When To Exercise

I’m often asked when is the most beneficial time to exercise? Well personally I enjoy working out first thing in the morning. But according to leading physiologist Mike Doherty who conducted research on a group of elite swimmers, the immune system can be compromised at different times of the day – and often in the morning. However, whilst it is true to say that the immune system is often compromised in elite athletes due to their intense levels of training, it is most unlikely to occur as a result of ordinary levels of activity such as we perform in the gym or the swimming pool before work in the morning.

For the average person the more varied an exercise programme, for example one which includes treadmill, weights and swimming, performed at any time of the day that suits one’s lifestyle is going to prove beneficial. Because a certain level of moderate activity can enhance the immune system, at the same time as it benefits the body by strengthening bone and muscle, maintaining suppleness and building stamina. All regular, moderate exercise will usually do more good than harm, and of course any activity is better than being inactive doing no exercise at all!

Remember the basic exercise rules:
• Warm up thoroughly
• Increase exercise gradually
• Build up intensity and repetitions slowly
• Stop if you feel any pain
• After activity always ensure a gentle warm down
• Give exercise a miss if you feel unwell

Strong bones

Osteoporosis, a debilitating condition caused by the loss of bone mineral, makes the bone susceptible to fracture, especially at the hip, wrist and spine. It is most common in menopausal women as the decline in oestrogen levels leads to an increase in the normal rat of mineral loss from bone.

You can help prevent osteoporosis eating a varied diet rich in vitamins and minerals, by consuming less caffeine and alcohol and by exercising.

Are you at risk?
Height and weight…….
Statistics show that tall women are more likely to develop osteoporosis. If you’re tall, pay extra attention to the things you can do to minimise your risk of developing osteoporosis.
If you are too thin, you could run and increased risk of developing osteoporosis. An overactive thyroid gland could be causing your lack of bodyweight. In addition, you don’t have sufficient adipose (fat) you will be less likely to produce oestrogen from this source.

Carrying a slight amount excess weight can actually push calcium into your bones. It is not helpful to be considerably overweight, however, as excess weight will put great pressure on your bones. If you do decide to lose weight, be careful. Research suggests that after the menopause it is better to stay the weigh you are that to go on a sudden weight-loss programme and lose more than 10 per cent of your body weight, which can double you risk of getting osteoporosis

Lack of exercise is a significant risk factor in the development of osteoporosis. If you sit and do nothing, calcium tends to leave your bones; if you run, calcium tends to enter your bones. The critical factor is that exercise should be more weight-bearing, such as walking, running or push-ups. The more you use your bones to make demands on them, the stronger they become. It is a great way to energise you body and becoming fitter and stronger all over.

Diet – what your bones need
This mineral is a major component of the structure of bones. You lose some calcium everyday, mainly in your urine, and it is vital that this is replaced. A daily dose of 1,000 mg is recommended, with an increase to 1,500 mg close to and thereafter the menopause. Make sure you diet supplies a large amount of calcium. You can also help this by making some positive changes and consider taking a calcium supplement, if necessary.

Calcium’s ‘partner’ in bones is phosphorus. The ideal would provide them in equal amounts, but the Western diet unusually contains an excess of phosphorus. A high phosphorus intake can remove calcium from bones and can also lead to reduced vitamin D activity and hence the absorption of calcium from the digestive system.
Meat, grains and protein-rich foods in general are rich in phosphorus, so reduce your intake of these foods to the minimum that will provide adequate protein. Most fruits and vegetables have a good balance of calcium and phosphorus. Avoid carbonated drinks.

About 70 per cent of the body’s magnesium is stored in the bones, where it replaces some of the calcium and has an important influence on bone structure. People with osteoporosis often have a deficiency of magnesium. Many medications prescribed for osteoporosis contains calcium and vitamin D but little or no magnesium, even though some people may need it more urgently that calcium.

Other essential minerals
In addition to those listed above, make sure that you are supplying your body with adequate levels of manganese, zinc, copper, silica and boron.

Vitamin A
Also known as retinol, vitamin A stimulates the production of progesterone, thought to be more useful than oestrogen in the prevention of osteoporosis. It is found in eggs and meat, especially liver. Carotenes, the precursors of vitamin A, are available from orange, red or green plant foods, such as carrots, beetroot, and leafy green vegetables.

Vitamins B6 and B12 and Folic Acid
These B vitamins help minimise levels of homocysteine. The effect can be enhanced by taking a supplements by taking a supplement with as much as 5 mg folic acid (ask PAUL C if this is still ok to rec). This is a safe dose, but it should be always taken in combination with vitamin B12.

Vitamin C
Vitamin C is essential for healthy collagen and increases the production of progesterone. It is usually found in combination with other bioflavonoid in foods such as oranges, strawberries, tomatoes and green vegetables. If choosing a supplement, look for one that contains vitamin C in calcium form (calcium ascorbate) in combination with bioflavonoids.

Vitamin D
By promoting calcium absorption from the intestinal tract vitamin D helps to maintain normal levels of blood calcium. An adequate intake of vitamin D will, for most people, make a big difference to calcium levels.

