyre S, Chalmers I, Horton R, Smith R. Using evidence to inform health policy: case study. BMJ2001; 322:222 -5[Free Full Text]

4. Cummins S, Macintyre S. ‘Food deserts’—evidence and assumption in health policy making. BMJ2002; 325:436 -8[Free Full Text]

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