British Academy: The UK's National Academy for the Humanities and Social Sciences
Enquiry, Evidence and Facts: An Interdisciplinary Conference
A Rhetorical Analysis of Evidence-based Policymaking
Dr Jill Russell
University College London, Holborn Union Building, Archway Campus, Highgate Hill, London N19 5LW
Professor Trish Greenhalgh
University College London, Holborn Union Building, Archway Campus, Highgate Hill, London N19 5LW
Dr Emma Byrne
Department of Computer Science, University of Wales, Aberystwyth, Ceredigion SY23 3DB
Professor Janet McDonnell
Central Saint Martins, University of the Arts, Southampton Row, London WC1B 4AP.
An abstract presented to the conference
‘Enquiry, Evidence and Facts: An Interdisciplinary conference’
at the British Academy, London, on 13 December 2007
Biographies
Professor Trisha Greenhalgh
Professor Trisha Greenhalgh is a non-principal GP in north London and Professor of Primary Health Care at University College London, where she has worked since 1986. She also holds a Consultant post in Primary Health Care at Barnet Primary Care Trust. Her diverse research interests fall into three main categories: (a) complex innovation in healthcare, especially the introduction and assimilation of ‘networked’ electronic health records; (b) service development for chronic disease management, with a particular focus on the provision of culturally congruent services for diabetes; and (c) the use of narrative methods in health services research, especially in the realm of audit and quality improvement.
Prof Greenhalgh is Programme Director of the Masters in International Primary Health Care at UCL (which currently offers 20 free scholarships annually to students from developing countries) and of the Dick Whittington Project (which welcomes 40 academically able teenagers from socio-economically deprived backgrounds annually to a pre-medicine summer school).
She has published over 90 papers in peer reviewed journals, is the author of 7 academic textbooks, and was awarded the OBE for Services to Medicine in 2001.
Dr Jill Russell
Jill Russell is a senior lecturer in the Department of Primary Care and Population Sciences at UCL. She has a background in social policy and medical sociology and has been involved with the UCL evidence, inference and enquiry programme from the outset. With Professor Trisha Greenhalgh she has been exploring decision-making in local health care policymaking drawing on a rhetorical argumentation perspective. Other current research interests include pedagogic research in open and distance learning, evaluation methodology, and an MRC funded project on the electronic patient record as technology in practice. She is a Distance Education Fellow of the University of London Centre for Distance Education.
Dr Emma Byrne
Emma Byrne is a research associate at Aberystwyth University, where she is currently working on the Robot Scientist project. Her background is in machine learning and logic. She is applying argumentation formalisms to policy discourses in the NHS in order to highlight conflicts over values. She is also involved in the work to reclaim healthy rhetoric for policy making.
Professor Janet McDonnell
Janet McDonnell is research co-ordinator at Central Saint Martins College of Art and Design, University of the Arts, London where she is Professor of Design Studies. She was a member of the academic staff at UCL in the Department of Computer Science from 1994-2004. She is a Chartered Electrical Engineer, a Fellow of the RSA and served on the Council of the Design Research Society for eight years. She has recently co-organised the 7th Design Thinking Research Symposium held in London in September 2007. Her research interests include the role and uses of informal argument in negotiating decisions.
Abstract
The focus of this paper is the construction and use of evidence in healthcare policymaking. Critiques of the ‘naïve rationalist’ model of policymaking abound in the sociological and political science literature, yet academic debate on healthcare policymaking continues to be couched in the dominant discourse of evidence-based medicine, whose underlying assumptions – that policies are driven by facts rather than values and these can be clearly separated; that ‘evidence’ is context-free, can be objectively weighed up and placed unproblematically in a ‘hierarchy’; and that policymaking is essentially an exercise in decision science – have constrained both thinking and practice. The starting point for our research has been that if we wish to study policymaking ‘as is’ rather than as the naïve rationalists believe it should be, then we require a framework of ideas that addresses the role of language, argument and discourse. We suggest that argumentation theory, and specifically rhetoric, is ideally suited to this purpose.
The aims of our research were to explore the micro-processes by which policymakers introduce, construct, interpret and apply evidence in policy discussions; to develop a case study of argumentation in priority setting deliberations in primary health care, and to use the insights from this case to inform debate on what might constitute ‘better’ policymaking in practice.
In this paper we present our analysis of the deliberations of a group of people charged with prioritising health care at a local level to illuminate the language, arguments and discourse through which policy is constructed and enacted. We demonstrate how our analytic approach has enabled us to:
- Examine closely the communicative and rhetorical strategies that policymakers use to direct attention to the problems and options they are assessing;
- Explore the complex ways policymakers formulate problems (how they ‘name and frame’ problems);
- Explore the ways policymakers’ arguments express or resist broader relations of power and belief;
- Examine how arguments are constructed for particular audiences;
- Explore how credibility and authority is established and how certain individuals come to be trusted and particular values given legitimacy;
- Explore the processes by which the group come to agree something is plausible, sensible, reasonable;
- Reveal the macro-politics of policymakers’ participation in larger discourses.
Our data suggests that the principles of evidence based medicine, combined with a principled-based approach to ethical decision-making, whilst helpful in structuring and guiding policymakers' deliberations, can also constrain critical, reasoned thinking about difficult rationing decisions. Our findings confirm the contingent and indeterminate nature of decision-making, and the role of shared human inquiry as a way of coming to reasonable decisions.
In conclusion, we suggest that the benefits of a rhetorical perspective are not limited to academic inquiry. Making visible the role of language, argument and discourse in policy discussions has the potential to play an emancipatory role in giving policymakers new insights into their work, and increasing awareness of the conditions that shape their actions and choices. We describe the action research in which we are currently engaged with policymakers, exploring the potential gains from understanding the activity they engage in as argumentative processes. Benefits, for example, include:
- A rich description of the naturalistic processes occurring around the policymaking table;
- Recognition of the legitimacy of different perspectives leading to greater understanding of others’ positions;
- Emphasis on processes of judgement and justification, rather than simply the decision-making outcome;
- Ability to probe assumptions critically, appreciate and be able to justify value judgements;
- More sophisticated understanding of the audience (appeal to audience through choice of arguments likely to gain adherence)
- Alternative framings —> pushing out the boundaries of the possible —> more creative thinking to solve complex problems.