Tag Archives: working in healthcare

Essential Books for Public Health Professionals Working in Healthcare

 

How To Talk About Books You Have Not Read 

How To Talk About Books You Have Not Read is a wonderful book by Pierre Bayard. The book can be read at two different levels as many books can. On one level it is a humorous book, a little like the book by Stephen Potter called One-Up-Manship, which has advice on how to impress people with one’s literary credentials even though one has never read the classics. Pierre Bayard, however, makes a very serious point – that no one will ever read all the books that they need to read or could read in their particular topic. It is far more important to know about a book and its core message, preferably in the author’s own words, and to understand how that book fits into the culture and relates to other books and concepts then not to know that a book existed.

The table below presents the Top Ten Books that are essential reading in this topic area. You can see all 10 books in the bulleted list below. 

For each book there is the full reference, the ‘Distilled Message’ (the essence of the book in the author’s own words) and ‘Why Is This Book Important?’ (the relevance of the book and other related titles or key terminology to note). 

  • Public Health, Ethics, and Equity 
  • Stewardship.  Choosing Service over Self-Interest..
  • A Public Enemy.
  • Social Determinants of Health.
  • The Politics of BSE.
  • Realistic Evaluation.
  • The Strategy of Preventive Medicine.
  • Organizational Culture and Leadership 
  • The Spirit Level.  Why More Equal Societies Almost Always Do Better.
  • Effectiveness and efficiency. Random reflections on health services.  
  • ·Public Health, Ethics, and Equity.  

Sudihr Anand, Fabienne Peter and Amartya Sen. (2004)  Oxford University Press 

Distilled message  “ …it has been our aim to launch a wide investigation of the ethical issues underlying inequalities in health. In order to examine health equity from a variety of perspectives …contributions centre on 5 themes

1. What is health equity?
2. Health equity and its relation to social justice
3. Health inequalities and responsibilities for health
4. Ethical issues in health evaluation and prioritization
5. Anthropological perspectives on health equity”

Why is this book important? The scope of Public Health is difficult to define.  If we focus on health promotion for example then the obvious focus of public health effort might appear to be on cigarette smoking and the modern diet.  However it is obvious that bringing about change in these risk factors is not simply a matter of giving people clear unbiased information, important though that is.  It is necessary to tackle the social determinants of health, the social factors that lead to smoking or a bad diet or any other risk factor.  As far as the social determinants are concerned it is again possible to consider these in different levels of depth.  An economic approach focuses on deprivation and inequality but many people feel that this is still too narrow and taking what is being called the human rights approach it is necessary to have a perspective of justice and that if the word justice in the world or any country in the health of not only the poorest people but also the whole population would be better.  This obviously raises ethical issues for public health professionals.  Is it right for them to have a salary that is much greater than the poorest people in society or even of the lowest people in a health service.  

In this book the authors start by looking at inequalities of health but they move from inequality and objective variable to equity.

Equity and its opposite inequity are still confused by many with equality and inequality.

Inequality is an objectively defined judgment, for example health inequalities such as variation in mortality rates, or health service inequalities, such as variation in the provision of services to different populations. There may be equality in the provision of health services, which is not equitable, if one population has greater need than the others. Similarly there may be unequal distribution of resources that is in the interest of equity in the higher amount of money per head, allocated to a population with high levels of deprivation and need, because it has been decided to do this in the interests of equity.

  • Stewardship.  Choosing Service over Self-Interest.  

Peter Block  (1993) Berrett-Koehler, (p.xx)

Distilled message “Stewardship is to hold something in trust for another.  Stewardship is defined in this book as the choice to preside over the orderly distribution of power.  This means giving people at the bottom and the boundaries of the organization choice over how to serve a customer, a citizen, a community.  It is the willingness to be accountable for the well-being of the larger organization by operating in service, rather than in control, of those around us.  Stated simply, it is accountability without control or compliance.”
Why is this book important? The term “steward” is an old-fashioned term encountered in Tolkien, for example, and the Shorter Oxford English Dictionary has many examples of the word “steward”, usually someone who is accountable to a king or a lord, responsible for management and order of an estate or a manor house.  More recently, however, the word has come to have a different meaning and a fourth dimension.

Of central importance is the book by Peter Block entitled Stewardship, subtitled Choosing Service over Self-Interest.   This could, of course, simply be a definition of altruism and Block writes about stewardship being “to hold something in trust for another”.   

However, a new meaning of the word “stewardship” is emerging and stewardship is something which, in a book called Permaculture, subtitled Principles and Pathways beyond Sustainability, addresses the question, “Will the resource be in better shape after my stewardship?”.   This relates to what is sometimes called intergenerational equity or environmental sustainability – we have to look after the planet for future generations.   It is our duty as stewards.

Increasingly the word “stewardship” is being used in healthcare with an appeal to the clinicians to think of themselves  not only as people who use resources but as the stewards of the resources.

  • A Public Enemy 

Henrik Ibsen  (1964)  Penguin Books, (p.219)

Distilled message “The fact is that the strongest man in the world is the man who stands alone.”
Why is this book

important

The Enemy of the People is the only play about a public health professional.  The hero and, he is a hero, is the head of public health in a small Norwegian Spa town.  He is an admired and respected person in the town, until he says that the waters, the waters on which the town’s wealth is based, are unsafe.

The political pressure on him grows, but subtle and direct and a good modern depiction of the oppositions, and hostility, he faced is the early scenes of Jaws when the coastguard is trying to convince the Town Council that they have a problem that requires action.

  • Social Determinants of Health.  

Michael Marmot and Richard G. Wilkinson  (1999)  Oxford University Press, (p.232-233)

Distilled message
  • Income support.
  • Policies should focus on reducing the proportion of children born into and living in poverty.
  • Policies should aim to reduce inequalities in income and wealth within populations.
  • Policies to ensure access to educational, training, and employment opportunities.
  • Barriers to access to health and social services should be removed.
  • Adequate follow-up support is needed for those leaving institutional care.
  • Housing policies should aim to provide enough affordable housing of reasonable standard.
  • Employment policies should aim to preserve and create jobs…Improving the health of migrants.”
Why is this book

Important

Michael Marmot has led the intellectual analysis of the social determinants of health and led the campaign for the social determinants to be recognised for the importance that they have.  The approach is a little narrower than the approach of, for example Amartya Sen.  They certainly argue in favour of social justice but argue that much can be done practically by tackling problems like bad housing and low income.

It is also certainly important to try to tackle cigarette smoking and alcohol abuse, as they are the two major causes of disease directly but success will only be achieved if success of social determinants of health is also tackled.

  • The Politics of BSE.   

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.
  • Realistic Evaluation.  

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.
  • 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.

 
  • 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.