Are there lessons from the C difficile experience with wider health policy implications, ask Annalijn Conklin, Sharif Ismail and Tom Ling
Hospital acquired infections have inspired a series of lurid media headlines over the past few years, often with good cause. C difficile claimed nearly 6,500 lives in England and Wales in 2006, according to figures published last year by the Office for National Statistics.
C difficile would present a potent challenge to any health system
The Department of Health has launched a number of initiatives to try to address the problem. There is now evidence of significant declines in incidence rates, but policy level solutions have been – and continue to be – difficult to pin down. Why? Are there lessons that can be learned from the C difficile experience that would offer wider health policy insights?
A complex problem
C difficile would present a potent challenge to any health system. First, the evidence base surrounding it is patchy. Basic epidemiological data limitations make it hard to tell what is going on: data on incidence in England and Wales was not systematically collected until 2004 and even then only in patients over 65.
Despite growing evidence on what works in clinical practice, there is enduring uncertainty over appropriate management level interventions. Recent investigations by the Healthcare Commission into outbreaks at Stoke Mandeville and Maidstone and Tunbridge Wells have offered pointers, but intuitive assumptions still hold sway.
However, the capacity to deal with the problem is also divided between various stakeholder groups – including civil servants, NHS management staff, clinicians and hospital cleaning staff – who often find it hard to co-ordinate their activities with one another.
The role of organisational barriers to effective cross-cutting working has long been recognised. But much less attention has been paid to differences in the way complex policy problems are understood by different groups. For C difficile, where the evidence base is so fragmented, building a shared understanding of the problem has been a crucial first step towards effectively tackling incidence rates.
To see how divergent understandings arise, we need to go back to first principles. Sociologists have long argued that – far from being “objective” – scientific knowledge is produced and reproduced by many individuals and groups through constant acts of negotiation and bargaining. Groups of professionals form “epistemic communities” that negotiate and then decide what bodies of evidence mean according to pre-defined rules and pre-assumptions.
For complex policy problems where many stakeholder groups are involved, the difficulties are acute. Who decides which types of evidence are appropriate as the basis for new initiatives? And how far does this depend on the nature of relationships between different groups?
A potential role for ‘linkage and exchange’
Fortunately, practical solutions are at hand. One possible approach is “linkage and exchange”, pioneered by Canadian health researchers looking to build formal bridges to overcome the gaps in knowledge and information between different stakeholder groups in public health.
At one level, this includes events at which practitioners and policymakers representing different groups are brought together to engage with a problem collaboratively. There are also UK precedents for this approach. In autumn 2007, for example, the Department of Health staged an international summit on C difficile which we attended. Our role involved presenting an independent review of what was then known about C difficile during the first session, to encourage participants to discuss the relative strengths and weaknesses in the evidence base, and gradually move towards a common understanding of the problem. Later sessions focused on specific areas of concern, defining the scope of possible interventions, and identifying areas for further research to improve our understanding of C difficile.
But linkage and exchange can also include more proactive, long term models in which individuals or “knowledge brokers” are specifically tasked with bringing about interactions and exchanges through a variety of soft processes. This approach has been used successfully in Canada, and its advantages are clear. By ensuring continuous interaction between stakeholder groups mediated by knowledge brokers, it encourages more proactive translation of research evidence. And it incentivises the kind of interdisciplinary communication that will help to build common understanding and foster effective cross-cutting work in the long term.
Future efforts at getting research into practice for complex health problems should explore opportunities for a multi-level approach modelled on linkage and exchange. Activities similar to the knowledge broker model outlined above will help to improve research translation and build common understanding of complex policy issues.
But these activities will be ineffective unless they are complemented by regular conferences and workshops to help build shared understanding between stakeholders across the healthcare system. Whether the focus is on individuals, meetings or networks, a health policy making strategy led by a consensus approach to the evidence base and improved research translation is ultimately likely to yield informed and coherent policy initiatives and thereby improve patient safety.
Annalijn Conklin, Sharif Ismail and Tom Ling
*The views expressed in this article belong solely to the authors based on their preparatory work and participation in an autumn 2007 initiative of the UK Department of Health to improve current understanding of C difficile. They do not necessarily reflect the views of the Department of Health.