Welcome to the Power to Persuade Blog - a new space for open discussion of the policy process. To kick us off, Tim Senior talks about the divides between research, policy and practice in health settings, picking up issues echoed across other areas of social policy. Tim Senior is a GP in an Aboriginal Community Controlled Health Service. He wears his academic and policy hats a little uncomfortably, and at a jaunty angle. He writes regularly for the British Journal of General Practice, and Croakey. He is crowdfunding for a Croakey Column looking at the health effects of government policy, which you can freely donate to here: http://pozi.be/wonkyhealth
I’m one of those irritating people you might call a doctor. I know doctors are irritating, because everywhere I go, people seem to find us irritating. We often believe we are right. We don’t like following policies or procedures. We don’t follow guidelines. And despite all of this, we are still a powerful lobby, people still listen to us.
We doctors frequently get irritated, too, though. We get irritated at those academics, sitting in their ivory towers, cloistered away from the real world. They are only interested in science and data, measuring irrelevant things to put in journals and fly around to conferences.
Everyone’s ire is especially reserved, though, for policy-makers. Derided as opaque, nerdy bean-counters, only interested in costs. There’s even a word that has taken on sufficient rancour in its meaning that it now needs no elaboration: bureaucrat. Politicians of all persuasions, presumably forgetting the derivation of their own job title, are keen to say they’ll get rid of policy-makers to protect front line staff.
On the other hand, collaboration is one of those words that is routinely used by everyone about the way we want to work. I don’t doubt that it’s true – or that my characterisation of different groups is a caricature. And yet, we keep bumping up against these attitudes, even if they are pretend.
Perhaps I am naïve, but I do actually believe that most people working in the system do want to create a system that works well for the people who need to use it. Part of the problem is that the machine we have built to do this is too big for any one group to be able to operate it all. That’s why we need activities like the Power to Persuade. We need to get together to describe the bits of the machine we operate, and hear about the other bits of the machine we have no idea about. Which does seem rather obvious.
What this technical analogy misses is the values that each of us hold. We’re not just looking at different bits of a machine. We have some fundamentally different beliefs about how the machine is operated or how it could be improved. These are related to the values of our respective professions.
Values, though, are slippery things to pin down. We often behave as if we can name them just by making a list of nice characteristics. You can tell values by behaviour, though.
An example might help here.
I’ve never met anyone say they are against being evidence-based. (That’s not to say there aren’t discussions about what constitutes best evidence or how it gets implemented). In general there is agreement that the way we work should be based on the best available evidence that what we do will work. This is true for particular medical treatments, and true for policy. We all know, though, that this doesn’t happen as often as we say we’d like it to. Doctors are often criticised for not doing what the evidence says we should. But we are not the only profession. Indigenous policy gets sidelined away from what we know works to what the media might say. There are various reasons for this, none of them being that we don’t believe in “evidence”.
I suspect that each profession has a slightly different meaning of “Evidence.” In the academic medical world, we tend to mean high quality scientific studies published in journal articles. The success of this use of evidence in the use of specific treatments in particular medical conditions has diverted from realising there are other important questions that come up not answerable by this evidence.
Evidence that particular health policies will work is much less amenable to randomised controlled trials (though there have been interesting campaigns to do just this). I have come across “evidence” meaning anything from “Let’s find high quality evaluations of other similar projects on which to base our plan,” to “I came across this report last week which back up what I want to do.”
Pragmatic coal-face GPs may well decry both sets of evidence as not being useful to the problems of the patient she is seeing.
When you get these opinions in a room together, you can see how each might find the others annoying. It’s rare that we ask “What do we all mean by evidence?” It’s even rarer that we ask “Is being evidence based really one of our values?” Lying behind the idea of evidence is that what works in one place will work in another place – that projects are transferrable. Following this value to its natural conclusion leads to a one-size-fits-all approach – which everyone says they don’t want.
There are other values we say we hold which clash with each other. We can tell the ones we hold most strongly by what wins out. For example, we all want to be patient-centred or person-centred, but this will often fly out of the window if people want a service that is not evidence-based, or need a service that is expensive. Each time we construct pathways around particular medical conditions, we take a medical model at the expense of a degree of patient centredness, showing where our real values lie.
This is not to say that one group is right, and one group is wrong. These are all legitimate discussions that need to be had to build and run effective, sustainable (two more values) services. We don’t usually get down to this values level, though.
How might these conversations happen? The first is to want it and to give everyone express permission to bring it up. The second step is that everyone has to listen very hard – there should be an emphasis on listening to understand other perspectives. We often listen to refute, to persuade others we are right, which is very different. Fascinating research on the use of rhetoric in policy development opens the door to this sort of deep analysis of professional values and the way issues are framed.
The nature of these conversations is that they can be annoying, and at times confrontational. But they can also get to the heart of the matter, and develop better policy, which is something that all of us can value.
Posted by Gemma Carey