Health scientist and policy maker Don Berwick summarises three eras in the relationship between science and policy in health care:
Era 1: Health as a self-regulating profession led by the royal colleges
Era 2: Agencies and practitioners held accountable for outcomes via markets and controls
Era 3: What he calls the ‘moral era’, with greater transparency, civility and the rejection of greed.
In the first era, running up to the 70s and 80s, the professions were paramount. Specialist knowledge was prepared for consumption by specialists. The quality of that evidence was judged by specialists, and they also decided which knowledge got applied and which did not. There were great advances in health attributable to the health professions in this era, but variations in outcomes by geography, class and race also persisted.
In the second era trust in the professions was replaced with accountability and measurement. This meant greater scrutiny. In some countries it also translated into incentives for practitioners, organisations and agencies. An industry of intermediary organisations emerged, doing research, drawing it together in What Works Centres, checking on quality and tying data to strategy.
Again, the health of nations continued to improve. But measurement did not always translate into learning. Worse, there is a lot of gaming -something we will come back to in the next session. If the goal is to succeed, then the commissioner looks for success and the provider reports what the commissioner wants to see. A lot has been published on success, but not much on failure.
The utility of the second era approach is reaching its natural limits. As much is clear from the unease expressed by those of you participating in this conversation. In the UK and the US, longevity of life is beginning to plateau after a century and a half of progress. And a revolution in science built on the power of machines is beginning to take hold.
We do not know what will come next. The weakest part of Berwick’s paper is his description of the third era. There isn’t much to argue against in what he says, but his list doesn’t add up to a way of thinking. We have to figure out together what era 3 will look like.
Reflections
1. Are we moving from era 2 to era 3, or from era 2 back to era 1? Do we need to learn to trust the practitioner, and better listen to the experience of those getting help?
2. The challenge going forward isn’t money, its a shared sense of what we are trying to achieve and why. The focus in era 2 was outcomes. In this interregnum between the eras there is a lot of focus on behaviour change. In the future, will there be a renaissance in interest in values?