Effects of Patient Narratives

Researchers from Yorkshire [1] report a fascinating study where the effects of patient narratives on attitude towards safety of newly qualified doctors were investigated in a RCT. Two outcomes measures were used: a scale of safety attitude and a scale of emotional affect. The intervention involved facilitated workshops where patients and early career doctors would discuss harrowing safety narratives. I thought this might be an effective educational intervention. However, there was no measured difference between intervention and control doctors on the safety attitude questionnaire. What about emotional effects? This result was interesting since both positive and negative affect increased in the intervention group; a ‘bimodal’ effect.

I have never been impressed with safety attitude/culture/climate questionnaires which cover all sorts of factual questions, such as whether the respondent knows that fatigue can cause error, so the null result on this end-point was not surprising. That said, the sub-scale dealing with the relevance of patient involvement did improve in the intervention group compared to control. The split effect on emotion is more puzzling and I think could be well explored by qualitative research. Maybe the young doctors felt inhibited in discussing some of their feelings because of the dynamic within the groups. I don’t think we should give up on stories about medical failure and the patient voice surely enriches the narrative.

— Richard Lilford, CLAHRC WM Director


  1. Jha V, Buckley H, Gabe R, et al. Patients as teachers: a randomised controlled trial on the use of personal stories of harm to raise awareness of patient safety for doctors in training. BMJ Qual Saf. [ePub]

Effects of Salt in Diet

Well there you have it, salt really is bad for you – based on a study of 107 randomised comparisons on the effects of reduced sodium intake on blood pressure, 99 cohorts on the effects of blood pressure on cardiovascular mortality, and a survey of the salt intake of three-quarters of all adults in the world.[1] It is hard to argue with the results of a study like that. Modelling based on the data from the above study, funded by the Bill and Melinda Gates Foundation, concludes that one in every ten deaths from cardiovascular disease can be attributed to a high salt intake. Incidentally, having 107 randomised comparisons makes it possible to examine the correlation between the reduction of salt intake in those trials, and the reduction in blood pressure. It turns out to be linear.

— Richard Lilford, CLAHRC WM Director


  1. Mozaffarian D, Fahimi S, Singh GM, Micha E, Khatibzadeh S, Engell RE, Lim S, Danaei G, Ezzati M, Powles J. Global Sodium Consumption and Death from Cardiovascular Causes. NEJM. 2014; 371: 624-34.

Can CLAHRC WM Enact Distributed Leadership

Why Distributed Leadership? 

The emergence of ‘Distributed Leadership’ (DL) reflects disillusionment with heroic models of leadership.[1] For Heifetz, the prevalence of ‘wicked issues’ [2] that health and social care organisations are required to address, means that leaders leave many problems unsolved and hence often have to disappoint the expectations of followers. DL offers a potential solution to this problem by seeking to reduce follower dependency by enabling followers to take on leadership; i.e. enact ‘adaptive’ leadership.[1] DL is also viewed as desirable in public services because it is inclusive, and aligns with recent organisational re-structuring towards the flatter organisation. It may foster collaborative and ethical practice, and avoid alienation associated with lack of power by those positioned as followers. Finally, DL leverages skills and strengths across the organisation to enhance organisational resourcefulness [3]; and is considered to be particularly appropriate for complex, contemporary organisations, where knowledge is distributed. Thus, Currie et al. [4] [5] [6] highlights that the government has increasingly viewed DL as a panacea for both poor organisational performance and the democratic deficit within public services. However, the government’s vision of DL as a policy panacea for poor organisational performance has been difficult to enact for two reasons – professional organisation and policy orientation towards individualised accountability.

Distributed Leadership in Health and Social Care? 

