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Background: Health policy in the UK and internationally has recently emphasised population health improvement and reduction of health inequalities whilst also embracing the challenge of greater public and patient engagement, both in individual treatment decisions and in policy making and priority setting. We argue that there are considerable tensions between these major public health policy initiatives.
Methods: I. Using social scientific methods of policy analysis we examine evidence-based health policy (exemplified in the UK by National Institute for Clinical Excellence (NICE) guidelines), policy promoting public and patient engagement (through strategies designed to promote patient information and choice and by requirements for health service agencies to engage patients and the public) and the policy goal of reducing health inequalities. II. To illustrate the population impact of patient choice we model paternalistic and shared decision making in the management of hypertension in a population-based cohort; a random age and sex stratified community sample of residents of south east Northumberland, England aged 65+, from 27 contiguous general practices.
Results: I. Evidence-based health policy and public and patient engagement. Engaging patients in decisions on their own treatment may not produce the same decisions as would be derived from a more paternalistic or prescriptive application of evidence-based guidelines. II. Health inequalities and public and patient engagement in decision making. Policy promoting patient choice facilitates the involvement of patients who are already more likely to engage in decision making - younger, well educated patients of higher social class - but may not improve communication with less articulate, less well educated patients. III. Mathematical modelling of the uptake of anti-hypertensive treatment in paternalistic application of evidence based guidelines and in shared decision making demonstrates that engaging patients in treatment choices may lead to fewer patients taking anti-hypertensive therapy, with a subsequent impact on population incidence of CVD.
Conclusions: We argue that there may well be unintended effects on population health of incongruities in major components of public health policy. Greater public and patient engagement may militate against the disease prevention goals of evidence-based policy. Further, these policies may better engage sections of the population who already benefit from greater access and better health associated with social status and opportunity, serving to increase inequalities by further marginalising those already suffering from relative exclusion.
See more of Oral Concurrrent Session A - Public Health 1
See more of The 26th Annual Meeting of the Society for Medical Decision Making (October 17-20, 2004)