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dedicated funding through WHO at the country level would be in response to a public health emergency. In terms of technical support, the UK will continue to sustain WHO by sharing its professional, clinical, academic, and governmental expertise. 64 UK institutes currently work with WHO as collaborating centres. These support WHO to fulfil its mandate and implement programmes, and to develop and strengthen institutional capacity in regions and countries. In a globalised world, where disease can spread faster than at any other time in human history, we need WHO to be strong and effective to meet the health challenges of the 21st century. We will continue to work with WHO to meet these challenges, as we have done for the past 60 years.
*Nicholas Banatvala, Simon Bland, Liam Donaldson Department of Health, Wellington House, 133–155 Waterloo Road, London SE1 8UG, UK (NB); UK Mission to the United Nations, Geneva, Switzerland, on behalf of UK Department for International Development and the Foreign and Commonwealth Office (SB); and Department of Health, London, UK (LD)
[email protected] We declare that we have no conflicts of interest. 1
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HM Government. Health is global: a UK Government strategy 2008–13. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati onsPolicyAndGuidance/DH_088702 (accessed April 23, 2009). HM Government. World Health Organization UK Institutional Strategy 2008–13. http://www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/DH_095296 (accessed April 23, 2009). WHO. Eleventh General Programme of Work. 2006–2015. http:// whqlibdoc.who.int/publications/2006/GPW_eng.pdf (accessed May 20, 2009). WHO. Medium-term strategic plan 2008–2013 and programme budget 2008–9. http://www.who.int/gb/e/e_amtsp.html (accessed April 23, 2009).
Improving social policy and practice: knowledge matters Action is needed beyond health care to improve life expectancy and health.1 Health for all is only possible through the provision of jobs, education, crime prevention, housing, and strong social-welfare systems. And health gains are the added benefit; improved social policies and services will first and foremost create better opportunities for the individual, and bring security and prosperity to the community. One of many illustrations is the dramatic difference in living conditions and health according to educational level, whether the outcome is maternal deaths in Bangladesh2 or diabetes-related deaths in the USA.3 Social policy has always been important, but never more so than now: there is every reason to fear that the current recession will affect health negatively in a more profound manner than anything doctors can hope to prevent or repair.4 It is thus reassuring that social policy has moved up the agenda in many countries with renewed commitments to maintaining or increasing funding to health, education, and social welfare. A world in economic crisis is scrambling to retain and even improve its social structure. However, social change does not come easily and equity can be an elusive goal; societal structures are deeply rooted and behavioural change can be difficult to inspire. The potential for doing more harm than good by intervening in peoples’ lives is also real. Exposing juvenile offenders to prison conditions and adult inmates who www.thelancet.com Vol 373 May 30, 2009
warn them of the consequences of continued criminal behaviour, for example, have intuitive appeal and are widely implemented. Whilst the initial findings from observational studies were positive, controlled studies revealed that juveniles in these programmes were more likely to reoffend, not less.5 Thus evidence-informed action is needed in all areas of social policy. Good intentions, strong opinions, endless reorganisations, and millions of dollars are not enough to bring about a safe childhood, equal opportunities, good education, less crime, more jobs, social security, and dignified care of the elderly. For such evidence to be useful, however, it must answer important questions for policy and practice in a trustworthy and easily accessible way. The Campbell Collaboration6 aims to establish a global library of relevant and reliable systematic reviews on effects of programmes and interventions in education, crime and justice, social welfare, and other social-policy domains such as development and disability. Such a library will inform decision making, reveal knowledge gaps, and create a stronger focus on what constitutes useful evidence among policy makers, funders, and researchers. This international network is picking up speed. It is based on cooperation among researchers from various backgrounds assisted by a small secretariat now hosted by the Norwegian Knowledge Centre for the Health Services. Work mainly takes place via five coordinating groups (social welfare, crime and justice,
Published Online May 14, 2009 DOI:10.1016/S01406736(09)60783-2
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education, methods, users) and a jointly registered group with the Cochrane Collaboration (developmental, psychosocial, and learning problems). Key factors that contribute to the enthusiasm in this network are collaboration, explicit standards, methodological assistance, thorough peer-review, open-access publishing, and a lean, efficient, and reasonably funded organisational structure. Annual colloquiums provide a meeting place for policy makers, practitioners, and researchers. Organising what is known on social and educational interventions is challenging for many reasons. Early child development, education, environment, employment, crime prevention, and social protection across the lifespan—wherever we look there is a need for improvements in services and policy. However, across the board there is a worrying lack of empirical research, too few experimental trials, a lot of disagreement about the role of research and, compared with clinical medicine, less integration of research and practice.7 Knowledge as a resource for improvements in social policy and practice is grossly underused. The challenge, therefore, is not only to gather what there is of evaluative research on education, child protection, crime prevention, and other fields, but also even more to bring about a shift in what social science, social scientists, practitioners, and policy makers bring to the table to inform decisions about what to do and what to refrain from doing. Research is an essential tool to steer improvement efforts where they are most needed, 1830
