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Richard Packer (2006) Palgrave MacMillan, (p.5) |
| Distilled message |
“The word ‘politics’ covers a host of matters from major issues of elevated principle to minor matters of interest to a few individuals only. This is because politics is a reflection of human nature, which while sometimes aspiring to the heavens is often concerned mainly with self. Accordingly, sometimes this book moves suddenly between the large and lofty and the small and rather grubby. I make no apology; it would not be an accurate account without both dimensions. |
| Why is this book important? |
This is one of a number of books that give insight into the relationship between politicians, officials and scientists written by the vet who was at the heart of the BSE drama. The relationships are subtle and not always understood by Public Health professionals.
Other books that give useful insight include:
- Creating Public Value by Mark Moore
- Administrative Behaviour by Herbert Simon
- Any of the novels of CP Snow particular Corridors of Power and The New Men.
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Ray Pawson & Nick Tilley (1997) Sage, (p.215-219) |
| Distilled message |
“The New Rules of Realistic Evaluation…
Rule 1: generative causation…
Rule 2: ontological depth…
Rule 3: Mechanisms…
Rule 4: Contexts…
Rule 5: Outcomes…
Rule 6: CMO configurations…
Rule 7: Teacher-learner processes…
Rule 8: Open Systems” |
| Why is this book important? |
Clinical practice and the evidence base of clinical practice have been dominated by two research methods in the last 50 years – the randomised controlled trial and the systematic review.
These methods have a part to play in Public Health also but in the field of public policy a new paradigm is emerging led largely by the work of Ray Pawson.
Ray Pawson argues that when one is evaluating complex interventions the reductionist method of the randomised controlled trial and the systematic review with meta analysis has its limitations. The method proposed by Pawson and Tilley can be briefly summarised by saying it is observation, intervention, and repeat observation.
This book is of great relevance and should be used more by people working in public health who need to innovate and evaluate. That they have no control group should not put them off. The other key book by Ray Pawson is called Evidence Based Policy and it is his critique of the relevance of the systematic review that is currently used in clinical research.
Both books are important books for public health professionals. |
- The Strategy of Preventive Medicine.
Geoffrey Rose (1992) Oxford University Press, (p.14) |
| Distilled message |
The following chapters will explore the principles and ramifications of both the high risk and the population strategies of prevention and their respective strengths and limitations. Finally, the conclusion will be that preventive medicine must embrace both, but, of the two, power resides with the population strategy
the strategy of preventive medicine |
| Why is this book
important? |
Geoffrey Rose is one of the giants of Public Health in the last decade of the 20th Century. His book The Strategy of Preventive Medicine brought together very elegantly the high risk approach and the population approach. He pointed out that many events would occur mostly in low risk people, because there are so many more of them even though each individual is at low risk and that it was necessary to complement and supplement the high risk approach to the population approach.
For example, we are probably in a muddle that he would disapprove of at present. We are identifying lots of individuals at low risk of coronary heart disease but we have not yet identified the individuals at very high risk, people with familial hypercholesterolemia. Furthermore because so much of our effort is going on people with lower risk we are not trying to shift the whole population curve.
The need to do this was further emphasised by George Davey Smith in the International Journal of Epidemiology.(1) At one time it was hoped the human genome project would allow us to identify all the individuals at high risk by identifying all those with a particular genome type. Unfortunately this does not seem to be possible and, for many years to come it will not be possible to identify people at very high risk using biomarkers other than the ones we know about already.
Thus we still need to adopt the principles advanced by Geoffrey Rose. We need to deal with individuals with very high risk and seek to shift the risk profile of the whole population.
- Davey Smith J (2011) Int J Epidemiology 40:537-562. Epidemiology; epigenetics and the ‘Glossary Prospect: embracing randomness in population health research and practice.
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- Organizational Culture and Leadership. (3rd Edition)
Edgar H. Schein (2004) Jossey-Bass, (p.17) |
| Distilled message |
“The culture of a group can now be defined as a pattern of shared basic assumptions that was learned by a group as it solved is problems of external adaptation and internal integration, that has worked well enough to be considered valid and, therefore, to be taught to new members as the correct way to perceive, think, and feel in relation to those problems.” |
| Why is this book
important |
An organisation can be said to consist of a structure, systems and a culture. Health services change structure all the time and increasingly focus on systems but still retain the same culture. The culture of an organization is defined in almost as many ways as team leadership, perhaps not surprisingly as the two terms are interwoven with one of the key responsibilities of the leader being to shape the culture of their organisation.
The culture of an organisation is the set of beliefs and assumptions that influence how people feel and behave. A large organisation can have many different cultures, pediatric departments have a different culture from trauma departments and within one hospital neighbouring wards can have very different cultures even though both are doing the same job. |
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- The Spirit Level. Why More Equal Societies Almost Always Do Better.
