Jim Connelly

A realistic theory of health sector management. The case for critical realism.

To date the practice of health sector management has not been sufficiently theorised. An adequate theory should be able to answer the pre-eminent critique of managerial rationality and ethics mounted by Alasdair MacIntyre in After Virtue and should also offer robust analytical and ethical resources to identify and engage with the social, political, economic and moral issues underlying health sector management. Critical realism with its ontology of generative mechanisms, agency-structure relationships, valorisation of activity and ideology critique offers such resources in an empirically orientated but adequately theorised realist framework. Rather than negate MacIntyre, critical realism incorporates and transcends his key arguments regarding the rationality and ethics of management. This article introduces the main elements of critical realism and clears a conceptual space for the cumulation of critical realist case-studies and managerial craft knowledge.

Skill mix, doctors and nurses: substitution or diversification?

This commentary surveys the current arguments for and against modifying the work of doctors and nurses by placing the main viewpoints - substitution and diversification - within the policy background, particularly that of the UK. We discuss the forces for modification: cost effectiveness, professional development, quality improvement and pragmatic management and how each provides a stand-point for evaluation of the issues. Policy makers and managers in the health sector should be aware of the rather fragmented evidence base for doctor-nurse substitution and should consider skill mix changes only when they are clear about: purpose, evidence base, acceptable risks, accountability and quality assurance. Doctor-nurse substitution is not necessarily cost effective, nor is it unfailingly a gain in nurse professionalism or in quality of care. Of the management perspectives available - advocacy, skepticism or pragmatism - the current evidence and policy base favours pragmatism over evaluations of the rightness or wrongness of a general policy.

Rethinking public health: new training for new times

The new public health agenda will require major changes in the way health authorities, local authorities, Trusts and Primary Care Groups organise and manage their activities. The requirement is for inter-agency co-ordination and inter-professional and inter-sectoral working to a shared agenda, yet the human and resources development planning to achieve these goals has not been done. This paper summarises the key training issues and argues for a collaborative, decentralised and quality assured approach to multidisciplinary public health management education and training. Only with such a joined up human resources plan can Our Healthier Nation succeed where The Health of the Nation signally failed.

The Psychological Impact of Screening for Risk of Coronary Heart Disease in Primary Care Settings

Aims A prospective study was conducted to identify the psychological impact of labelling middle-aged men as having above average risk for coronary heart disease. A second aim was to find out the psychological effect of participation in a subsequent clinical trial. Methods 5813 men attended nine special screening clinics in England and Scotland for baseline measurement of psychological symptoms and coronary disease risk factors. Each man was later informed of his risk status by letter as either above average risk (high-risk) or no special risk (low-risk). In three clinics some men also received an intermediate risk (moderate-risk) between high-risk and low-risk. Follow-up psychological measurements were made after labelling and 3 months later. Results Men who received either the high-risk label (n = 838) or the low-risk label (n = 3114) showed a decrease in reported psychological symptoms after labelling. Men receiving the unexpected intermediate risk (moderate-risk) label, which communicated specific test abnormalities, increased their psychological symptoms to ‘case’ levels on the General Health Questionnaire; relative risk (compared with low-risk) was 1.80 (95% confidence interval 1.19-2,71) after adjustment for confounding factors. Compliers with a subsequent clinical trial decreased their risk of becoming cases and, if ill at trial entry, increased their case remission rate. Conclusions The ascription of an ‘above average risk’ label for coronary disease to middle-aged men does not adversely affect the psychological state of those who receive it if they have received preparation for risk labelling. However, communicating abnormal coronary disease test results without adequate preparation confers short-term psychological harm. Non-specific support from familiar general practice professionals received by participants in a clinical trial reduces the risk of psychological ill-health. All coronary disease screening programmes should include adequate pre-labelling preparation for all risk labels and abnormal results.

Public health policy: Between victim blaming and the nanny state ‐ will the third way work?

Abstract The green paper Our Healthier Nation sets out an ambitious agenda to increase life expectancy for all in England and to specifically decrease inequalities in health. It uses the idea of a ‘contract’ between government and people as a legitimating concept for the actions necessary to achieve specific targets in the areas of cardiovascular disease, cancers, accidents and mental health. This contract eschews sole reliance on either a materialist structuralist or a lifestyle change prescription for health and defines itself as a ‘third way’. What are the chances that this public health policy will succeed where its predecessor The Health of the Nation failed? This article explores the similarities and differences between the green paper and the earlier policy, collates evidence on effectiveness of social, environmental, individual and organisational approaches to public health and discusses the likely chances of policy success from a yet to be articulated third way to health.

Effective practice in the NHS and the contribution from public health: a qualitative study

Reports on a study which explored the views of key stakeholders regarding the meaning and implementation of effective health care and clinical governance in NHS Trusts, and the role for public health professionals. The authors used a national questionnaire survey to derive a sample for qualitative telephone interviews and two area case studies. The authors found that the meaning of effective health care and the means employed for implementation varied. Mergers were seen as hindrances to gaining organisational engagement whilst others, such as the White Paper on quality and the notion of clinical governance, were seen as facilitating. A widespread aspiration was a more integrated and corporate quality culture where quality was central, not marginal. The authors conclude that there is widespread concern among Trusts to change their culture and assert effective health care as a central value. Public health skills, rather than the discipline itself, are seen as important for such culture change.