to evaluate what progress we make, and to develop new ideas on the basis of accumulative learning from failures and successes. Policy makers and researchers must address this particular challenge in a direct and practical way. Otherwise we will never learn if change was for better or for worse. To improve the current state of affairs we first and foremost need to incorporate evaluative research into the processes for changing, adapting, improving, organising, or otherwise seeking quality in the services we provide. Hence applied research needs to be prioritised and to become relevant, valid, and part of how services are designed.8 We need, in short, to seriously start developing a learning society. For that to happen, several key actors need to respond. Professions such as the police, teachers, social workers, and public health practitioners need to move science from the outside to the core of their mission, to become an organic part of how we all work. Scientists must answer questions that are crucial to how the professions and services function, and to their results. Those who undertake and organise research must implement better standards in evaluation and in training researchers in these methods. Social science speaks directly to how we can improve society; that is, through changing how people choose to behave and to relate to one another. It must also speak to how we can evaluate attempts to improve the world and thus become relevant, pertinent, and potent. Epidemiology, now lost in an endless trail of papers on questionable associations derived from observational studies, must become yet again a discipline that supports improvement in public health. Governments need to develop an experimental approach to social reform,9 and politicians, chief executive officers, and research councils must ask for and fund more rigorous evaluations as part of an integrated approach to continuous quality improvement. As a result we should see many more primary studies of an empirical nature that address the many knowledge gaps and hopefully evaluate bold new initiatives. The Government of Mexico passed legislation in 2003 which required that impact evaluations be done for various public programmes, explicitly recognising the value of learning what works and why as a guide for future budget decisions.10 The present focus on comparative research in the USA as part of sweeping reforms also sets an important example.11 www.thelancet.com Vol 373 May 30, 2009
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To know what is known and not known, world libraries of summarised evidence must be built and maintained. The Cochrane and Campbell Collaborations are now established well-functioning production systems for high-quality systematic reviews. There is a need to concentrate on those two systems rather than building competing systems, smaller or larger. Any local knowledge broker, clearing house, or technology assessment office needs to ask themselves how they are, in addition to serving their own local context, contributing to this global build-up of knowledge. The remarkable success of the Cochrane Collaboration can easily hide the fact that such organisations are vulnerable and in need of better support systems. We need more systematic reviewers, review quality needs to be improved, and updating needs to be addressed to ensure that reviews remain relevant for policy questions. Governments and other funders must support infrastructure, review groups, training, and dissemination. All of us need to participate in creating new and improved opportunities for direct dialogue between researchers, end users, and policy makers. Knowledge matters. It informs decisions about individuals, services, and society if it is relevant, valid, synthesised, readable, delivered, and used wisely. We can develop a learning society based on a belief in the possibility of change, innovation, and an ethical obligation to investigate when the balance between good and harm is unknown. For this to happen we need to do pragmatic and valid research which aims to tackle important problems, to build up global libraries of systematic reviews of such attempts, to create user-friendly versions of
guidance either on knowledge or knowledge gaps, and to engender support and engagement among researchers, policy makers, and practitioners. Arild Bjørndal Norwegian Knowledge Centre for the Health Services/Institute of General Practice and Community Medicine, University of Oslo, 0130 Oslo, Norway
[email protected] I co-chair the Steering Group of the Campbell Collaboration. 1
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Commission on Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health. 2008. http://www.who.int/pmnch/topics/economics/ tacklinghealthinequities/en/index.html (accessed April 18, 2009). Chowdhury ME, Botlero R, Koblinsky M, Saha SK, Dieltiens G, Ronsmans C. Determinants of reduction in maternal mortality in Matlab, Bangladesh: a 30-year cohort study. Lancet 2007; 370: 1320–28. Miech RA, Kim J, McConnell C, Hamman RF. A growing disparity in diabetes-related mortality: US trends, 1998–2005. Am J Prev Med 2009; 36: 126–32. Woolf SH. Social policy as Health policy. JAMA 2009; 301: 1166–69. Petrosino A, Turpin-Petrosino C, Buehler J. ‘Scared straight’ and other juvenile awareness programs for preventing juvenile delinquency (updated C2 review). Campbell Syst Rev 2004: 2. http://db.c2admin. org/doc-pdf/Petrosino_ScaredStraight_Review.pdf (accessed April 18, 2009). The Campbell Collaboration. http://www.campbellcollaboration.org (accessed April 18 2009). Noonan E, ed. Better evidence for a better world. March, 2009. http:// www.campbellcollaboration.org/artman2/uploads/1/3ie_Campbell_ working_paper_21.pdf (accessed April 20, 2009). Weisburd D, Neyroud P. Police science: toward a new paradigm. Executive session on policing and public safety. Boston: National Institute of Justice, U.S. Department of Justice, and the Program in Criminal Policy and Management, John F. Kennedy School of Government, Harvard University (in press). Campbell DT. Reforms as experiments. Am Psychologist 1969; 24: 409–29. Congress of the United Mexican States. General law of social development: Title V. Evaluation of the social development policy. Jan 20, 2004. http:// www.coneval.gob.mx/contenido/normateca/2348.pdf (accessed April 18, 2009) (in Spanish). Pear R. US to compare medical treatments. New York Times Feb15, 2009. www.nytimes.com/2009/02/16/health/policy/16health.html (accessed April 20 2009).
The paediatric analgesia wheel: are you ready to roll? In children, drug doses must be calculated on the basis of weight or body surface area, which can lead to errors.1,2 England’s Department of Health has highlighted this danger, calling for improved safety in prescribing for newborn babies and young children.3 According to the National Patient Safety Agency, children under 4 years were involved in 2081 (10·1%) of the 20 594 medication errors with age reported between January, 2005 and June, 2006—a disproportionately high number considering a bed occupancy of 5·6%.4 The true number could be much greater since many medication errors www.thelancet.com Vol 373 May 30, 2009
go unreported, with the annual incidence of paediatric medication errors in England estimated to be 50 000.5 Alongside information and training, new tools are needed to increase medication safety for children. Enter the paediatric analgesia wheel—a double-sided, pocketsized tool designed by Richard Hixson and colleagues to display precalculated doses and conveniently administered volumes of analgesics and antiemetics commonly used in children (to within 5% of the exact dose specified in the British National Formulary for Children [BNFC] 2006). Maximum dosage frequency and 1831
