Prof Mike Kelly NICE and LSHTM

"Evidence at the coal face: the murky space between evidence , practice and policy in health inequalities"

Prof Mike KellyNICE and LSHTM

The Political Context

• Pre-1997 inequalities in health debates

• The Acheson Report

• The Our Healthier Nation White Paper

• Emphasis on delivery post 1997

• Clear commitment to tackling inequalities in health

• Commitment to a social determinants approach

Saving Lives: Our Healthier Nation

• “To improve the health of everyone, particularly the worst off, taking into account, the social, economic and environmental factors affecting health”.

R&D Strategy

• Systematic approach to using scientific evidence in public health

• provide high quality evidence to reduce inequalities in health

• identifying gaps

• make the evidence base accessible

• The unintended consequences of health policy and health delivery

• Regressive population health

Remit to support work on reducing inequalities

• What is effective?

• What is ineffective?

• What is harmful or dangerous?

Starting Point

• Quality of the research, not privileging types of or hierarchies of evidence

• What constitutes good evidence?

• What are the thresholds of such quality?

• Who determines the thresholds of quality if they are not self evident?

• Teenage pregnancy• HIV/AIDS• STIs• Smoking• Alcohol• Drugs• Obesity• Low birth weight• Breastfeeding• Housing• Suicide• Life course

• Social support in pregnancy• Physical activity• Mental health• Accidental injury• Health Impact Assessment• Transport• Gradients and gaps• Second hand smoke• Work, employment and

worklessness• Chronic illness

What has the review process demonstrated?

Social variation and social difference

• Different dimensions of social difference

• Biological and social variation

• Differential responses to interventions

• Social determinants complex

• Theoretical and empirical dimensions of the contours and dimensions of inequality not well described.

• The conceptual and operational apparatus for describing the mechanism of social determinants underdeveloped.

• The precise nature of the causal pathways to the different dimensions of inequality is under-investigated

• The health interaction between different aspects of inequalities not highly developed.

Things we don’t know

• Lack of evidence of what works (less than 0.4% of studies)

• Lack of cost effectiveness data

• Preponderance of downstream rather than upstream evidence

Measurement problems

• When to measure

• What degree of change to expect

Gaps in the evidence

• Gaps in the initial formulation of primary research studies.

• Gap between evidence and practice

• Failure to distinguish between determinants of health and determinants of inequalities in health

• Morbidity data much less secure than mortality data

• Extremely limited evidence about major policy initiatives

Barriers to building the evidence base

• Commitments to particular policy options in spite of the evidence (the Mintzberg dilemma).

• Commitments to particular epistemological positions (the Jowett dilemma)

• Antipathy towards HDA• Thinness of the evidence• Institutional Resistance

Institutional Resistance

• Prejudice ‘I already know the answer’

• Lack of fit ‘That’s not the answer I wanted’

• Institutional Inertia ‘I’m too busy’

• Antipathy ‘You used to be HEA!’

• Disappointment ‘Is that all there is?’

Problems for the Evidence Based approach

• Practical difficulties e.g. of linking qualitative and quantitative data

• Ideological opposition

• Academic scepticism

Primacy of the problem

• Human, social and economic costs of health inequalities

• Stubbornness of the health divide

• The most disadvantaged

“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