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May 2010

What is Evidence Based Policy?

Carl Heneghan
Last edited 30th May 2010

In defining Evidence-Based Policy my first thoughts were to think of the original definition of EBM by Sackett.

Evidence-Based Medicine is the ‘conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients,’ and its practice requires ‘integrating individual clinical expertise with the best available external clinical evidence from systematic research.’

In this article, individual clinical expertise is referred to as ‘the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice.’

In contrast Evidence-Based Policy is public policy informed by rigorously established objective evidence. See the contrast, where is the requirement for expertise? Whilst Governments ‘must produce policies that really deal with problems, that are forward-looking and shaped by evidence rather than a response to short-term pressures; that tackle causes not symptoms.’ theyre is no mention of expertise.

Whist in EBM Increased expertise can be observed in many ways, such as effective and efficient diagnosis and in understanding patients’ values and circumstances to make the right clinical decisions, in Evidence-Based Policy there is no such reliance on expertise. In fact, who are the experts practising such Evidence-Based Policy? Never mind whose values should be taken into account when implementing such policies.

Therefore, to move the field forward my new definition for Evidence-Based Policy would be: public policy informed by rigorously established evidence that takes into account healthcare expertise and understands the public values and circumstances affected.

Now, where are the experts?

If you’re reading this you’re probably thinking what has cross promotional marketing to do with children. Personally when I first heard the term I was thinking what exactly is it?

Simply, cross-promotional marketing is the act of strategically aligning businesses that target the same market but do not directly compete with each other. Whenever two organizations join forces to attract their mutual customers they can more than double the number of prospects they each reach.

For example, in 1996 MacDonalds and Disney signed a ten year deal to cross-promote. Get it? Same market, but not in direct competition and double the reach. A subsequent survey by Eric Schlosser of US schoolchildren found that the only fictional character with greater recognitions than Ronald MacDonald – who had 96% recognition – was Santa Claus. Oh, by the way, MacDonalds operates more playgrounds – designed to attract children and their parents to its restaurants – than any other private entity in the US;

This sort of promotion is also seen with film tie-ins such as Burger King and Toy Story.

Sorry to be a spoilt sport, but given the obesity epidemic - currently 10% of children worldwide are either overweight or obese - it’s time to rethink cross-promotion.

Beware; next time you are out and about, particularly if you have children, you will start to see cross-promotion all around you.

A Health Select Committee report on the use of Management Consultants in the NHS and Department of Health estimated that the NHS spends upto £600 million per year on consultancy services, representing one fifth of total annual public sector consultancy spending, and the amount has increased in recent years. All areas of the health service: Strategic Health Authorities, Primary Care Trusts and NHS Trusts seem to like spending their money on external consultants, who often charge in excess of £1,000. Based on the committee’s recommendations, the government’s response last year was to call for centralized and local collection of data about what is being spent on management consultancy in the different sectors of the health service.

Last night, I was at the Royal Society of Medicine in London for a Salon, hosted by Diagnosis. Set up by junior doctors, Emma Stanton and Claire Lemer a few months ago, Diagnosis is a "healthcare consultancy for organisations such as the NHS, Department of Health and arms length bodies such as the Health Foundation”.

Management consulting can be traced back to a firm, Arthur D Little, set up by an MIT professor of the same name in 1886. Particularly after the Second World War, there was a huge demand for consultants who could offer a new perspective and strategic expertise within organisations. If you speak to management consultants, and I spoke to a few at last night’s networking event, they all mention “quality” and “performance improvement” as the key skills which they bring to an organisation. Interestingly, the same words appear repeatedly throughout Lord Darzi’s NHS Next Stage Review. Perhaps he wants doctors to be more management consultants and less medical consultants.

