Evidence based medicine provides a template for evidence based policy, but not in the way you expect

Guest post by Dr Kathryn Oliver and Dr Warren Pearce to celebrate the publication of their new Open Access article ‘Three lessons from evidence-based medicine and policy‘ in Palgrave Communications,

Part of the  Open Access series ‘politics of evidence based policymaking‘ (for which we still welcome submissions).

Hooray! New paper by me and @WarrenPearce on key questions for the EBP field- OA! https://t.co/kN8Ax7BjqN

— Kathryn Oliver (@oliver_kathryn) December 12, 2017

Evidence-based medicine (EBM) is often described as a ‘template’ for evidence-based policymaking (EBPM).

Critics of this idea would be 100% right if EBM lived up to its inaccurate caricature, in which there is an inflexible ‘hierarchy of evidence’ which dismisses too much useful knowledge and closes off the ability of practitioners to use their judgement.

In politics, this would be disastrous because there are many sources of legitimate knowledge and ‘the evidence’ cannot and should not become an alternative to political choice. And, of course, politicians must use their judgement, as – unlike medicine – there is no menu of possible answers to any problem.

Yet, modern forms of EBM – or, at least, sensible approaches to it – do not live up to this caricature. Instead, EBM began as a way to support individual decision-makers, and has evolved to reflect new ways of thinking about three main dilemmas. The answers to these dilemmas can help improve policymaking.

How to be more transparent

First, evidence-informed clinical practice guidelines lead the way in transparency. There’s a clear, transparent process to frame a problem, gather and assess evidence, and, through a deliberative discussion with relevant stakeholders, decide on clinical recommendations. Alongside other tools and processes, this demonstrates transparency which increases trust in the system.

How to balance research and practitioner knowledge

Second, dialogues in EBM help us understand how to balance research and practitioner knowledge. EBM has moved beyond the provision of research evidence, towards recognising and legitimising a negotiation between individual contexts, the expertise of decision-makers, and technical advice on interpreting research findings for different settings.

How to be more explicit about how you balance evidence, power, and values

Third, EBM helps us think about how to share power to co-produce policy and to think about how we combine evidence, values, and our ideas about who commands the most legitimate sources of power and accountability. We know that new structures for dialogue and decision-making can formalise and codify processes, but they do not necessarily lead to inclusion of a diverse set of voices. Power matters in dictating what knowledge is produced, for whom, and what is done with it. EBM has offered as many negative as positive lessons so far, particularly when sources of research expertise have been reluctant to let go enough to really co-produce knowledge or policy, but new studies and frameworks are at least keeping this debate alive.

Overall, our discussion of EBM challenges critics to identify its real-world application, not the old caricature. If so, it can help show us how one of the most active research agendas, on the relationship between high quality evidence and effective action, provides lessons for politics. In the main, the lesson is that our aim is not simply to maximise the use of evidence in policy, but to maximise the credibility of evidence and legitimacy of evidence advocates when so many other people have a legitimate claim to knowledge and authoritative action.

3 lessons from evidence-based medicine & policy:
1. be more transparent
2. balance evidence with other interests
3. understand power

New by @oliver_kathryn & me in @PalCommsOA https://t.co/z7L7qO3FFF #EBP #EBM pic.twitter.com/wDUrZLQlVh

— Warren Pearce (@WarrenPearce) December 12, 2017

There is no blueprint for evidence-based policy, so what do you do?

In my speech to COPOLAD I began by stating that, although we talk about our hopes for evidence-based policy and policymaking (EBP and EBPM), we don’t really know what it is.

I also argued that EBPM is not like our image of evidence-based medicine (EBM), in which there is a clear idea of: (a) which methods/ evidence counts, and (b) the main aim, to replace bad interventions with good.

In other words, in EBPM there is no blueprint for action, either in the abstract or in specific cases of learning from good practice.

To me, this point is underappreciated in the study of EBPM: we identify the politics of EBPM, to highlight the pathologies of/ ‘irrational’ side to policymaking, but we don’t appreciate the more humdrum limits to EBPM even when the political process is healthy and policymakers are fully committed to something more ‘rational’.

Examples from best practice

The examples from our next panel session* demonstrated these limitations to EBPM very well.

The panel contained four examples of impressive policy developments with the potential to outline good practice on the application of public health and harm reduction approaches to drugs policy (including the much-praised Portuguese model).

However, it quickly became apparent that no country-level experience translated into a blueprint for action, for some of the following reasons:

• It is not always clear what problems policymakers have been trying to solve.
• It is not always clear how their solutions, in this case, interact with all other relevant policy solutions in related fields.
• It is difficult to demonstrate clear evidence of success, either before or after the introduction of policies. Instead, most policies are built on initial deductions from relevant evidence, followed by trial-and-error and some evaluations.

In other words, we note routinely the high-level political obstacles to policy emulation, but these examples demonstrate the problems that would still exist even if those initial obstacles were overcome.

A key solution is easier said than done: if providing lessons to others, describe it systematically, in a form that describes the steps to take to turn this model into action (and in a form that we can compare with other experiences). To that end, providers of lessons might note:

• The problem they were trying to solve (and how they framed it to generate attention, support, and action, within their political systems)
• The detailed nature of the solution they selected (and the conditions under which it became possible to select that intervention)
• The evidence they used to guide their initial policies (and how they gathered it)
• The evidence they collected to monitor the delivery of the intervention, evaluate its impact (was it successful?), and identify cause and effect (why was it successful?)

Realistically this is when the process least resembles (the ideal of) EBM because few evaluations of success will be based on a randomised control trial or some equivalent (and other policymakers may not draw primarily on RCT evidence even when it exists).

Instead, as with much harm reduction and prevention policy, a lot of the justification for success will be based on a counterfactual (what would have happened if we did not intervene?), which is itself based on:

(a) the belief that our object of policy is a complex environment containing many ‘wicked problems’, in which the effects of one intervention cannot be separated easily from that of another (which makes it difficult, and perhaps even inappropriate, to rely on RCTs)

(b) an assessment of the unintended consequence of previous (generally more punitive) policies.

So, the first step to ‘evidence-based policymaking’ is to make a commitment to it. The second is to work out what it is. The third is to do it in a systematic way that allows others to learn from your experience.

The latter may be more political than it looks: few countries (or, at least, the people seeking re-election within them) will want to tell the rest of the world: we innovated and we don’t think it worked.

*I also discuss this problem of evidence-based best practice within single countries