Path Dependence and Health Policy: Intersections between the Past and the Future

Abstract

On walmgate street in york, england, you can order kebabs or burgers from a restaurant with a storefront that is exactly one perch long, a property boundary and unit of measurement that survives from Viking times.1 Its persistence hundreds of years and many generations later in the modern streetscape is a classic example of path dependence. While path dependence is perhaps most obvious in the case of physical structures, they are by no means the only context in which current decisions or situations are shaped by past circumstances. Examples in economic, cultural and other contexts abound. Indeed, one could argue that embedding effective practice and healthy behaviours – or uprooting well-established practices that no longer serve us well – is one of the key challenges of health management and policy. At the core is the fundamental question: how can we make the right thing to do the easy thing to do? This applies to thousands of micro-level decisions made every day, such as how best to organize a surgical cart, and to broad challenges in health promotion, such as which features of urban design are most likely to encourage physical activity at the population level. This issue of Healthcare Policy / Politiques de Sante features a number of papers that address aspects of this challenge, from documenting gaps and their causes to exploring policy options to address them. Brian Hutchison focuses on primary healthcare reform. This is an area of enduring policy focus around the world, reflecting its complexity and importance to health and healthcare systems. Hutchison's paper takes a fresh look at what has changed, what has not and why. In contrast, Sisira Sarma and his colleagues examine a very specific aspect of family practice: whether use of health information technology in primary care is associated with patient visit numbers and visit length. Pharmaceutical policy is another highly complex area where history and context affect decisions and outcomes today. This issue of the journal explores a number of facets of this domain, from cost-control mechanisms in private or public drug plans (Jillian Kratzer et al.) to potential conflict of interest in reimbursement decisions (David Hughes and Bryn Williams-Jones). The policy choices that we make in these and other areas are likely to influence costs and outcomes for years to come. Likewise, Jason Sutherland and Trafford Crump address the mismatch between patient needs and resources used represented by alternative level of care in hospitals. Future decisions about the policy alternatives that they discuss may well be informed by the analysis of Saad Rais and colleagues on high-cost users of healthcare services. Many of the home care clients studied by Diane Doran and her co-authors from across the country would fall into this category. Their research provides important insight into the frequency and types of adverse events experienced for those receiving home care. Whichever areas of health policy are your current focus, I hope that you will find new insights and food for thought in the journal's pages. After all, to twist George Santayana's famous quotation somewhat, those who are unaware of how the past influences the present are condemned to repeat it – and to reinforce gaps in quality, access and health that exist today or, alternatively, risk inadvertently disrupting those paths that help us to achieve better health, better care and better value.