Within the health and social care domain, first, power is likely to be concentrated with specialist doctors,[7] so that others have struggle to assert themselves in influencing doctors; e.g. nurses [8] and managers.[9] [10] Further, despite policy encouragement to allow for DL to service users, health and social care delivery is likely to remain professionally defined as a consequence of traditional professional hierarchy.[11]

Second, public managers in England are forced to enact ‘target-based leadership’, which is orientated more towards individualism, rather than collectivism, as accountability has been concentrated in the few, rather than the many.[4] [5] [6] Its effects upon leadership ‘on the ground’ within English health and social care organisations has been highlighted by the way those at the apex of the management hierarchy have been castigated for failures in the delivery of health and social care. Recent examples include the ‘sacking’ of health and social care leaders, such as the Director of Children’s Services, the Haringey Local Safeguarding Children’s Board, following the death of ‘Baby P’,[12] and the resignations of CEOs of hospital trusts at Mid-Staffordshire and Maidstone and Tunbridge Wells, following patient deaths attributed due to poor quality service. Within this context, leadership is likely to be concentrated, rather than distributed, because any leader situated at the top of the organisation may be unwilling to distribute leadership to others, and others unwilling to take on leadership.

In summary, I suggest that in English health and social care organisations, professional hierarchy and traditional power relationships, combined with a strong centralised performance regime, will act to stymie policy makers’ aspirations for enacting DL. As such, the health and social care context creates a paradox for DL.

Distributed Leadership in CLAHRCs?

Readers may reflect upon these points above, in assessing prospects for CLAHRCs to distribute leadership in an authentic manner consistent with the ‘C’ in the CLAHRC acronym; i.e. ‘Collaboration’. Let the debate begin regarding the extent we might distribute leadership across clinician scientists and social scientists, NHS managers and academics, NHS managers and clinicians, extending to patients and carers. Indeed CLAHRCs may constitute an exemplary site for the study of DL – see our study 2 in the Implementation and Organisational Studies theme of CLAHRC WM.

— Graeme Currie, Professor of Public Management, Warwick Business School, Lead IOS Theme & Deputy Director CLAHRC-WM.


  1. Heifetz RA. Leadership without Easy Answers. Cambridge, MA: Harvard University Press; 1994.
  2. Rittel H, Webber M. Dilemmas in a General Theory of Planning. Policy Sci. 1973; 4: 155-169.
  3. Gronn P. Distributed leadership as a unit of analysis. Leadership Quart. 2002; 13: 423-451.
  4. Currie G, Lockett A, Suhomlinova O. The institutionalization of distributed leadership: A ‘Catch-22’ in English public services. Hum Relat. 2009; 62(11): 1735-61.
  5. Currie G, Lockett A, Suhomlinova O. Leadership and institutional change in the public sector: The case of secondary schools in England. Leadership Quart. 2009; 20(5): 664-79.
  6. Martin GP, Currie G, Finn R. Leadership, Service Reform and Public-Service Networks: The Case of Cancer-Genetics Pilots in the English NHS. J Public Adm Res Theory. 2009; 19(4): 769-94.
  7. Fitzgerald L, Ferlie E. Professionals: back to the future? Hum Relat. 2000; 53(5): 713-39.
  8. Nancarrow SA, Borthwick AM. Dynamic professional boundaries in the health care workforce. Sociol Health Illn. 2005; 23: 897-919.
  9. Ackroyd S. Traditional and new management in the NHS hospital service and their effects on nursing. In: Soothill K, Henry C, Kendrick K, editors. Themes and Perspectives in Nursing. London: Chapman and Hall; 1996. p. 337-355.
  10. Ferlie E, Ashburner L, Fitzgerald L, Pettigrew A. The new public management in action. Oxford: Oxford University Press; 1996.
  11. Martin GP. ‘Ordinary people only’: knowledge, representativeness and the publics of public participation in healthcare. Sociol Health Illn. 2008; 30(1): 35-54.
  12. Laming, Lord. The Protection of Children in England: A Progress Report. London: The Stationery Office. 2009.

Baby Gender Preferences

A large amount of international research is done sitting at the desk and analysing large datasets. Arguably the largest and most widely used dataset concerning low- and middle-income countries is the Demographic and Health Services (DHS) dataset. This dataset is based on repeated cross-sectional questionnaires in many low- and medium-income countries. The emphasis is on reproductive and infant health. Large databases often disappoint, but DHS is producing some gems.

