Why good evidence still leads to bad decisions
Dr Margaret McCartney has been a GP in Glasgow for more than two decades. The job, she says, is mostly dealing with uncertainty.
“Every single patient that you see could have something terribly wrong with them. All the time you’re dealing with uncertainty, all the time you’re dealing with incomplete knowledge.”
That uncertainty, multiplied across millions of consultations and overlaid with shrinking budgets, commercial pressure and contested public debate, is the subject of the new Centre for Evidence and Values in Healthcare. The Centre brings together the School of Medicine, the Business School and the Department of Philosophy at the University of St Andrews to look at how healthcare decisions are made. Its aim is not to tell people what to think, but to help them think more clearly about what they do, and why.
Dr McCartney directs the Centre and is one of four founders, alongside Professor Frank Sullivan, Professor of Primary Care Medicine and an academic GP; Professor Kevin Orr, Professor of Leadership and Governance at the Business School; and Dr Joseph Millum, Senior Lecturer in Philosophy, a consultant to the World Health Organisation. The team is supported by Katrin Metsis, a social scientist and doctoral research fellow who works with Dr McCartney on health inequalities, and Claire McBarron, who coordinates the Centre’s activities.
Dr McCartney says the impulse to create something like this was building for a long time. “There have been so many things that have gone badly wrong in healthcare. Why did that happen? Was it predictable? Could you have learned from the past a bit more than perhaps you appear to have done?” The Centre, she says, is meant to be a place where evidence-based medicine and ethical questions can be discussed together, “because quite often there’s been patient harm as a result of those two things not being adequately considered”.
Why mix three disciplines that usually keep their own counsel? “Often we revert to our own silos, and we look at things in isolation from each other,” Professor Orr says. “But the complexity and the importance of questions around healthcare are best addressed through an interdisciplinary lens. That’s the gap the Centre is hopefully filling.”
Conflicts of interest in medicine were the subject of Dr McCartney’s PhD, and they are now one of the Centre’s first major research strands. Its first research paper, published in BMJ Open in September 2025, set out to map what an effective system for declaring and managing conflicts of interest should actually look like. Written by all four founders with colleagues, the study used a structured consensus method featuring two rounds of surveys followed by interviews, with around 45 academics, healthcare professionals, regulators, patients and citizens drawn from ten countries. One finding was a cultural one. Some of the most influential figures in medicine, the team heard, treat questions about their own conflicts as faintly impertinent; the more eminent the clinician, the less acceptable the question seems.
“Among some of the practitioners we interviewed who had very large bits of funding from pharmaceutical companies, there was sometimes a sense that the cream rises to the top,” Professor Orr says. “Because you have risen to the top, and because you have attracted this funding, it’s almost impertinent to be asked about conflicts of interest.”
Dr McCartney’s view is that most doctors do not have a significant conflict of interest. “But the small number that do have a disproportionate impact on what the health service ends up doing, whether by influencing guidelines, by being thought leaders, by making decisions about how we should treat what.” Many safeguards in place, she says, have been developed by what she calls “GOBSAT ideas – good old boys sat around a table,” rather than by research.
She says transparency alone is not enough. “It can make people feel reassured that they’ve dealt with their conflict of interest, whereas all they’ve done is declared it. They haven’t got rid of it.” The team is now developing a digital framework that would allow interests to be declared once and then surface wherever a doctor writes a paper, gives a talk or sits on a committee, with guidance on the decisions they should step away from. “But things like that need to be tested,” she says. “I think it might work, but we don’t know if it works or not. It could help. It might make things worse.”
The Centre’s interest in commercial bias also extends beyond the pharmaceutical industry to what are sometimes called the commercial determinants of health – the influence of the alcohol, tobacco, food and transport industries on the conditions in which people live, get sick and recover.
Philosophy brings a third angle to the work. Dr Millum, who spent 15 years as a bioethicist at the United States National Institutes of Health (NIH), sees evidence and values as inseparable rather than competing. “Where things go wrong is where people think that evidence or scientific data can operate independently of value judgements.” Decisions about whether to expand primary care, build hospitals or train more nurses, he argues, are always both empirical and ethical. “The evidence is going to tell us what we end up with. The values will help us assess which policy options we prefer. The mistake is to think that they are independent.”
