Many individual clinical decisions are based on thingslike habit, ‘self-evident’ facts, custom and ideology, all less desirable than decisions based on some evidence. So those in power have recognised this andhave encouraged moves towards evidence-basedmedicine, so that some demonstration of advantage is now demanded before many new procedures are popularised, certainly before they attract publicsubsidy.

It is difficult to translate ideas into action, even whenthe ideas are based on good evidence. It is necessarytoo to know something about implementation and theblockages to implementation, quite apart from havingan admirable interest in evidence to underpin one’sview of what should be done.

To illustrate this we need go no further than the history of smoking tobacco and the evidence of theharm tobacco smoking does.

The link between tobacco smoking and disease hasbeen known for at least 50 years and yet one-quarterof our population smokes, taking an addictive drug anda damaging set of plant products voluntarily. Peoplewho smoke do so to satisfy their need for the addictivedrug and are damaged in the process. The companiesmarket their product (with the death and disease thatfollow) aggressively in other countries. Governmentschoose not to interfere effectively, partly for quirky ideological reasons and partly because those activitiesare sources of major revenues for the governmentsthemselves.

Fifty years and still one-quarter of the population smoking! Action here has certainly not been sufficientlyeffective. It was not for lack of powerful evidence either - for there is plenty of good evidence.

Perceptions too may be distorted. Consider the decline in fatal tuberculosis in this

country over about a century and a half. Some clinicians believe that effective chemotherapy was thepivotal event, but evidence shows that there was a dramatic and steady decline in mortality long beforethere was any effective chemotherapy. Of course,chemotherapy was important for the residuum.However, ideology and idiosyncratic perception play a

part in defining ‘realities’ seen by clinicians. So theybecome a part of the equation too.

A final illustration shows that we just do not know about some traditional treatments. We have never been able to ‘prove’ that trans-urethral resectionof the prostate (TURP) is effective treatment for lower urinary tract obstruction. Certainly any urinaryobstruction is relieved, but incontinence, recurrence of lower urinary tract symptoms, impotence and operative and anaesthetic complications all need to be factored in to the assessment of overall clinical benefit. Yet, although proper assessment is still aheadof us, TURP remains a logical, mainstream andrespectable treatment for lower urinary tract obstruc-tion. Most males would still have a TURP for anenlarged prostate with symptoms. The design of an experiment to test that particular treatment wouldbe difficult and may not be acceptable - particularly to institutional ethics committees.

So it is quite problematical trying to translate ‘evidence’ into action.

Let us look for a moment at the political process.Most politicians are good people with a genuine desireto see their communities better off.

But consider Cabinet for a moment. There is one Minister for Health; and that Minister may havea couple of allies with similar special knowledge or withsympathetic views. But around that table there are alsoa Minister for Defence, a Minister for Foreign Affairs,a Minister for Primary Industry, a Minister forCommunications and so on. There may be 25 differentMinisters, most of whom know little of health apartfrom their own personal experiences of illness.

In that environment, any Minister for Health is in aminority. The others do not have the facts or data available to the specialist Minister and anyhow, theyeach have a specialised area of their own to worry aboutand to oversee. As if all that were not enough, they havea zero-sum game in which everyone knows that the law or opportunity cost will work - more for A maymean less for B if the cake remains of constant size. Inaddition, many Ministers have other, more personalagendas, which have more to do with their own futuresthan with the good of the community.

So, perhaps a first task is to imprint some of the available information on the other Ministers so that aMinister for Health will have a more educated body of colleagues whenever he or she addresses Cabinet.

J. Qual. Clin. Practice (2000) 20, 173–174

From health information to health action*

HONOURABLE EMERITUS PROFESSOR PETER BAUME AO, MD, HON LITTD, FRACP

The Social Policy Research Centre, The University of New South Wales (Email: p.baume@unsw.edu.au)

*A speech given by Professor Peter Baume at the launch ofAustralia’s Health 2000 to Australian Institute of Health andWelfare’s Seventh Biennial Health Report, Canberra, June 22nd,2000.

A second task might be to convince colleagues that theirown vital interests would be served by supporting ahealth-related proposition.

Next, consider power as a commodity - not just in aCabinet meeting, but more widely. Power is what manypeople live for. They pursue it, value it and judge others by whether they are accreting or shedding power.Sir Michael Marmot, an Australian by the way, has suggested strongly in his seminal Whitehall studies thatit is control over decisions (that is, one form of power)that may make officers healthier or sicker. With thatinformation, is it any wonder that Aboriginal health issuch a problem in Australia - for control over many oftheir own decisions is what black people often do not have. Of course, that is only one of the factors operating in relation to Aboriginal health - there aremany others.

However, consider power a bit further. Policy changeoften alters power relationships. People generally willoppose any measure that promises or threatens toreduce their power or their access to power. Often thatopposition will be dressed up in other language. So onehas to be careful that one does not unwittingly makeclinicians, hospital superintendents, nursing staff intolosers with any proposed change. The clever agents ofchange find ways to make many people into winners(half-lead petrol made and marketed by Shell is a goodexample) - unless they do so, many proposals aredoomed.

Power has many forms and many dimensions. Powerover resources, power over decisions, power over people, power to prevent actions occurring and otherforms of power.

Once upon a time the Government of New SouthWales wanted to close a health facility in the centralwest of the State. The town involved was more con-cerned about employment than health. The Govern-ment reinvented that facility as a different resource,maintained the Town’s employment and closed thehealth facility with no trouble.

Next, consider that many people rely on body

language signals, or on personal communications more than they rely on intellectually rigorous argu-ments. They are more willing to accept the substanceof authoritative statements if they trust the people making those statements. That applies to Cabinets, totelevision shows and to town meetings. So we need tohave skilful communicators - which many in the healthgame are not - if there is to be a maximum chance of the findings of a particular study or the bottom lineof a particular argument being accepted and actedupon.

Next, one might consider something that those inpublic health and epidemiology speak of a lot. It concerns intersectoral action. We might win greaterreturn as a society, for instance, from designing betterroads, better roadside furniture and better cars, perhaps from improving our capacity to transport people quickly, from reducing or eliminating lead inpetrol, than we would get from the same investment incurative services. Immediately one says this, one hasopposition from those in clinical services who want noinitiative that might operate in opposition to them getting any available money - unless it is an add on withno adverse resource consequences for them.

So there are many reasons besides the existence of evidence that affect the translation of evidence intoclinical practice. Many of the matters are open to usto do differently or better. That we do not understandwell enough or try hard enough says something aboutthe arrogance that seems to come with professionalcompetence and seniority, but that is another subject.

One thing seems certain as we enter this excitingCentury. Old ways have taken us only so far and weneed now to go further. The provision of high qualityinformation about processes and about outcomes will each be important in empowering those who tryto convert findings into action to succeed.

We can do many associated things better than wehave traditionally. With our proud history we know that we can do these things and it remains now for colleagues among us to give effect to changes.

174 P BAUME