Public Health Experience: Why Submit Case Study?

Harvesting Tacit Knowledge

It is generally agreed that we have neglected the knowledge derived from experience, focusing instead on the knowledge derived from the analysis of routinely collected data, stats or information, and knowledge derived from research, namely evidence.

This is a resource of vital importance and a resource that will grow. It is expected that each Public Health professional will submit a case report each year and this will be kept as a closed resource to encourage people to describe their failures as well as their successes. It is hoped that professionals will report on the projects that did not go so well as well as on those that were highly successful, for there is a proverb in management that we learn more from out mistakes than our successes. There is another proverb that says that although it is important not to re-invent the wheel, it is sometimes necessary, but what is really important is that we do not re-invent the flat tyre.


There are three general categories under which the Public Health Experience Case Studies will fall:

Health Protection

Health Protection is a term used to encompass a set of activities within the Public Health function. It involves:

  • Ensuring the safety and quality of food, water, air and the general environment
  • Preventing the transmission of communicable diseases
  • Managing outbreaks and the other incidents which threaten the public health.

Health Promotion

The process of enabling people to increase control over their health and its determinants, and thereby improve their health. 
These determinants of health could include income, housing, food security, employment, and quality working conditions.
Health Care
The diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in humans.

Benefits of submitting Case Studies

Everyone who submits a case report will receive proof of publication for inclusion in their development portfolio and we will think of ways in which particularly powerful case reports are rewarded. In the meantime it is in all our interests to build a powerful casebook, our interests as individuals and as a professional group.

Sometimes we can bring the change by bureaucratic authority, sometimes because we have large amounts of money at our disposal, usually these conditions do not apply. Instead we have to rely on what Max Weber called sapiential authority and the use of knowledge with confidence and authority. This in turn creates charisma, and charismatic authority is another important type of authority in which Public Health professionals have to rely.

Submitting your Case Study

To submit your case study please visit the Contact Us tab.

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


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


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


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


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


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


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.



Essential Terms for Public Health Professionals working in Healthcare

Language creates reality, it does not describe it.  That is one of the principles that has emerged from anthropology, linguistics and philosophy from authors as diverse as Ludwig Wittgenstein, John Searle and Benjamin Lee Whorf. Confusion about language and the meaning of the terms being used is one of the main causes of arguments, fruitless arguments, which disappear if everyone shares the same understanding of the terms being used.

Public Health professionals use a language that is rich in terms and which have no universally agreed definition; terms such as social justice or sustainability.  There are other terms where there is an agreed meaning, usually more technical scientific terms such as meta-analysis.  One of the reasons why public health professionals do not have a strong corporate culture is because no attempt has been made to develop a common core of concepts, and terms relating to these concepts, with the objective that everyone practising as a public health professional would use the term and concept with the same meaning.

A project has been designed to develop such a common core.  There are of course dictionaries of public health, notably by John Last and by Professor Williams in Swansea, but within the concept of a dictionary there is a glossary, a subset of terms of vital importance for everyone in the community of practice to use.  It could also be argued that if such a set of terms were identified and the meanings agreed, that they should be taught to new practitioners at an early stage in their induction to the profession.

A project was sponsored to stimulate discussion on core terms and common meanings and the first set of 10 terms represented here are a basis for discussion. For each term there is a bottom line drawn from one of the sources cited and a short commentary.

  • Culture: Culture is the set of important understandings (often unstated) that members of a community share in common.
  • Emergence: Much coming from little.
  • Equity: Equity is a subjective judgment of unfairness.
  • Health Promotion: Health promotion is the process of enabling people to increase control over, and to improve, their health.
  • Health Protection: “Health protection comprises legal or fiscal controls, other regulations and policies, and voluntary codes of practice, aimed at … the prevention of ill-health.
  •  Justice: To ask whether a society is just is to ask how it distributes the things we prize – income and wealth, duties and rights, powers and opportunities, offices and honours.
  • Risk: “The chance that something (good or bad) will happen.”
  • Sustainability: “Protecting resources from one generation to the next.”
  • System: A set of activities with a common set of objectives with an annual report
  • Value: “…value is expressed as what we gain relative to what we give up – the benefit relative to the cost.”