Vitamin K
The vitamin encourages calcium deposition in the bones. Many post-menopausal women stop calcium in urine whey they take vitamin K. Leafy vegetables are the richest sources. Because it is fat soluble, vitamin K should be eaten or taken with some form of fat. Another form, vitamin K2, is produced by bacteria and other microrganisms in the digestive tract. For most healthy people, this is a major source of vitamin K. Vitamin K is not stored in the body, and so is less likely to be toxic in high doses. A recommended does in 10 mg a day, but up to 50 mg has been used without any adverse effects.

Other risk factors to consider
– excess alcohol
– excess caffeine
– carbonated drinks
– smoking
– excess salt
– Prescription medication, such as sleeping pills and steroids. They are particularly harmful and can have an adverse effect on the bones. If you are taking these, speak to your doctor or a qualified practitioner about supplements you can take for bone support or natural alternatives to help reduce the medication. Look into natural alternatives to sleeping pills or steroids.

Hints for health
Eat a varied diet throughout your life as osteoporosis can start before the menopause. For strong bones, make sure your diet is especially rich in vitamins D and K, calcium and magnesium.

Recipe for strong bones
Fruit and nut crumble.
Serves 6
Preparation time 15 minutes plus soaking time
Cooking time 35-40 minutes
This can be enjoyed for an energising and wholesome breakfast, after dinner for a healthy desert or delicious midday snack.

Dried fruit such as apricots and prunes add to the iron content of the diet. Absorption of iron is by vitamin C, but inhibited by a number of factors including drinking tea. This delicious recipe contains natural foods that provide essential minerals for bone support.

6 oz dried apricots
4 oz dried pitted prunes
4 oz dried figs
2 0z dried apples
1 pint of apple juice
3 ½ oz of wholewheat /rye/spelt flour
2 oz margarine
2 oz brown unrefined sugar sifted (you can find this at local health food store)
2 oz hazelnuts chopped
To serve and garnish
Low fat yogurt – natural or soya
Rosemary springs

1. Place the dried fruits in a bowl with the apple juice and leave overnight to soak. Transfer to a saucepan and simmer for 10-15 minutes, until softened. Turn into an ovenproof dish.
2. Sift the flour into a bowl and rub in the margarine until the mixture resembles breadcrumbs.
3. Stir in the sugar, reserving a little to serve, and the hazelnuts, then sprinkle the crumble over the fruit (sugar does not need to be added to this recipe if you are trying to avoid)
4. Bake in a preheated oven at 200oC (400oF), Gas mark 6 for 25-30 minutes.
5. Serve with a low fat yogurt, if you liked, sprinkled with the reserved sugar and garnish with rosemary.

My Debut On Bbc Tv’s Breakfast Time

Memories on the 25th Anniversary of BBC Breakfast Time – February 2007.  The BBC had pinched me from HTV where I was doing a programme called Here Today. They saw me wearing my green leotard and tights and doing a piece on exercise, which was the first time it had been done on TV.

Before that, I used to do keep-fit in scarlet leotard and tights at Butlins holiday camps in both Minehead and Barry Island. Then someone on BBC Breakfast Time had the bright idea of sending me to Waterloo Station on the first day of transmission to work out with the commuters.

It was 6.30 am, freezing cold and all I wore was the shiny green outfit and I had bare feet.  I think the early morning commuting public must have thought I was barking mad!

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.”

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.

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

Ten Key Value Questions in Choosing Healthcare

For decades to come need and demand will increase faster than the resources available. Society will need to maximise value from the resources it allocates for public services including healthcare and to do this ten questions need to be addressed

Question 1: How much money should we spend on healthcare?

Question 2: Is the money allocated for the infrastructure that supports clinical care at a level which will maximise value?

Question 3: Have we distributed the money for clinical care to different parts of the country by a method that recognises both variation in need and maximises value for the whole population?

These questions are primarily the responsibility of the Cabinet and the Secretary of State for Health. Then comes the role of the Commissioners. They will want they resources they allocate to be used in ways that have a positive answer to questions 5-10 but they hold those to whom they have allocated resources to do this. The answer to Question 4 is, however the primary responsibility of commissioners. It is important to note that specialist commissioners produce some of the answers to question 5 but do so with regard to the effect their decision this has on the distribution of resources to the different and the thirty sub groups of the population outlined in Appendix 1

Question 4: Has money been allocated to different patient groups in a way that is not only equitable but also maximises value for the whole population?

Question 5: Are all the interventions being offered likely to confer a good balance of benefit and harm, at affordable cost, for this group of patients?

Question 6: Are the patients most likely to benefit, and least likely to be harmed from the interventions, clearly defined?

Question 7: Is effectiveness being maximised?

Question 8: Are clinical risks being minimised?

Question 9: Can costs be cut without increasing harm or reducing effectiveness

Question 10: Could each patient’s experience be improved?

This game focuses on Question 4 which is not only a responsibility of commissioners. They have to make decisions about the allocation of resources between programmes, for example between respiratory disease and cancer. Clinicians will be responsible for the allocation of resources within programmes, for example between asthma, COPD and sleep apnoea within the respiratory programme budget and, with patient involvement making decisions within each system , and the STAR tool is a related game designed specifically for this purpose (2)