Abstract
An article in this issue, 1 the title of which I have imitated in order to state the theme of this editorial, is an important contribution to international discourse about how systematic reviews, and Cochrane reviews in particular, can inform policy and practice. Although its authors focus on ‘identifying low-value health care,’ the method they devised could also be used to assess the value of care processes and public health interventions, as well as to prioritize services in the inescapable presence of scarce resources.
I have experienced joy and dismay during four decades of helping policy makers decide whether and then how to use the findings of rigorous research. 2 Joy has occurred when policy makers delight in learning about the methods and potential uses of research results; when they trust researchers who are willing and able to advise them in person or in writing; and when they take the political risks of making decisions that are informed by research (for example, the risks of antagonizing manufacturers of drugs and devices, physicians in particular specialties, and groups that advocate on behalf of research and patient care for patients with particular diseases).
Policy makers as well as researchers have been sources of dismay. Many policy makers are unwilling or unable to invest time in learning about methods; to trust particular researchers and policy advisors; and many are reluctant to antagonize powerful interest groups and, as a result, risk losing an election or a senior position in the executive branch of government. Similarly, many researchers are unwilling or unable to understand how the politics of policy making works; to communicate effectively about why research findings could inform policy and practice; and to avoid using words and body language that policy makers perceive as condescending.
Some of the researchers who read this journal may find it helpful to know and perhaps apply several principles that inform the politics of policy making, much as some policy makers appreciate knowing about inclusion and exclusion criteria, sources of bias, and statistical analysis. The first of these principles is that there is no such thing as disinterested scientific advice in the politics of making policy. Anyone who seeks to inform policy automatically becomes involved in politics — sometimes partisan but often competition for bureaucratic turf and with issue-oriented lobbyists for commercial, professional, and advocacy groups who assume that everyone is as self-interested as they are.
Another principle that could be useful to researchers is that public agencies are populated by two very different groups. I call one group Generalists and the other Specialists. Generalists allocate scarce resources among competing claimants. They hold elected office or staff those who do, or serve in high positions in the executive branch of government and whose appointments must, in some countries, be confirmed by legislative bodies. Everyone else in government is a Specialist. These public servants usually prioritize increasing the budgets of the units in which they work and ascending in bureaucratic hierarchies. Specialists often have long-standing relationships with members of their professions or practitioners of their disciplines with whom they share eagerness to make, modify, or prevent particular policies.
Generalists know that Specialists’ priorities and external relationships are incentives for disloyalty to them. Specialists have been caught leaking information to lobbyists as well as to professional and advocacy groups who share their self-interest in particular policies or appropriations. Another incentive to disloyalty is specialists’ fear of demotion, transfer or, worse, not outlasting the generalists to whom they report. Sometimes specialists’ incentives to disloyalty include maintaining cordial relationships with colleagues in professional or commercial organizations who might someday offer them, or promote their candidacy for, lucrative jobs.
A third principle is that researchers or outside advisers who seek to inform policy must earn the trust of generalists. They can do that by, for example, describing research results without lecturing generalists about what they mean for policy; maintaining absolute confidentiality about conversations they have with generalists and members of their staff; demonstrating willingness to talk, write, testify, or inform journalists when they are asked, often at short notice, and understanding that the explosiveness of politics will require them to spend many hours waiting. Generalists and their staff will, however, usually respect teaching and family obligations, especially when a researcher or adviser proves his or her dedication to, in American political jargon, ‘do whatever it takes.’
Many researchers in a number of countries abide by these principles, often as a matter of political good sense, without articulating them. But sometimes they have good reasons for ignoring a principle. For example, everyone who wants research findings to inform policy needs to have cordial relationships with particular specialists in government. Another example: many researchers risk their reputations among academic colleagues when, as invariably happens, their work is politicized because scarce resources are at stake. Nevertheless, most people who want high quality systematic reviews to be used in making policy know the value of being trusted by policy makers and their staff, even if some of them are surprised to discover how much time and effort it takes to earn and maintain that trust.
More important, public bodies or publicly funded organizations in a growing number of countries are informing policy because they follow the principles I have described and have expert knowledge of relevant systematic reviews and primary studies. With apologies for the many public bodies I am ignoring, here are several examples, chosen because each of them has a different role in making policy. Organizations that have informed national policy and attracted international attention include the Pharmaceutical Benefits Advisory Committee in Australia, the Pharmaceutical Management Agency (PHARMAC) in New Zealand, and the National Institute for Health and Clinical Excellence in England and Wales. Others that have informed policy within countries and jurisdictions within them include the Drug Evaluation Review Project and the Medicaid Evidence Based Decisions project in the United States; the Saskatchewan Health Quality Council, and the Glasgow Centre for Population Health.
The article that stimulated this editorial 1 is likely to be useful to these organizations and others whose staff and governing bodies combine political skills with close attention to the best available research on health and health services. It applies methods that yield results that are likely to be useful to policy makers who are committed to dis-investing in low-value health care. No less important are its lessons for policy makers who invest public funds in order to maximize the health of individuals, families, and populations.