Public Health Essentials

One of the complaints people make about Public Health is that every public health professional seems to describe it in a different way when asked.  This is necessarily so, to a degree.  The Director of Public Health or a Consultant in Public Health in an inner city  is likely to have a different set of priorities and problems than doing a job with the same title in a West Country  rural population.    We need people to understand that public health is a type of professional practice that is adaptive and is practised differently in different contexts.  However the criticism has some substance too.  If you were to ask twenty public health professionals to write down what they meant by ‘deprivation’ or ‘well being’ or the difference between ‘quality’ and ‘value’ then, at present, you would get very different results.  Similarly if you were to ask people what the ten most important texts that they studied training you would get different results.

What we need to do  in the creation of a common culture is to agree a common language and a common set of concepts.  Just as cardiologists have a common concept of what is meant by heart failure and psychiatrists of bipolar disorder so too do we need a set of concepts relating to equity or well-being or quality assurance.  This does not mean uniformity; cardiologists disagree about the management of chronic chest pain and psychiatrists of course disagree significantly about both the nature of the problem they tackle and the appropriateness of different interventions but these disciplines do have a common language and set of concepts.

The Public Health Essentials project seeks to identify those terms which we should use the same meaning wherever we are working.  This can be difficult because of a widely used term such as value often has more than one meaning so we will have to reach agreement as to which meaning is the most useful meaning for us to have throughout the Network of Public Health Organisations.  In identifying common concepts it is appropriate to use key texts from which these contexts have arrived for example Geoffrey Rose’s book on the Strategy of Preventive Medicine is a proxy for the concept of ‘shifting the curve’, the balance between high risk strategies and whole population strategies.

Because we are a distributed organisation, close to the populations we serve it is also difficult for people to know one another. We are also willing to show the texts that have influenced each member of the distributed leadership during the course of their professional life.

Population-based Healthcare

What is Population-based Healthcare?

Population healthcare focuses primarily on populations defined by a common need which may be a symptom such as breathlessness, a condition such as arthritis or a common characteristic such as frailty in old age, not on institutions, or specialties or technologies. Its aim is to maximise value and equity for those populations and the individuals within them.

The population healthcare methodology involves a collaborative working of multidisciplinary stakeholders to determine appropriate outcome measures for various systems, and getting populations reporting on these on an annual basis. Atrial Fibrillation, falls and fragility fractures, homelessness, chronic pelvic pain are some of the first set of systems being developed, and it is anticipated that this method will be used across all the 30 programmes and 100 recognised systems.

The first twenty of these programmes are based on the International Classification of Diseases (ICD), arranged in order of programme budget expenditure.

Each of the twenty condition focussed programmes has a large number of rare diseases as well as the common problems.

Where appropriate, major symptoms are associated with one relevant programme, although more than one specialty may be involved with a particular symptom such as breathlessness.

The remaining ten programmes focus on populations defined by a common characteristic such as age or having more than one problem.

Traffic Jam Learning

Traffic Jam Learning ; learn the key concepts and skills for 21st century healthcare while driving or just sitting

How many minutes do you spend in a car each day?

Even if you are lucky and don’t have a traffic jam there is a lot of down time. It’s not all bad of course, going in there is time to think, plan and prepare, even to rehearse a difficult consultation or conversation with a colleague (remember the SAS doctrine – Plan, Rehearse, Execute)
Going home it can be a chance to unwind and relax but the car is also a great place for learning by listening and reflecting, and completing the learning record at the end of the journey.
Of course if you can walk to work you can also do walking learning but DONT attempt cycling learning

Glossary: Population and Personalised Care

This Glossary is about Population and Personalised Care the latter being  a style of clinical and general management which always considers the patients’ perspective as the most important and is committed to increasing patient Engagement, Empowerment or Involvement, which may be regarded as synonyms. Personalised care is an element of patient centred care and is the other side of the coin from population care. This is a diffuse and fast moving field with language evolving at a rapid rate. Here are the key terms and concepts.

  • Value “What is gained relative to what we give up – the benefit relative to the cost but not only to the direct cost, which is the efficiency of a service, but the Opportunity Cost, or the Opportunity Lost to put it another way and there are three dimensions to value in healthcare
    • o Allocative value, determined by how the assets are distributed to different sub groups in the population
    • o Technical value, determined by how well resources are used for all the people in need in the population
    • o Personalised value, determined by how well the decisions relate to the values of each individual

Waste is any activity in a process that consumes resources without adding value for the patient

Cost effectiveness

The relationship between the cost of an intervention and its impact.


Optimality is reached when resources or productivity create maximal benefit with the least harm. Beyond optimality there is overuse.