The authors of a recent World Bank report were interested in a possible preference for sons in sub-Saharan Africa.[1] However, the difference in birth ratio of boys and girls seen in China and India was not found in Africa. So they examined reproductive choices in families where the existing children were all girls or boys. They found that people continue to have children to a greater extent when their existing children are girls rather than boys. There still appears to be a strong cultural preference for boys over much of the world, although manifested in a more subtle way in Africa than in Asia; perhaps because people do not have access to ultrasound to determine the sex of the early foetus, or perhaps because they are less reluctant to have large families. The findings show that many people can control their fertility, suggesting, perhaps, that behavioural factors rather than poor access to contraception is the main cause of the slower decline in family size seen in Africa compared to Asia and South America.

— Richard Lilford, Director CLAHRC WM


  1. Milazzo A. Son Preference, Fertility and Family Structure. Evidence from Reproductive Behavior among Nigerian Women. Policy Research Working Paper 6869. Washington, D.C.: World Bank Development Research Group. 2014.

Should Bicyclists Wear Helmets?

Readers of a recent article in the BMJ [1] may have puzzled over the failure of evidence to confirm the intuitive theory that bicycle helmet legislation saves lives. How to explain such a finding when, given a standardised blow to the head, helmets reduce damage in the cranium?[2] One possibility is risk compensation whereby cyclists armed with a helmet are overbold. Another is that drivers are more careful when overtaking a bare-headed cyclist. Support for the latter hypothesis is produced by Walker’s study of 2007, based on telemetric measurements of vehicle distance from bicycles whose riders were, or were not wearing helmets.[3] Beware of theories that are too tidy – subsequent re-analysis of the same data shows that the effect size is tiny after controlling for other variables, and disappears if driver distances are dichotomised into ‘safe’ and ‘unsafe’ at one metre.[4] It is doubtful if the small differences in Walker’s paper could account for the lack of effectiveness observed for bicycle helmets. Should we start again and carry out further empirical work of cyclist-related variables that may affect driver behaviour? Occasionally I see a parent riding with a child to school and I like to think that drivers take extra care in such a situation.

— Richard Lilford, CLAHRC WM Director


  1. Dennis J, Ramsay T, Turgeon AF, Zarychanski R. Helmet legislation and admissions to hospital for cycling related head injuries in Canadian provinces and territories: interrupted time series analysis. BMJ. 2013; 346: f2674.
  2. McIntosh AS, Lai A, Schilter E. Bicycle Helmets: Head Impact Dynamics in Helmeted and Unhelmeted Oblique Impact Tests. Traffic Inj Prev. 2013; 14(5): 501-8.
  3. Walker I. Drivers overtaking bicyclists: objective data on the effects of riding position, helmet use, vehicle type and apparent gender. Accid Anal Prev. 2007; 39(2): 417-25.
  4. Olivier J, Walter SR. Bicycle helmet wearing is not associated with close motor vehicle passing: a re-analysis of Walker, 2007. PLoS One. 2013; 8(9): e75424.

Meta-analysis vs. Pivotal Trial

Which is better – a meta-analysis of all good quality evidence, or the results of the most precise trial contributing to that meta-analysis? Of course there can’t be a definitive answer to that question if there is no gold standard. However, a single large trial does produce the more pessimistic evidence on treatment effect on average, according to Berlin and Golub.[1] Given a premise that bias tends towards ‘optimistic’ results, then the large “definitive” trial is the less biased on average.

— Richard Lilford, CLAHRC WM Director


  1. Berlin JA, Golub RM. Meta-analysis as Evidence. Building a Better Pyramid. JAMA. 2014; 312(6): 603-5.

Back to the threshold

What is the most a nation should pay for a year of healthy life?

In England, NICE pays £20,000–£30,000 for a healthy year of life – this is not far off the nominal $50,000 evoked by many commentators in the USA. In a recent article,[1] Neumann and colleagues ask whether this is the correct level, especially as it has not changed in two decades, despite inflation and economic growth.

When I directed the Methodology Research Programme in the NHS R&D programme, forerunner of the NIHR, we commissioned a number of research projects to try and find the optional threshold where the value provided per pound by the new technology is exceeded by the value of the services it displaces. Since nobody knows what these displaced services are, let alone their value, the threshold price is enigmatic.

The authors cite evidence from studies showing that Americans are prepared to ‘trade-up’ and would pay more than £50,000 for a healthy life year. The World Bank, for reasons that I have never fully understood, recommends a threshold of three times per capita GDP, which would suggest that both the U.S. and English thresholds are on the low side.

