Keeping scepticism alive in health care improvement

Just because health care practices are widespread or institutionally embedded doesn’t mean they actually benefit patients. 

Accepted practices can be based on convention, simplicity, or the insistence of powerful actors, rather than empirical evidence. In other words, scepticism is at the heart of health care improvement. 

Improvement is not sceptical for its own sake: it also generates high-quality evidence about what works well and what does not. This informs changes designed to improve health care processes and outcomes.

Unfortunately, health care improvement activities often don’t improve health care. Many well-designed improvement efforts yield no benefits, and those that do usually have modest effects. 

Improvement efforts can be poorly coordinated, so that changes which result in benefits in one area can make things worse elsewhere. 

Hard-won marginal gains in specific areas of clinical practice can be undermined by systemic crises like workforce shortages, chronic under-investment in public health and social care, and lack of pandemic preparedness. 

These problems are relatively well recognised, and some responses to them come from within health care improvement: improvement researchers adopt sceptical perspectives towards improvement itself, studying when and why interventions work – and when they don’t. 

Implementation scientists promote the systematic uptake of evidence-based improvement findings, identifying ways to surmount the barriers that obstruct this in practice. 

More critically, sociologists have identified how power and status influence improvement practice and highlighted the reductiveness of efforts that treat complex, dynamic, human health care systems as mechanical and linear processes. 

These sceptical currents support debate about how improvement is done, but the value of improvement as a practice remains largely unquestioned within policy and service contexts, and other key aspects go unchallenged.

Improvement activities use up resources, including the time and energy of professionals. Their opportunity costs as well as their direct costs need to be considered alongside their benefits.

At least sometimes, it will be better not to pursue improvements at all. 

Aspects of widespread improvement practices may also have unintended bad consequences (see Springer article below), such as placing undue emphasis on more measurable goals and values while overlooking others.

Health care improvement has become institutionalised. As part of their training, junior doctors must carry out clinical audits or quality improvement projects. 

Departments, teams, and professionals with a specific quality improvement remit sit within most health care organisations. 

Improvement activities are incentivised and disincentivised by government payment structures and penalties. 

Personal incentives relating to promotion, pay, and status within health care organisations are therefore attached to improvement activities being carried out. 

These factors can make improvement activities an assumed norm, rather than having to be assessed on their merits. 

This is reinforced by the popular ideal of ​‘continuous improvement’ and the oft-repeated mantra of Paul Batalden and Frank Davidoff: 

If greater justification is demanded for not doing improvement rather than doing it, then it can be difficult to push back on questionable improvement projects and practices. 

In practice, then, there are sometimes limits to the scepticism that health care improvement as a field will take seriously.

Philosophy has an important role to play in helping scepticism to thrive in improvement.

Philosophical scepticism can be used to point out and examine assumptions and conventions.

This is done not to undermine improvement activities or knowledge, but to reflect on what is valuable and important and the extent to which this is reflected in the work. 

Sceptical questioning can be counter-cultural and difficult to entertain because it calls fundamental tenets of the field into doubt. 

Could greater improvements in health outcomes be secured by shifting the focus away from health care institutions and towards preventative medicine and the social determinants of health? 

Should continuous improvement be downplayed in areas of good practice while there are still domains in which care and system functioning is inadequate? 

And is continuous improvement a desirable aim at all: at a certain point, should health care be deemed good enough, and the pursuit of further improvements considered unjustified when they have significant opportunity costs in other areas of social policy? 

Can critical currents in health care improvement studies also tend to reify certain values and make unjustified assumptions about which improvement concerns matter most? 

Philosophy is well-placed to foster and explore the implications of such forms of scepticism. 

As a discipline, philosophy is characterised by unusual methodological flexibility, often engaging in ​‘meta-methodological’ debate about the nature and limits of the research methods used in other disciplines. 

This promotes openness about the kinds of questions that can be asked and enables a wide scope of objects of study. Including philosophers in health care improvement work strengthens the ​‘skill mix’ in unconventional ways. 

Philosophers can inhabit a ​‘trickster’ role. Tricksters are archetypal characters who question norms and authority and playfully disrupt the established order. 

Like tricksters, philosophers adopt, and can encourage others to adopt, questioning, critical attitudes towards the world, challenging established concepts, categories, and institutions. 

Philosophers — along with others, including patients and academics from other critical disciplines — can also occupy an ​‘insider-outsider’ stance. 

As insiders, philosophers can take the realities of health care and improvement as a starting point. This ensures that their work is meaningful and intelligible to practitioners. 

At the same time, as outsiders, who are typically not paid or employed by health care or improvement organisations, philosophers can question the current goals and characteristics of practice and raise the possibility of more transformative change. 

These are questions that it might be difficult for ​‘insiders’ to improvement practice to put forward. Philosophers can make a difference as sceptical friends of improvers — prompting them to think about the ways in which their own sceptical practice risks becoming ossified and, over time, becoming shaped by disciplinary and institutional norms and values. 

An openness to philosophy and exploration of radical and transformative ideas can help the field of improvement face its own crises of legitimacy as well as the challenges facing health care systems. 

Philosophers can make a difference as sceptical friends of improvers — prompting them to think about the ways in which their own sceptical practice risks becoming ossified and, over time, becoming shaped by disciplinary and institutional norms and values. 

An openness to philosophy and exploration of radical and transformative ideas can help the field of improvement face its own crises of legitimacy as well as the challenges facing health care systems.