Tackling health inequalities: Reformers must check the evidence

“The poor are always with us”, and in recent decades the gap between the haves and the have-nots in Britain has widened.

Some argue that more equal societies have higher levels of wellbeing. Others see the unexploited talent of the disadvantaged as a morally repugnant waste.

Whatever your perspective, the principal challenge is how to identify interventions that are effective in improving the lot of the poor and reducing inequality at least cost.

This economic perspective is a product of the simple fact that society’s resources are finite. As a consequence, each and every policy choice has an opportunity cost. A decision to invest in childcare for children up to the age of three means that less resources are available to fund income support for fellow citizens with learning difficulties. A decision to fund counselling for heroin addicts is also a decision to deprive other services such as community psychiatric nursing of funding. Taking newborn babies into care because their mothers are drug addicts , and that may damage the new-born’s life chances, is expensive and means local authorities have less funding for adult social care.

Each and every investment decision involves giving up the funding of other services which would benefit people in need of care. There is no such thing as a “free” service.

Most reforms in health and social care are evidence-free in terms of their effects on recipients. A reform is an experiment on fellow citizens, usually involving considerable amounts of public and private funding.

Experimenting with pharmaceuticals brings with it a legal obligation to evaluate effectiveness (even if this obligation may not always be carried out transparently and systematically). However, there is no such obligation to evaluate health and social care reforms. Practitioners and policymakers are free to change the use of society’s scarce resources and are too rarely made to account scientifically for their experimentation on the poor and vulnerable.

Decision makers in health and social care are continually reforming – that is experimenting – on their customers, and asserting novelty and success.

Often they are merely replicating in ignorance the reforms adopted by others. These reformers get kudos for changing service delivery, yet they fail to evaluate in a scientific manner, assert success in implausible ways such as vigorously delivered opinion, and add little or nothing to the evidence base. The blind lead the blind and recipients of care suffer.

Protecting these vulnerable people from the ill-informed but well-intentioned reforms of senior figures such as Andrew Lansley, Chris Grayling and Michael Gove, and the local choices of managers in statutory and private services, requires adherence to some simple principles.

First, check your reform against the existing evidence base. In healthcare there is the Cochrane Collaboration database. For reformers in social care, education, crime and the judiciary there is the emerging (yet grossly underfunded) Campbell collaboration.

Second, ensure that your reform’s budget includes funding for the systematic evaluation of your experiment on society’s vulnerable. National funding has created academic expertise with whom you can collaborate in identifying the cost effectiveness of reforms. Work with these “ivory tower” colleagues to improve the knowledge base.

Third, ensure that your reform is logged nationally so there is little duplication and waste, and mutual learning, from your efforts.

Failure to follow these three steps is unethical – a failure to evaluate may waste society’s scarce resources. Such waste is inefficient and deprives potential beneficiaries of care from which they could benefit.

Identifying what interventions give the “biggest bang for the buck” is the moral obligation of all reformers. Yet immoral behaviour is ubiquitous.

The causes of this include reformers’ ignorance of science – let alone how to evaluate scientifically. It is also a product of academics’ failure to convert the “ungodly” whose intentions may be pure but whose practices may blight the poor.