I think the only way to approach the problem is to accept the challenge of finding out what services really are substituted by that gleaming new machine. Granted, what is displaced will vary from place to place. Granted, it will be hard to discern what is displaced because this is implicit not explicit. But detailed observations of decision makers at work could provide evidence of the types of service that are typically rationed in a cost-limited service. I hypothesise that rationing is by “dilution”. That is to say, a nurse is not appointed to ward D17 and there is delay (“slippage”) with the appointment for a new rehabilitation consultant.

The real consequences of setting the threshold too high will be patients waiting longer for their pain relief, less rigorous checks on vital signs, and less comforting words spoken when bad news must be broken. These were the type of opportunity cost I kept in my mind when serving on the NICE appraisal committee.

— Richard Lilford, CLAHRC WM Director


  1. Neumann PJ, Cohen JT, Weinstein MC. Updating cost-effectiveness–the curious resilience of the $50,000-per-QALY threshold. N Eng J Med. 2014;371(9):796-7.

The Most Important Applied Research Paper This Year? Perhaps Any Year?

Walk through a poor rural or urban landscape and the vista seems to repeat itself unchanged. But delve deeper and differences appear. One robust finding from India is that poor Muslim children have a much better survival rate than poor Hindu children – childhood mortality is about one-fifth lower among Muslims. This finding is unaltered by adjusting for known confounders and, in any case, Muslim children in India are poorer and less educated than their Hindu peers. In development circles this is known as the “Muslim mortality paradox”. It was solved by Geruso and Spears in July this year [1] in a brilliant study based on the USAID Demographic Health Survey. Muslims are much less likely to defecate in the open than are Hindus. Hindus often regard defecation in the home as unclean and are more likely than Muslims to go outside to relieve themselves, even if the house is equipped with a functioning lavatory. The study shows a significant correlation between defecation in the open and mortality and confirms what has been thought by many politicians, right back to Mahatma Gandhi, who said “Sanitation is more important than independence”. I believe that we can draw a cause and effect inference from this data because:

  • It withstands adjustment for sex, mother’s education and wealth, and mother’s age at birth. In fact, controlling for education and wealth widens the gap in mortality between religions.
  • Muslims are no more likely to wash their hands, use soap or filter water than Hindus, and are less likely to have access to running water according to the data; again a bias against the hypothesis.
  • It has a good biological explanation. Chronic/recurrent infection/infestation causes stunting due to enteropathy [2] and perhaps a persistently altered microbiome.
  • The increased risk among Hindus who use a lavatory declines in proportion to the proportion of surrounding people who also use a lavatory.
  • Breastfed Hindu children experience much smaller increases in risk than non-breastfed Hindu peers – to me this was ‘the clincher’.

The effect of poor sanitation is so large, that it accounts for a greater quantum of mortality than the difference between the richest and poorest 20% of the population. The findings make the case for improved sanitation in all poor rural and urban areas of the world. In a previous blog I discussed failed approaches to improved health in slums – slum clearance just moves the problem elsewhere; land tenures creates slum-lords, etc. Behaviour change and other methods to improve sanitation could be the big breakthrough in improving lives of slum dwellers and rural poor people alike. CLAHRC Africa is already conducing a pilot study in West Africa, led by Dr Semira Manaseki-Holland, and we are aware of only three cluster intervention trials, all of which are use of solar-powered disinfection of drinking water.[3] [4] [5] However, the USAID Water, Sanitation and Hygiene (WASH) programme is co-ordinating further studies. We think that the step wedge design [6] is particularly suitable for evaluation in such interventions and they should include sound economic and educational end-points, along with health measures.

