The Continuing Relevance of Academics to Health System Reform
In the drily titled Science and Government, C.P. Snow (2013) describes the role of a former Oxford Chemistry Academic and a committee of academics and experts in ensuring that radar was installed in time for the Battle of Britain. Contrasting the story of success of radar with the strategic and humanitarian failure of strategic bombing, Snow argues for the importance of open policy, that is, policy developed and tested by experts. But throughout his narrative, the main characters are academics and experts who propose and argue for and against different policy options as Britain prepares for and fights the Second World War.
So why is Science and Government relevant today and why is it relevant to an issue of Healthcare Papers describing how to move toward a learning health system? In short, it remains relevant precisely because of the important role played by academics and experts. Without Sir Henry Tizard (the Oxford chemist and chair of the Aeronautical Research Committee) and his committee of academics, Britain would likely not have had the early warning abilities of radar. Likewise, without the advice of Frederick Lindemann (Viscount Cherwell), Britain would likely not have opted for strategic or area bombing that Snow argues actually lengthened the war. But the role of academics in both cases goes well beyond the usual domains of knowledge creation and knowledge transfer. Both Tizard (and his committee) and Lindemann were called on to give advice in areas where there was incomplete evidence, but where the consequences of the wrong advice could be catastrophic. They had to advocate credibly for what they believed – based on limited evidence – to be the best advice and to work directly in the implementation of this advice. And beyond the case of radar, they also created a bridge to other academics and pockets of expertise that were critical to the British war effort.
Health reform should never be compared to war, but there are numerous lessons in Science and Government for current efforts to create a learning health system. The importance of academics interweaves throughout the 11 volumes of the Institute of Medicine’s Learning Health System Series, often more implicit than explicit. Academics play the same implicit role across the papers in this issue. So what are the roles of academics, and why are they best positioned to fill these roles, in health system reform? Building off the history described in Science and Government and our own, much less dramatic, experience, we suggest that academics have three key roles in promoting health system reform.
The first role, as always for academics, is the creation of new knowledge and the sharing of knowledge through education, knowledge transfer and public engagement. Nothing should shake the academics’ commitment to this role. At its best, this role extends what is known about health system performance and helps decision-makers navigate challenging spots in health system reform. It also provides the foundation for innovations from inside and outside of the academy that can improve health system performance. The collection of understandings about how radar could work was critical to convincing Tizard’s committee that radar would work. However, the safety of this role requires academics to maintain their integrity and independence. Although they may have to work under oaths of confidentiality or privacy when working with decision-makers, they need to protect their ability in these situations to speak truth to power and to pursue new avenues of knowledge.
The second role is the extension of knowledge. Academics should be at the leading edge of their science. What they and their peers have discovered is important, but equally important is their ability to reason based on this work and help describe the outlines of what is not yet proven. This ability was critical to the creation of radar. When Tizard and his colleagues first began advocating for radar, some of the critical components were still unproven. Academics are often reluctant to extend knowledge and this is an appropriate reluctance, but with the right framing and contextualization, advice that provides some guidance in the face of uncertainty about what works can be critical. But again, as Snow notes, it is best if this advice benefits from the input of multiple experts and academics so as not to push too far beyond the bounds of what is known. For this role, it is critical that academics maintain their collegiality and respect for diverse opinions, and to widen that collegiality to individuals working outside the academy.
The third role is the creation of bridges to other academics and among academics, decision-makers and practitioners in an environment that can foster debate. Once again, this re-enforces the open policy process advocated by Snow. Tizard’s advice was better and more credible, because he engaged a group of other experts and he engaged decision-makers at all levels of the defense establishment. This made sure that the advice was the best it could be and grounded in the realities of the conflict that was coming. A number of papers have emphasized engagement as a powerful tool for policy development (Backstrand 2003). It is important for academics to realize that such engagement extends to their colleagues as well as to decision-makers and, increasingly often, to the broader public.
However, all of this also makes the argument for an inclusive definition of academics. As we struggle with the challenges of building learning health systems and improving health system performance, academics should find themselves regularly working outside of the scholarly or research setting. To the extent that they can maintain the roles noted above and, as importantly, maintain the relationships (Lomas and Brown 2009) with other academics and experts, they will be able to support the continuing development of learning health systems. The recommendations in this issue of Healthcare Papers could be extremely valuable, but we must always keep in mind the importance of individuals in leading and supporting health system evolution.
About the Author
Adalsteinn D. Brown, DPhil, Editor-in-Chief, Healthcare Papers, Director, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
Sabina Nuti, Director of MeS Lab, Associate Professor of Management, Scuola Superiore Sant’Anna, Pisa, Italy
Backstrand, K. 2003. “Civic Science for Sustainability: Reframing the Role of Experts, Policy-Makers, and Citizens in Environmental Governance.” Global Environmental Politics 3(4): 24–41.
Lomas, J. and A.D. Brown. 2009. “Research and Advice Giving: A Functional View of Evidence- Informed Policy Advice in a Canadian Ministry of Health.” Millbank Quarterly 87: 903–26.
Snow, C. P. 2013. Science and Government. The Godkin Lectures on the Essentials of Free Government and the Duties of Citizens. Cambridge: Harvard University Press.
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