The most important issue in health is, of course, to recognise that there is no most important issue in health. How could one possibly choose between the evisceration of the NHS, the abandonment of social care, grotesquely widening health inequalities, the looming nightmare of antimicrobial resistance, or the incipient planetary catastrophe of climate change?
So I’m not going to try and define any single, most important problem, because that’s a mug's game. What I would like to do instead is explore why it is that we are so often drawn back to trying to rank issues by importance, and why we find the complexity of these problems so challenging. What I’d like to propose is a set of approaches that can be used to conceptualise them in ways that may help us to achieve better outcomes.
There are many factors underpinning our collective failure successfully to tackle these messy, complex challenges. The ways in which we conceptualise these problems, and the models we use for the generation and use of evidence to address them, are a common thread running through the fabric of our failures.
Let’s take obesity. Despite extensive rhetoric about upstream, structural drivers of health much, if not most, obesity policy focuses on individual level behaviours – the phenomenon of ‘lifestyle drift’. This is despite a pretty clear understanding that as a general rule upstream measures are the most effective and cost-effective ways to influence behaviour, and the least likely to widen inequalities. The published evidence base is skewed towards downstream individual level ‘interventions’ rather than upstream ‘actions’, and this is aligned with the dominance of notions of individual responsibility in much public and political discourse.
Why? My contention is that one of the main reasons for this is the influence of models of evidence generation that have arisen from a traditional, focused scientific model of linear cause and effect. This is the model that influences research funding, academic reward structures, publication priorities, and even the (self) selection of individuals who work in scientific research.
But the kinds of tools and approaches that are ideally suited to differentiate between a drug and a placebo in a double blind randomised controlled trial are not necessarily the best methods to provide us with the knowledge required to understand how to build a health-enhancing, equity-promoting environmentally sustainable city, let alone how to influence policy and practice to make that happen.
If we are successfully to achieve these kinds of outcomes we need instead to consider the generation and use of evidence in complex adaptive systems, viewing our actions as events within systems, not merely as discrete ‘interventions’. This conceptual shift will not, indeed cannot, happen overnight, but it needs rapidly to accelerate if we are to move beyond the impasses we face with seemingly intractable problems such as obesity, entrenched inequalities, or climate change. And that’s pretty important.
Harry Rutter is an academic public health physician based at the London School of Hygiene and Tropical Medicine. He is a senior strategic adviser to Public Health England, and is working with the Health Foundation to improve the impact of public health research on policy and practice.