The fundamental tenet of Diagnosis is that there is a vast untapped resource among health professionals which can be as useful as any existing management consultancy, and importantly has a clinical perspective which the large consultancies such as McKinsey are lacking. "Diagnosis invites high potential junior doctors, medical students and allied health professionals into a virtual talent pool as Associates. Individuals are contracted at a daily rate to contribute towards a portfolio of projects that can be carried out alongside clinical and other professional commitments." Traditionally, doctors have felt that management and performance improvement roles are the remit of other people within the healthcare arena, and so have missed out on a great opportunity to influence and change healthcare, but also to use their expertise and experience in an unconventional way. One recent project involves producing an innovative 'Induction to the NHS' DVD for 7,000 newly qualified junior doctors. Stanton and Lemer are both passionate about the role of doctors as future healthcare leaders to change the culture of the NHS and you cannot help but be inspired by the massive combined potential that must be lurking throughout the organisation.

Another word that was bandied about a lot was “trust”. The trust that a client should have in their friendly management consultant. The trust that a patient should have in their doctor. In the 2002 Radio 4 Reith Lectures, Onora O’Neill, Cambridge philosopher, spoke of the “crisis of trust” in public organisations. There is surprisingly little consensus on what trust means in the healthcare setting and little evidence that any particular intervention can change a patient’s trust in their doctor. However, doctors do have a unique position of trust with patients and society which may also put them in a unique position to change healthcare practices.

Healthcare under siege

Carl Heneghan
Last edited 13th May 2010

The Oxford Society of Medicine, tonight at St Catherine’s College held an event to discuss how best to support medical education in the Occupied Palestinian Territory. ‘What is it that inspires Doctors to work in the Occupied Territories,’ was the theme of the night

The key themes of the night were:
1 How have health services in the Occupied Palestinian Territory suffered as a result of their isolation and fragmentation, and how can this be resolved?
2 What are the current barriers to education in the Occupied Palestinian Territory, and how can these be addressed?
3 What is the potential for increasing research capacities the Occupied Palestinian Territory?
4 Does the UK have special responsibility to help medical education in the Occupied Palestinian Territory? And if so, how can this be achieved?

The panel gave ten minute talks: Dr Nick Dudley - Consultant Endocrine Surgeon at the Department of Surgery, John Radcliffe Hospital started the night by talking about ‘Facts on the ground.’ In 1946 Palestinian land occupation was 94%, by 2010 this figure is 10% and there are currently 4.7 million refugees. Over 100 UN resolutions have been contravened in the occupation. The impact is to deprive Palestinians of their livelihood, water resources are scarce, and the construction of the settlements justifies the wall and the road matrix, which is currently 450 km in length. Oh and it’s electrified. On the ground this means 39% of Palestinians are encircled or separated from their land, 34% live outside the wall. ‘Passing check points is deeply humiliating.’

Could the stats be any worse, well 70% of small businesses have closed in the last ten years whilst 132 pupils have been killed on their way to school, 12,000 homes destroyed since 1967. In Gaza, 80% of the population exist on £2 dollars a day whilst the blockade prevents exports and viable business.

Dr Richard Horton - Editor-in-chief of The Lancet - talked about his trip there earlier this year, ‘What could we do to help?’ One of the pressing needs is to systematically train researchers, training Phds, supporting Masters Students. Supporting the Universities to better understand the Palestinian case, understand the needs, and focus on supporting human rights. ‘There is a lot we can do’ says Richard Horton.
Checkpoints are like going through ‘Cattle gates, deeply humiliating.’

Prof. Colin Green - Professor of Surgical Science at UCL and UNESCO Chair of Cryobiology with the Ukraine Academy of Science – opened with ‘It isn’t all doom and gloom, and there are beacons of light.’ A group of us in 1989 started thinking about starting a Medical School, which took its first students in 1994.

Starting with 32 students, near Jerusalem (50% were women) students undertook a seven year course. The first students graduated in 2001, 23 of them. In a short space of time they have grown to 800 students in four different campuses. I think he’s right, and He is determined to go on working with the schools. The weaknesses are the specialities only one pathologist in the whole of the West Bank. ‘Family practice is very poor,’ it seems everyone goes to the hospital: ‘We need champions of primary care,’ enthused Prof Green. In addition, it seems what is also desperately missing is psychiatrists. What are we to do?

