How many countries are there? On evidence and PHBs

Image via http://damirbecirovic.com/
Image via http://damirbecirovic.com/

How many countries are there?

This seems like a straightforward question to answer, doesn’t it? Most primary school children could give you an answer, and even if they couldn’t they could quickly look it up in an Atlas.

But perhaps it’s not as simple a question to answer as we think. Scotland and Wales are countries, aren’t they(?), and yet they don’t appear on the list of countries recognised by the United Nations: the UN reckons there are 193 countries, including “the United Kingdom”. My Times World Atlas from 1986 says there were 173 countries. And football’s governing body, FIFA, currently has a list of 209 countries with football rankings.

So, in order to know how many countries there are we need to ask ourselves at least two prior questions: (1) What do we mean by a “country”?; and (2) Who are we asking?

Maybe the question is a bit complicated, so let’s ask ourselves an easier question by going up a level: how many continents on the world are there?

Erm, well. National Geographic reports: “By convention there are seven continents… [but] some geographers list only six [and] in some parts of the world students learn there are just five continents.” Which means the answer again depends on asking other questions, including: (1) What do we mean by a “continent”?; and (2) Who are we asking?

This “facts” business is tricky, isn’t it?

I share this by way of thinking about what we mean by “evidence” in the context of “evidence-based policy” and the recent example of Personal Health Budgets.

A significant announcement by Simon Stevens, the Chief Executive of NHS England, about Personal Health Budgets gave rise to some teeth-gnashing earlier this month.

The gnashing focused on the evidence base that underpins the effectiveness of Personal Health Budgets. Some folks, especially the well-known Ben Goldacre of Bad Science fame, are not convinced by the current status of the PHBs evidence. They think there should be at least a Randomised Control Trial (RCT) to test whether Personal Health Budgets work. Others, including advocates of personalisation in public services more generally, noted both the results of the existing evaluation of the Personal Health Budgets pilot and the value of all types of evidence, especially including the views of patients/users themselves.

Both groups therefore lay claim to “evidence-based policy”, which leads me to two reflections:

  1. It’s hardly an original thought (indeed, there are entire disciplines dedicated to such questions) but we must remember there is value associated with all different types of evidence and research methods. The value derived, and of the associated evidence arrived at, depends on what types of answers you’re hoping to uncover, how questions are framed and what pre-questions and/or assumptions underpin the framing of those questions. Different people have different thresholds for evidence and research methods, quite aside from the fact that one type of evidence or research method that’s a gold standard in one discipline could be next to useless in another.

For me, this is the equivalent of the first pre-question we came to in considering countries and continents: What do we mean by “evidence”?

  1. Let’s not even get into the “policy” bit of “evidence-based policy”. For example, when has policy ever been based on evidence anyway? Does policy making happen in a rational, evidence-led vacuum that is protected from the whims of politicians and public opinion which, heaven forfend, may not be evidence based? Notwithstanding questions of what we mean by evidence, it’s safe to say that not all policy is based on what evidence there is. This is therefore the equivalent of the second pre-question we came to in considering countries and continents: Who are we asking what we mean by “evidence”?

The up-shot of this in the context of the evidence base for Personal Health Budgets is that Ben Goldacre and advocates of personalisation are both right, and they’re both wrong. There cannot be a definitive answer to the question of whether Personal Health Budgets are effective until some other, perhaps unanswerable questions, are considered.

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rich_w

Man of letters & numbers; also occasionally of action. Husband to NTW. Dad of three. Friendly geek.

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