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line: politics, evidence and guidelines Professor Mike Kelly - - PowerPoint PPT Presentation
line: politics, evidence and guidelines Professor Mike Kelly - - PowerPoint PPT Presentation
Sociology on the front line: politics, evidence and guidelines Professor Mike Kelly Institute of Public Health University of Cambridge UNIVERSITY OF The Primary Care Unit CAMBRIDGE NICE The National Institute for Health and Care
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
- Ministers including Secretaries of State.
- Politicians.
- Officials.
- Media.
- Local authorities.
- Public health practitioners.
- Vested interests.
- Researchers.
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
The task for pubic health at NICE from 2005
- To apply the principles of Evidence
Based Medicine (EBM) to public health.
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
The task from 2005
- To apply the principles of EBM to
public health.
- To develop the methods to do so.
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
The process
- Evidence review.
– Broad inclusive searches. – Pluralistic approach to evidence.
- Evidence appraisal.
– Quality of the evidence not the quality of the method. – Does it help answer the question?
- Judgements made about the evidence.
– Empirical judgments – Rationalist judgments.
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
Assessing cost -effectiveness
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
Assessing Cost Effectiveness
Probabilit y
- f
rejection Cost per QALY (£K)
10 20 30 40 50 1
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
Assessing health inequalities.
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
The health gradient
Health state Social status
Hi Lo Lo Hi
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
The health gradient
Health state Social status
Hi Lo Lo Hi
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
The health gradient
Health state Social status
Hi Lo Lo Hi
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
Shifting the health gradient
Health state Social status
Hi Lo Lo Hi
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
- Theoretical and empirical dimensions of the
contours and dimensions of inequality not well described – the axes of differentiation and their intersection completely missing from the evidence base.
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
- The ways in which interventions work in
different segments of the population not well understood
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
Politics and evidence.
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
The Mintzberg Dilemma
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
The Jowett Dilemma
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit “First come I; my name is Jowett. There’s no knowledge but I know it. I am master of this college: What I don’t know isn’t knowledge.” The Masque of Balliol
- Revd. H.C. Beeching
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
Institutional resistance
- Change only possible at the margin.
- Resources.
- Habitual decision making.
- Power.
- Reductionism and behaviour change.
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
Alcohol
- NICE (2010) Alcohol use disorders:
preventing harmful drinking, London: NICE. www.nice.org.uk/PH24
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
Recommendations
- price
- availability
- marketing
- screening and brief interventions
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
“Government rejects health watchdog's alcohol policy” The Independent Wednesday 02 June 2010
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
A non dialogue between evidence producers and policymakers
- Academic concerns with the integrity of the science.
- Lengthy gestation.
- “Need more research”.
- Definition of the problem.
- The policy needs of the moment.
- Policy questions seldom the same as scientific questions.
- Political questions are foreshortened - three minutes to
explain a complex idea
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
Conclusion.
- From the Elizabethan Poor Law, through the Poor Law
Amendment Act 1834, the Public Health Acts of the 1870s, the National Insurance legislation of Lloyd George, the establishment of the Welfare State and to every attempt at reform thereafter four problems appear and reappear:-
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UNIVERSITY OF
CAMBRIDGE
The Primary Care Unit
- Central versus Local administration.
- Voluntary/ Permissive versus compulsion.
- How to fund it.
- “The poor are always with us” - health inequalities.