Dr Millum’s role, as he describes it, is rarely to deliver answers. At the NIH, he conducted ethics consultations in the hospital, and the work was almost always a conversation. “What I’m an expert in is talking to you and helping you to articulate your values and then thinking with you about whether they are defensible.” The Centre, he says, can do something similar at scale by giving people the tools to articulate their values and to use evidence effectively.
He also argues that the picture is more complicated than people assume. “You start off thinking it’s about money. Then you realise that’s the tip of the iceberg.” Most medical researchers, he points out, genuinely believe their treatments will work. “Statistically, they can’t all be right. Most of them will be wrong. But that belief is what drives you to keep working.” Without that conviction, he says, the breakthroughs do not come.
Professor Orr’s research on policymaking in contested environments, including work on cannabis regulation in California, has examined how slowly public health voices can move when commercial interests organise faster. He sees the same pattern in UK healthcare today, in the way private screening companies advertise.
“You’ve probably seen these TV adverts from big private healthcare companies, which are very skilfully amplifying people’s anxieties,” he says. The advertising messages are blunt, while the realities are not. “Some of the subtleties of the realities of screening – the dilemmas involved in terms of making decisions on the part of healthcare professionals operating at the front line, where they’re often under-resourced – are nuanced, while the commercial advertisements are often anything but.
Making arguments for evidence-based healthcare takes place in a noisy environment. Dr McCartney sees the consequences in her consulting room. Private screening services, she says, increasingly send patients back to NHS GPs to interpret false-positive test results the NHS would never have offered. “It creates conflict, it creates stress, it increases costs, it decreases satisfaction, and it fragments care”, she explains. “Frankly, it’s disgraceful that there is so much profit from non-evidence-based health testing.”
The Centre runs events designed as a safe space for clinicians, policymakers, patients and researchers to talk honestly about difficult questions. It launched in October 2025 with its inaugural event, Evidence and Values in Healthcare: Why they matter, at Parliament Hall in St Andrews. Speakers included Sir David Haslam, former Chair of the National Institute for Health and Care Excellence (NICE) and former President of the Royal College of General Practitioners, and the patient safety advocate Karen Titchener, alongside the Deputy Director of NHS Scotland, the Scottish Government’s head of population health policy, and the screening expert Dr Angela Raffle. A full report from the inaugural event is available on the Centre’s website.
The Centre’s funding comes from the Della Fish Foundation, set up in memory of the late Professor Della Fish, a postgraduate medical educator at King’s College London who spent her career arguing that medicine was a moral practice as much as a technical one, and that practitioners should never be detached from the values underpinning their work. The grant covers the Centre’s first two years; the team aims to make it self-sustaining beyond that. Alongside the events, the Centre is rolling out teaching materials on conflicts of interest for medical undergraduates, developing leadership programmes, and building what Dr McCartney calls a network of “friends of the Centre. People working in different areas, just trying to put that evidence and values conversation into places where it can count”. The team also produces policy briefings, supports policymakers in distilling evidence into usable form and welcomes contact from healthcare professionals, patients and journalists.
For Dr McCartney, working with colleagues outside medicine has changed her perspective. “In medicine, we can end up thinking we’ve got all these problems and how do we solve them, and we kind of forget that there are these whole other areas of expertise where people with different knowledge and perspectives who are thinking about these big problems and trying to help.” Professor Orr’s outside view, she says, “enables you to see your own work differently”.
Asked what success looks like, Dr Millum is precise: “A process for improving your decision-making.”
The Centre’s next event brings doctors, vets and dentists into the same room to examine overdiagnosis, equity of access and the consolidation of independent practice into corporate ownership. Professor Emerita Allyson Pollock will give the keynote on the evolution of general practice into a business, with speakers from VetPartners, the University of Glasgow and Professor Orr on outsourcing. The business of healthcare runs from 9.30am to 4.30pm on Friday 19 June 2026, at the Edinburgh Quaker Meeting House. Tickets are £75.