Big decisions on health playing out like card games with high stakes

A good place to start thinking about any type of public policy is the maxim, “no one knows everything, but everyone knows something”

Of all the card games I played when growing up, my favourite by some distance was 500. One of those tricks and trumps games, it’s more complex than euchre but simpler than bridge.

With all these games, the first stage of each round is to determine which suit – hearts, diamonds, clubs or spades – is trumps.

A trump card, even if it is of relatively low value, beats a high-value card of any other suit. This process shapes how valuable each card is in each round. In 500, the Jack of Spades is highly valuable when spades are trumps, but of limited value if the trump suit is diamonds.

For years, I have used this metaphor as a way of understanding what sort of knowledge counts in policy. A good place to start thinking about any type of public policy is the maxim, “no one knows everything, but everyone knows something”. In other words, there is no place in the policy process where omnipotent and all-knowing experts gather every piece of relevant information, sift and analyse it, and identify optimal solutions to problems.

However, many different players – including researchers and practitioners – know many different things relevant to specific policy issues. And, typically, different bits of knowledge have conflicting policy implications.

The policy process resembles a game of 500 in which different players hold different combinations of cards (things they know). The outcome is determined not only by who has good cards (potentially powerful knowledge), but by who gets to define trumps, how well each player plays their cards and, sometimes, by plain dumb luck.

Here’s a simple example to consider: How many cochlear implants for adults with hearing impairments should be publicly funded? The Ministry of Health funds one implant, but not two.

Clinical research, by and large, demonstrates that cochlear implants are highly effective, and having two implants is considerably more effective than having one. In a public funding context, where a dollar spent on one thing cannot be spent on another, it is important to know how cost-effective cochlear implants are compared with other things. It is also crucial to know whether we have the workforce capacity to meet increased demand for implants.

Many people with profound hearing loss have strongly advocated for the funding of two implants, while others in the deaf community regard cochlear implants as a threat to the viability of deaf culture, and don’t support public funding for any implants.

How do all these diverse and conflicting claims to knowledge get handled in health policy processes? At the end of the day, which knowledge counts the most?

The answers vary considerably from issue to issue and time to time.

In processes for deciding which pharmaceuticals are publicly funded, value for money – as defined through cost-utility analyses – clearly trumps public opinion and the preferences of clinicians. However, for other health policy issues, including euthanasia and cannabis decriminalisation, the key battle is in the court of public opinion. In yet others, what works for the health workforce has the largest influence (eg, the rollout of bowel cancer screening).

To be a skilled policy player, therefore, you need to know which suit is trumps at any time, and play your hand accordingly.

Good players also know they need to pay attention to their weak suits as well as their strong ones, because their weak suit may be the trump suit. To go back to the cochlear implant debate, groups advocating for public funding of two implants need to be able to engage with the cost-effectiveness studies as well as the research on clinical effectiveness, and support from their constituency. Becoming proficient in all these types of policy knowledge is a core skill in policy advocacy.

In health policy, there will always be, and should always be, debate about which type of knowledge should be trumps.

For those who suggest evidence of the effectiveness of interventions should always win out over other factors, what happens when this type of knowledge is impossible or incredibly costly to generate? Many ways of spending health resources do not lend themselves to meaningful analyses of this type – should these be systematically undervalued?

For those who wish their health policy decisions to have impeccable democratic credentials, how would this be possible to organise over the whole gamut of problems that require attention?

Finally, for those who suggest the needs and preferences of the health workforce should always win out, who – which patients, and which sections of our community – would systematically lose out under such a regime?

In 500, players can opt for “no trumps” (strangely, this now sounds like a political slogan). No-trumps games are the most unpredictable of all and are played at the highest stakes. Every suit (type of knowledge) is potentially valuable, but any suit could end up being worthless. In the current policy environment, with a new government playing its cards close to its chest, I suspect the highly important debates about health funding and health-system structure will be like a no-trumps game.

Tim Tenbensel is associate professor, health policy, in the School of Population Health at the University of Auckland