The Health Development Agency’s approach to evidence Professor Mike Kelly

The rise of the evidence based approach in Britain

Cochrane, A.L.(1972) Effectiveness and Efficiency: Random Reflections on Health Services, British Medical Journal/Nuffield Provincial Hospitals Trust, London.

Archie Cochrane’s Principles The best care available to all- universalism The need for a means to determine what was best-rationality The importance of rooting out harmful or useless practice-compassion The necessity of ascertaining costs and benefits-accountability

The legacy The importance of the randomised control trial Clinical resistance Health economics

The legacy The Cochrane and Campbell Collaborations The importance of the systematic review and meta analysis NHS Centre for Reviews and Dissemination Health Evidence Bulletins Wales The Health Development Agency

The inequalities conundrum The unintended consequences of health policy and health delivery Regressive population health Widening inequalities

HDA Remit to support work on reducing inequalities What is effective? What is ineffective? What is harmful or dangerous?

Application of similar evidence based principles in public health

Key problems

Lack of evidence of what works (less than 0.4% of studies) Lack of cost effectiveness data

The evidence about upstream and downstream interventions Bulk of the evidence about downstream interventions

Biological variation and social variation Social differences in the population Different dimensions of social difference Differential responses to interventions

When should effectiveness be measured?

Starting Point for the HDA to synthesise review level work in public health priority areas to bring in other forms of scientific evidence to bring evidence and practice together to target public health priorities and get the evidence into action

Teenage pregnancy HIV/AIDS STIs Smoking Alcohol Drugs Obesity Low birth weight Breastfeeding Housing Qualitative evidence Definitions of inequalities Social support in pregnancy Physical activity Mental health Accidental injury Depression Health Impact Assessment Transport Child poverty Health Impact Assessment Gradients and gaps

Evidence Briefings Strengths and weaknesses of the evidence Identification of gaps Implications for practice and policy Recommendations for future research

Comprehensive,systematic up to date map of the evidence Passive resource Baseline resource from which other products can be developed

Evidence Reviews Broader approach to data and evidence

Epistemological and related problems

Biases Biases of method (the dominance of the RCT) Compounding biases (errors repeated) Content biases (some problems not investigated)

Practical problems Evidence synthesis of qualitative and quantitative information Threshold standards Academic hostility Practitioner hostility

What the evidence does not tell you How to do it Process data Implementation problems Local infrastructures

Two different aspects of how things work Plausibility: a scientific assessment – biologically, organizationally, socially, psychologically. Likelihood of success: the nature of local conditions married to tacit knowledge of practitioners

Thinking beyond the evidence The evidence as a framework of plausible possibilities The evidence as a starting point for intervention not an imperative or a recipe

Developing Guidance and Resources: A new form of synthesis Involving the practitioners Establishment of Evidence and Guidance Collaborating Centres

Permissions and facilitations For practitioners to think creatively beyond the evidence For researchers to take responsibility for their evidence

Muted voices Dominant discourses of evidence Qualitative methods of data elicitation Access to tacit knowledge Access to life worlds

Conclusion Embracing a range of evidence and learning Evidence from traditional research Evidence from practice Evidence into practice and policy Practice into evidence