— Richard Lilford, CLAHRC WM Director


  1. Geruso M, & Spears D. Sanitation and health externalities: Resolving the Muslim mortality paradox. 2014. Working paper, University of Texas, Austin.
  2. Spears D, Ghosh A, Cumming O. Open Defecation and Childhood Stunting in India: An Ecological Analysis of New Data from 112 Districts. PLoS One. 2013. 8(9): e73784.
  3. du Preez M, McGuigan KG, Conroy RM. Solar Disinfection of Drinking Water In the Prevention of Dysentery in South African Children Aged under 5 Years: The Role of Participant Motivation. Environ Sci Technol. 2010; 44(2): 8744-9.
  4. du Preez M, Conroy RM, Ligondo S, et al. Randomized Intervention Study of Solar Disinfection of Drinking Water in the Prevention of Dysentery in Kenyan Children Aged under 5 Years. Environ Sci Technol. 2011; 45(21): 9315-23.
  5. McGuigan KG, Samaiyar P, du Preez M, Conroy RM. High Compliance Randomized Controlled Field Trial of Solar Disinfection of Drinking Water and Its Impact on Childhood Diarrhea in Rural Cambodia. Environ Sci Technol. 2011; 45(18): 7862-7.
  6. Hemming K, Lilford RJ, Girling AJ. Stepped-wedge cluster randomised controlled trials: a generic framework including parallel and multiple level designs. Stat Med. 2014

Treatment and Prevention: Cardiovascular Risk in Low-, Middle- and High-Income Countries

A recent paper in the New England Journal of Medicine [1] examined data on 156,424 people from 17 countries. It demonstrated that although a mean cardiovascular risk score (INTERHEART) was highest in high-income countries, intermediate in middle-income countries, and lowest in low-income countries, the rates of major cardiovascular disease and death were substantially higher in low-income countries than in high-income countries.

Previous work has shown that improvements in medical and surgical treatments (including secondary prevention, heart failure treatments, initial treatments of myocardial infarction, anti-hypertensives and treatment of hypercholesterolaemia) are responsible for 40-55% of the total decrease in cardiovascular mortality (depending on country and time-period studied) while trends in risk factors (including reductions in total cholesterol, systolic blood pressure and smoking) account for 30-60% of the total reduction in cardiovascular mortality.[2] [3] [4] [5]

It is necessary to tackle the relatively high burden of cardiovascular risk factors in high-income countries through Public Health programmes and policy, but the NEJM paper suggests that increased access to high-quality health care and more frequent use of proven pharmacological and surgical therapies may reduce disease burden in low- and middle-income countries. Increases in the prevalence of cardiovascular risk factors (smoking, obesity, diabetes) in low- and middle-income countries, in the context of continued poor access to high-quality health care could have severe consequences.

— Oyinlola Oyebode, Associate Professor in Public Health


  1. Yusuf S, Rangarajan S, Teo K, et al. Cardiovascular Risk and Events in 17 Low-, Middle-, and High-Income Countries. N Eng J Med. 2014; 371(9): 818-27.
  2. Unal B, Critchely JA, Capewell S. Explaining the Decline in Coronary Heart Disease Mortality in England and Wales Between 1981 and 2000. Circulation. 2004; 109: 1101-7.
  3. Ford ES, Ajani UA, Croft JB, et al. Explaining the decrease in U.S. deaths from coronary disease, 1980-2000. N Engl J Med. 2007; 356(23): 2388-98.
  4. Wijeysundera HC, Machado M, Farahati F, et al. Association of temporal trends in risk factors and treatment uptake with coronary heart disease mortality, 1994-2005. JAMA. 2010; 303(18): 1841-7.
  5. Bajekal M, Scholes S, Love H, et al. Analysing Recent Socioeconomic Trends in Coronary Heart Disease Mortality in England, 2000–2007: A Population Modelling Study. PLoS Med. 2012; 9(6): e1001237.

Superstition and Trading

As readers of this CLAHRC WM News Blog know, the CLAHRC WM Director is a fan of the Enlightenment, and he was amused by a recent paper by Bhattacharya et al.,[1] which is a vindication of Enlightenment values. They were interested in whether superstition adversely affects human welfare by looking at trading in the Taiwan Futures Exchange. In Mandarin, pronunciation of the number “8” is similar to the word meaning “prosper” or “wealth”, while the number “4” is pronounced similarly to “death”. The authors defined a “superstition index” for individual traders based on the proportion of prices ending in these numbers and found a significant association between numerical superstition and poorer investment performance.

— Richard Lilford, CLAHRC WM Director


  1. Bhattacharya U, KuoW-Y, Lin T-C, Zhao J. Do Superstitious Traders Lose Money? Soc Sci Res Network. [Online]