Mr Nick Maynard - Consultant Upper Gastro-Intestinal Surgeon at the John Radcliffe Hospital, talked about his recent trip to Palestine. Three years ago he knew nothing about the region, but since this time He has learnt a lot from the medical students, whilst teaching out there. It took medical student at one of his teaching sessions 3 and half hours to get there. ‘There is never a better time for doctors to go there and teach.’

‘On that note’ what should we be doing?

Got any answers?

Reflecting on electing

Ami Banerjee
Last edited 6th May 2010

Today, as people queue at polling booths around the country, I wonder how much they will be influenced by the health policies of the main political parties. You would hope that it has a big bearing on people’s voting choices as the NHS is the UK’s biggest employer with a 1.5 million-strong workforce responsible for the health of 60 million people. Both the Lancet and the BMJ have tried to tease out what the different parties are offering over the last couple of weeks.

A Lancet editorial looks at how the three main parties fare in achieving aims of “better services”, “fairer services”, “protecting health” and “advancing health”. It concludes that the Conservatives and Liberal Democrats lead over Labour in terms of “fairer services” but Labour is likely to deliver better services and is ahead in terms of global health policy. There are many similarities between the health manifestos of the three main parties but the more you analyse, the less detail you find, particularly regarding how the NHS will be funded in difficult economic times and how limited resources will be allocated. This vagueness is there in the manifestos of the smaller parties as well.

There have been many calls to bring evidence to the realm of policy making, but it is difficult to find objective evidence-based statements in the policy documents of three major parties. This lack of evidence means that voter decisions are less likely to be based on facts, and are more likely to be influenced by political spin. For example, it is impossible to escape the political football that is cancer care, kicked from Labour to Conservatives throughout this election campaign, but data about how services will be funded, or how the burden of cancer compares with burden of other diseases in the UK is lacking. There is little or no mention of cost-effectiveness of drugs. This information is available in the public domain, but it is barely ever quoted, and, as far as I can tell, evidence-based medicine is not mentioned in any of the manifestos. Instead we get politicised promises of “an appointment within a week” by Labour versus “access to more cancer drugs” under Conservatives. You can only be an informed voter if there is good quality information from all the political parties.

Improving trial publications: where do we start?

Carl Heneghan
Last edited 3rd May 2010

There has been considerable interest in the transparent publication of trial results in both the media and the big journals. Whilst calls for drug companies to be more open with research findings are on the increase.

Delamothe argues:
‘that patients should demand as a condition of their participation in trials that their anonymised data should be made available to anyone who asks for them and that ethics committees should back them up, insisting that protocols allow for data sharing.'

Half of trials supporting FDA applications go unpublished 5 years after approval. A further example of the controversy in action, is the recent Cochrane review on Tamiflu in adults, which Fiona Godlee, editor of the BMJ questions ‘Why don’t we have all the evidence on oseltamivir?’

But, the problem is once we have all this data who is going to look at it? Even one trial alone is going to take a year’s work. Who is independent enough to do this work and who will fund it? There are only a few epidemiologists in the world barmy enough to do this sort of work. I should know I’m one of them.

A recent systematic review published in BMC trials of pharmacological interventions for acute ischaemic stroke that were completed, revealed of 940 trials 125 (20%) were completed but not published in full. Gibson who led the work states: ‘Responsibility for non-publication lies with investigators, but pharmaceutical companies, research ethics committees, journals and governments can all encourage the timely publication of trial data. ‘

Therefore the question right now is not ‘let us have the raw data’ but, ‘let’s get the stuff published in the first place.' My standpoint would be to have a two year maximum to publication from the end of the trial outcome assessment. Otherwise trial registration should be removed from which ever organisation registered the trial in the first place.

Only simple solutions will make a differnce and its where we should start.

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