Programme Budgeting and Marginal Analysis;

The fundamental idea behind programme budgeting is decision making based on explicit criteria related to the wellbeing of the whole population, as opposed to decision making by compromise among various institutional, parochial, or other vested interests. Marginal Analysis consists of starting with a particular mix of services and analyzing changes in that mix. If resources can be shifted to produce greater benefit then this should be done.

Opportunity Cost;

The value of the next best alternative forgone as a result of the decision made.


Equity is a subjective judgment of unfairness.

  • System – A set of activities with a common set of objectives with an annual report.
  • o Network – If a system is a set of activities with a common set of objectives, the network is the set of organizations and individuals that deliver the systems.
  • o Pathway – The actual care process of care experienced by each individual patient/client; also described as maps that define best practice.
  • o Quality -The degree to which a service meets preset standards of goodness in the delivery of the system’s objectives.
  • Culture – “Culture is the shared assumptions of a group that is has learned in coping with external tasks and dealing with internal relationships. Akey cultural issue is the development of a culture of stewardship.
  • Population healthcare –the design and delivery of the care with a primary focus on the population in need, not the healthcare institutions, where the populations in need are defined not bureaucratically but by the optimum population size for high value care for individuals and the group in need Population medicine or population clinical practice – a style of practise in which the clinician feels, and is given responsibility for, all of the people in the population in need whether or not they have been referred
  • Personalised Care or Personalised Medicine  –  the tailoring of care to take into account each individual’ s unique  needs, preferences and values. The term has become popularised recently to describe clinical decision making in the era of the genome but another term for clinical decision making incorporating genomic information is
    • o Stratified Medicine – decision making based on the patients degree of risk, including risk suggested by genomics and based on the long standing practice of risk stratification of elderly people based on social and medical, but not genomic characteristics
    • o Precision Medicine decision making taking into account genomic information either in diagnosis – ‘molecular diagnostics’ –or choice of drug treatment –‘pharmacogenomics’.
  • Principal and Agent – legally the patient is the principal, the clinician the agent, even if there is no money involved. Some people feel the shift in the balance of power occurred with the founding of the NHS when the patient was not charged for consulting the GP. The pendulum swung further because of
    • o Information Asymmetry – the fact that the clinician has, until the advent of the Internet much more technical knowledge
    • o Trust – Faith in another to perform a task that is not in the other’s interest
    • o Autonomy – Freedom to make decisions or act without reference to others
    • o Informed Consent – Consent to treatment given with full understanding of the magnitude and probabilities of the good and adverse outcomes
  • Empathy – In his book on Emotional Intelligence Daniel Goldman identifies three types of empathy – cognitive empathy is the ability to understand what another person is thinking   Emotional empathy is the ability to feel what another person is feeling. Empathic concern is the ability to sense what another person needs for you.
  • Evidence and Value based decision making – Decision making that ensures the patient is fully informed about the strength of evidence about the probability and magnitude of both risks and benefits of the options being considered and that the patient has been helped to reflect on, clarify and express their preferences based on the value they place on the possible benefit, the possible harm and on the risk they are taking.
    • o Health Literacy – The cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information. The term Statistical literacy – the ability to understand and communicate probabilities which is shared by both patients and clinicians, sometimes called risk literacy is increasingly used
    • o Framing –  the conscious or unconscious presentation of data in ways that influence their interpretation and decision making
    • o Shared Decision Making – is a style of decision making in which clinicians and patients are both involved
    • o Preference Sensitive Decision Making – is a style of decision making in which the patient’s preferences are explicitly elicited, to avoid
    • o Silent Misdiagnosis – namely failure to diagnose accurately the patient’s values and preferences even though their disease has been correctly diagnosed
    • o Informed Consent
    • o Patient Decision Aids – a tool to support the patient during decision making, particularly before and after the face to face consultation and they are increasingly  delivered using digital means variously called eHealth, mHealth, digital health or Telemedicine which may be regarded as synonyms
  • Patient defined and reported outcomes are objective measures using validated tools

subjective measures of outcome, including the degree to which the treatment addressed the problem that was bothering the patient most, rather than their diagnosis and the patient’s experience.

Necessary, Appropriate, Inappropriate or Futile Classification of interventions based on the probabilities of benefit and harm

Burden of Treatment – the impact of the process of care on the affected individual and their carers

Technical Value in Healthcare

Technical Value in Healthcare: determined by how well resources are used within services for each individual and the whole population .