Richard Wilkinson & Kate Pickett (2009) Penguin, (P.264.265) |
| Distilled message |
“After several decades in which we have lived with the oppressive sense that there is no alternative to the social and environmental failure of modern societies, we can now regain the sense of optimism which comes from knowing that the problems can be solved. We know that greater equality will help us rein in consumerism and ease the introduction of policies to tackle global warming. We can see how the development of modern technology makes profit-making institutions appear increasingly anti-social as they find themselves threatened by the rapidly expanding potential for public good which new technology offers. We are on the verge of creating a qualitatively better and more truly sociable society for all.” |
| Why is this book
Important |
The simple message here is that societies that are more equal, using a measure called the Gini ratio, are better for everybody, including the rich.
In the 19th Century it was enlightened self interest that led to the development to the Public Health Revolution. The rich realised that they could get cholera just like the poor and this was an important driver of change. Richard Wilkinson, Michael Marmot and their colleagues are hoping that this awakening will occur in England, holding up Norway as a role model.
Here is their definition of the Gini co-efficient.
“There are lots of ways of measuring income inequality and they are all so closely related to each other that it doesn’t usually make much difference which you use. Instead of the top and bottom 20 per cent, we could compare the top and bottom 10 or 30 percent. Or we could have looked at the proportion of all incomes which go to the poorer half of the population. Typically, the poorest half of the population get something like 20 or 25 per cent of all incomes and the richest half get the remaining 75 or 80 per cent. Other more sophisticated measures include one called the Gini coefficient. It measures inequality across the whole society rather than simply comparing the extremes. If all income went to one person (maximum inequality) and everyone else got nothing, the Gini coefficient would be equal to 1. If income was shared equally and everyone got exactly the same (perfect equality), the Gini would equal 0. The lower its value, the more equal a society is. The most common values tend to be between 0.3 and 0.5.”
Source: Wilkinson, R,., Pickett, K. (2010) The Spirit Level. Why Equality is Better for Everyone. Penguin Books (p.118). |
- Effectiveness and efficiency. Random reflections on health services
Cochrane, A.L. (1971) The Nuffield Provincial Hospitals Trust. |
| Distilled message |
“There are two preliminary steps which are essential before this cost/benefit approach becomes a practical possibility, and it is with these two steps that I am chiefly concerned. The first is, of course, to measure the effect of a particular medical action in altering the natural history of a particular disease for the better. Since the introduction of the randomized controlled trial (RCT) our knowledge in this sphere has greatly increased but is still sadly limited. It is in this sense that I use the word ‘effective’ in this book, and I use it in relation to research results. As opposed to the results obtained when a therapy is applied in routine clinical practice in a defined community.” (p2) |
| Why is this book
Important |
Effectiveness and efficiency
This book, published in 1972, changed the paradigm in healthcare from one in which the only concern was that the care should be free and that the doctor’s experience was the only criterion for deciding whether or not a treatment was right. Its influence flourished in the 1980’s when it paved the way for the Cochrane Collaboration and Evidence Based Medicine
In the last three decades of the 20th century, health service payers and managers were appropriately preoccupied with effectiveness and efficiency and only services that did more good than harm, at reasonable cost, were considered for funding. However, of developed countries, only the United Kingdom faced serious resource constraints in the 1980s and was forced to think about opportunity costs rather than simply taking new interventions that had a favourable result from cost-benefit or cost-effectiveness analyses. Since then, every other major developed economy, which is committed to offering healthcare to its whole population, has had to face up to limits placed on healthcare spending. In Germany, Japan, and Italy, for example, evidence-based decision-making has become much more explicit. The United States remains an exception but President Obama is determined to end that.
It was in the United Kingdom, therefore, that the response to the work of Archie Cochrane was most enthusiastic.
‘He lived and died, a severe porphyric, who smoked too much, without the consolation of a wife, a religious belief, or a merit award, but he didn’t do too badly.’
These were the words of Archie Cochrane when he wrote his own obituary for the British Medical Journal. As befits the man, they were ironic, clear, accurate, and understated. Few people had more influence on healthcare in the last fifty years of the 20th century than Archie Cochrane; firstly, by his insistence on the importance of the randomised controlled trial; secondly, by his challenge to the medical and research establishments that they should organise all of their knowledge properly, leading to the creation of the Cochrane Collaboration; and thirdly, by the publication of his Random Reflections on Health Services with the title Effectiveness and Efficiency. This small book, published in 1972, was ahead of its time in that it captured and predicted 20th century healthcare’s focus on effectiveness and efficiency.
The era of effectiveness
‘All effective treatments must be free.’
This, wrote Cochrane, was the device his banner carried at a Communist rally in the 1930s, written after considerable thought but making no impact on the communists on the march. But it did make an impact on Cochrane, who remained obsessed with the need for treatments to be demonstrated to be effective and then, if they were, for those treatments to be made available through a National Health Service. For Cochrane it was clear that the single best method for demonstrating the effectiveness of a treatment was the randomised controlled clinical trial and he promoted the importance of the trial with commitment, energy, intelligence, and a considerable degree of cunning throughout the rest of his professional career. As a result, the term ‘effectiveness’ entered the general vocabulary not only of the research worker but of all those who manage and pay for healthcare. |