Monday, 22 October 2012

EVIDENCE IS NOT ENOUGH

Stockholm as paradigm example?

On Saturday, Conductive World reported that Move & Walk will not be having its service contract renewed to provide 'habilitation' to children and young people in Stockholm:
 

In response to this, Rony Schenker stated an important position, on evidence-based practice –

Returning from the conference in Pisa, I am even more convinced and can say it very clearly: with no evidence that what we do works, there is no future for Conductive Education!!!

If we were overlooked in the past because of ignorance we are overlooked at present because of lack of evidence. No financial support will be provided to services which are not evidence-based. This is the case already, and will be more so in the near future.

Our existence is dependent upon evidence.


Rony also remarked –

I know that not everybody in the conductive community approves the idea of evidence-based practice.

I have to admit having my own problems with this concept, at least as it often presented. The term 'evidence-based practice' seems usually to be used as though it is solely a matter of outcome-evaluation. rather than relating to the actual processes of practice. This, and the matter of ill-founded methodologies and outcomes, could be addressed in the long term by a better class of research. In the real world, however, decisions have to be made now, in the light of situations that are more pressing and more material to the decision-makers. Perhaps this storm in the Stockholm tea-pot offers a useful, concrete example to illumine this.

Real politics

I do not know the basis for the Stockholm council's decision not to renew Move & Walk's service contact. Nor do I know the rules and regulations governing such contracts in Sweden, though I suspect that they will include consideration of cost (overall costs and unit costs) and breadth and viability of service, and evn the articulation and plausibility of submissions. There will have also have been 'politics', macro- and micro-.This must be regarded as a universal given, manifest in this case in the particular world of Scandi politics, a multitude of small parties, shifting alliances, plots, deals, horse-trading – and things not always quite as presented to the voters.

The main protagonist here is Stig Nyman, the veteran Christian Democrat councilor with responsibility for this procurement. He has a long-standing concern for healthcare, including habilitation and rehabilitation. So far at least, the matter of Move & Walk has not rippled the surface of his blog but he has made his position crystal-clear in an interview published in Föräldrakraft ('Parent Power') –

I do take on board what is written in all the emails that I am now receiving but … we have complied with the law on public procurement. We cannot change the conditions of bids that have been received… We live with the Public Procurement Act and can not run around it. When the contract expires for a given activity, we procure, we have no choice. And when we reviewed the bids this was this outcome… treatments should not be discontinued, without the children's and young people's getting the same treatment [as at Move & Walk] at Rehab Station.

We have assessed the measures needed, according to all the rules, and we believe that what is offered corresponds well to the entitlements that we have. Our assessment is also based upon the national guidelines of National Board of Health that we must follow.

As for Move & Walk, it continues operations so you can go there, but then you have to pay yourself. If we were to make a direct award to Move & Walk it would be a violation of the Public Procurement Act.

It is clear that [parents' voice] matters, but it amazes me that people are reacting now, when the contract is completed. When we presented the basis for the contract [in May], no one responded. In practice, it is not possible to meet everybody's wishes. We start from health care law, the national guidelines and the Public Procurement Act...

Freedom of choice is well-established in Stockholm but it is not possible in such a limited operation involving 200 or maybe 300 people. The Public Procurement Act prescribes nothing about choice and also previously there was no choice, then it was just the operations of Move & Walk. Now we have made a contract and it is another caregiver – still without choice...

I am pleased with the decisions that we have made. Rehab Station won on quality score.

I am no stranger to [protests]. Had they come in the spring then there would have been a theoretical chance to look at them.

This contract runs for three years, from 1 April 2013. The procurement decision may be appealed by Move & Walk, but most appeals are rejected.

Filippa Reinfeld, a Moderate Party councilor also involved, has so far declined to respond to questions on this matter. She will doubtless have plenty of opportunity over the coming week.

The place of evidence

The Council faced a decision that had to be made: a choice between Company A and Company B. This had to be made according to prescribed rules (which I do not know) and in the light of specific considerations such as the quality of the rival bids, costs involved and any number of 'political' considerations (which I also do not know). In the event, one bid won the contract, the other lost. It happens all the time, that is what the bidding process is meant for.

In the event too, the two bids represented competing ideologies, one being conductive, the other 'traditional habilitation', the one uni-professional, the other likely multi- or trans-professional. I do not know specifically, however, what either bid meant in practice. I have a vague impression of Hungarian conductors on the one hand, and Swedish therapists on the other – doing what precisely in either case, according to what service model of 'habilitation', I do not know.

As far as I know there is no convincing evidence to have emerged on the efficacy, relative or otherwise, of either approach represented by the two bids, nor have plausible alternative strategies or paradigms been advanced to break the methodological deadlock. And if not by now, when? I wonder whether I should be feeling differently about this had I been in Pisa last week.

In the meantime, real-world decision-makers will continue to do their thing – with the fascinating possibility that, even were appropriate evidence to emerge, their inclination might still be to do what they find most convenient anyway, or just plain possible, in their given circumstance. 

Were I still working in the field, I would be less concerned for 'evidence' to ensure my daily bread, and that of my employees – and rather more with managing public awareness, with thoroughgoing parental participation in the political process, with PR and media-management, and with enhancing the sheer comprehensibility and plausibility of Conductive Education.  'Evidence' might be nice to have – but not, I suspect, decisive.

References

Bengtsson, V. (2012) Landstingsrådet: vi kan inte lyssna på alla önskemål, Föräldrakraft, 18 October
http://www.foraldrakraft.se/articles/v%C3%A5rd-amp-omsorg/landstingsr%C3%A5det-vi-kan-inte-lyssna-p%C3%A5-alla-%C3%B6nskem%C3%A5l 

Sutton, A (2012): Move & Walk loses Stockholm contract: major blow for Swedish CE service, Conductive World, 20 October
http://www.conductive-world.info/2012/10/move-walk-loses-stockholm-contract.html









2 comments:

  1. There are some measurements of processes of practice available which are standardized and therefore valid, not less than outcome measures(e.g. MPOC56 and the MPOC-SP to measure processes of care and family-centered service
    http://www.canchild.ca/en/measures/mpoc56_mpoc20.asp

    ReplyDelete
  2. "Were I still working in the field, I would be less concerned for 'evidence' to ensure my daily bread, and that of my employees – and rather more with managing public awareness, with thoroughgoing parental participation in the political process, with PR and media-management, and with enhancing the sheer comprehensibility and plausibility of Conductive Education. 'Evidence' might be nice to have – but not, I suspect, decisive."
    I am afraid I disagree with you this time Andrew.
    Evidence is the name of the game, and Sweden BTW, is a leading force of this trend (and will be hosting the next ICP Conference in 2015 with the leadership of Ann-Christin Eliasson and Hans Forssberg)

    ReplyDelete