Technical Value

…the proper objective is the value of health care delivery, or the patient health outcomes relative to the total cost (inputs) of attaining those outcomes. (1)

Productivity is measured by the relationship between outputs and cost, for example the number of peopletreated per bed per year . Efficiency is measured by the relationship between outcomes, not outputs, and costs, where the costs may be expressed not only as money but also as carbon or time, including the time of patients and carers. Technical value has to take into account not only efficiency but also the possibility of overuse and underuse

This is not only achieved by evidence-based decision-making, essential though that is.  The balance of good to harm changes as the amount of resources invested in an intervention or service increases as Avedis Donabedian showed in his classic diagram in 1980 which is reproduced below:

Value is replacing quality as the dominant paradigm for healthcare in the 21st century. Value is of course increased by quality improvement, by doing things better, cheaper, safer and greener; but doing things right is only half the story – it is also essential to do the right things by making the right decisions about identifying and discontinuing lower value activities.

How to Determine Allocative Value in Healthcare

Allocative Value in Healthcare: determined by how assets are allocated to services for different purposes.

Allocative Efficiency

Allocative value, or allocative efficiency as it is also known, has until recently being largely ignored in healthcare in part because of the dominant part that the United States plays in thinking and writing about healthcare. Allocative value requires a consideration not only of institutional quality but also of the impact that a healthcare service has on the population. There has recently been good work through the Choosing Wisely Campaign but the main aim is to reduce costs, not to help decision making for a whole population. Allocative value is a hot topic when needing to make a finite sum cover a whole population.

There are three levels of decision making needed to increase Allocative value in healthcare once the decision on how much to top slice for research and education and the decision on geographical resource allocation has been made.  These three levels of allocative decision making are:

  • Between programs, for example between cancer and mental health or vice versa
  • Within program between system, for example between asthma, COPD, sleep apnoea and breathlessness within the respiratory program and
  • Within system, for example within the resources available for COPD

Personal Value in Healthcare

Personal Value in Healthcare: the delivery of services informed by what matters to the individual.

Patient Centered Care

The term personalisation is used increasingly and, as a consequence, has developed an increasing number of meanings.

One of the earliest uses was in the definition of Evidence Based Medicine. Although accused of being cook book medicine, the origination of Evidence Based Medicine emphasised the need to relate the evidence to the unique clinical condition to the individual patient and his/her values:

Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients’ predicaments, rights, and preferences in making clinical decisions about their care.

Source: Sackett, D. L., Rosenberg, W.M.C., Gray, J.A.M., Haynes, R.B., Richardson, W.S. Evidence based medicine: what it is and what it isn’t. BMJ 312 (p.71).

The model described is perhaps better illustrated as a diagram:

Patient Centered Care

This emphasises the need to take into account patients and their values to effectively deliver patient centered care. In some ways the term personalized medicine or personalized care is analogous to the concept of customisation in industry, made famous by Toyota and Dell Computers, and more recently, by the Mini factory in Oxford.

Customisation uses the benefits of large-scale construction when it makes sense but then customises the products to suit the needs of the individual. More recently the term personalisation has been associated with the use of genomic information as though it were a new term, but genomic information is not qualitatively different from biochemical information.  It is just information that needs to be tailored to the individual and should make the treatment specific to the unique clinical problems of that individual.

Other terms that have been used to describe how medicine will be practised when genomic information is available are the terms ‘precision medicine’ and ‘stratified medicine’ but the term personalised is probably now the most commonly used term.

It is important to remember that personalisation is just as important whether there is no genomic information available, as when there is genomic information available.

 The Oxford Value Improvement Programme


Tremendous progress has been made over the last forty years due to the second healthcare revolution, with the first healthcare revolution having been the public health revolution of the nineteenth century. Hip replacement, transplantation, and chemotherapy are examples of the high tech revolution funded by increased investment and, in the last twenty years, optimised by improvements in quality, safety and evidence based decision making. However there are still three outstanding problems which are found in every health service no matter how they are structured and funded: One of these problems is huge and unwarranted variation in access, quality, cost and outcome, and an analysis of unwarranted variation reveals the other two –

  • Overuse, which leads to waste, that is anything that does not add value to the outcome for patients or uses resources that could give greater value if used for another group of patients and often, patient harm, even when the quality of care is high
  • Underuse which leads to failure to prevent the diseases that healthcare can prevent, stroke and vascular dementia in atrial fibrillation for example, and often inequity

In the next decade need and demand will increase by at least 20 % so what can we do to tackle these outstanding problems and meet the growing need and demand?


The first step is to focus on value – on triple value The key transformation is from a focus on the quality of service for the patients treated by the individual institutions in Oxfordshire to improving value for the population as a whole and for every individual in the population with triple aims

  • Increasing personal value by ensuring that we focus on each individual’s problem as well as their diagnosis and ensuring that their values are taken into account in personalised decision making
  • Increasing allocative value by ensuring the optimal distribution of resources not only between different programmes such as the programme for people with cancer and the programme for people with mental health problems but also the population based systems within each programme for example within the respiratory health programme optimising allocation betten the services for people with asthma, those with copd and those wit hsleep apnea
  • Increasing technical value from the way the resources are used for all the people with a particular health need such as back pain, or atrial fibrillation or being at the end of life not only by delivering high quality care efficiently but by relating to all the people in need and minimising bot over use and underuse

Low quality care is low value , but high quality care may be of low value too if it does not add value for the population or the individual. The focus has to be on value


Firstly we need to continue to

1. Prevent disease, disability, dementia and frailty to reduce need
2. Improve outcome by provide only effective, evidence based interventions
3. Improve outcome by increasing quality and safety of process
4. Increase productivity by reducing cost

These measures reduce need and improve efficiency BUT we also need to increase value by

  1. Ensuring that every individual receives high personal value by providing people with full information about the risks and benefits of the intervention being offered and relating that to the problem that bothers them most and their values and preferences
  2. Shifting resource from budgets where there is evidence from unwarranted variation of overuse or lower value to budgets for populations in which there is evidence of underuse and inequity
  3. Ensuring that those people in the population who will derive most value from a service reach that service
  4. Implementing high value innovation funded by reduced spending on lower value interventions
  5. Increasing rates of higher value intervention eg helping a higher proportion of people die well at home funded by reduced spending on lower value care in hospital in that population

The Oxford Value Improvement Programme is focused on developing the systems, culture and skills required for all nine of these key tasks and improving the tenth factor – the morale of the people who deliver the service

Transformation Shop

We have different resources for different needs, which can help drive improvements organisationally, individually or both.

Organisational Development 

Our aim is to help organisations transform their culture and develop integrated systems of care.  We will help single organisations that want to transform its culture/service or a group of organisations that want to work together to develop networks to deliver integrated systems of care to their populations.

We start with a transformation workshop which helps the key people in the organisation: 

  • Identify the main pressures they will face in the next decade
  • Agree on the principal features of a service transformed to flourish in the new environment

As a result of the Transformation Workshop, organisations can commit to one of our transformation programmes:

The Integrated Systems Development Programme

The Culture Foundations Programme

Individual Development

These programmes are designed for people who want to lead improvement of health and healthcare – either a whole professional group that knows it needs new skills and knowledge to flourish in the new paradigm or individuals who want to transform the care they provide but are too busy for an MBA.

Professional  Development Programme  helping very busy people create and adapt to the new paradigm

Individual & Organisational Development

Masters level modules – on the Five Giants we still have to conquer and the Enablers of transformation

The How To Handbooks – Knowledge Geared For Action
As well as enhancing the Transformation Programmes, the How To Handbooks can be read alone. They are available on paper, Kindle, and digital versions are available for Iphone, Smartphone, Mac, or PC. The first set of titles is:

  • How To Create the Right Healthcare Culture
  • How To Manage Knowledge in a Health Service (coming soon!)

    Healthcare Foundations is a BVHC podcast service. A subscription to this service entitles you to receive podcasts on current healthcare topics that are important to you – topics such as redistribution of resources, streamlining, reducing waste and increasing value will be illuminated by introducing you to distillates from the 1000 greatest books about or relevant to the health of populations and the delivery of high value healthcare. We also have podcasts from 1000 great articles on the science of health service management. 

    Master the language of healthcare -Language creates the social reality of the world in which we work.  Being clear about the meaning of terms is one of the key steps in shaping culture. Even if a word has more than one meaning, it is essential that everyone in a health service is aware of this and agrees which meaning should be used.  For this reason, BVHC has developed the Glossary of 21st Century Healthcare and a range of other resources to help clarify, and make more consistent, the language of healthcare. 

    The BetterValueHealthcare Bookstore – for really good coffee and 1000 really important book

 We also create bespoke solutions to meet your needs – find out more here.