Do the Right Thing?

This is my first venture into the world of blogging, so don’t be surprised if the tone of this entry differs to those of more polished writers. Given a platform to sound off I feel a bit spoiled for choice. But here goes.

In Philip K Dick’s 1968 dystopian novel “Do Androids Dream of Electric Sheep?” the protagonist, wrestling with his conscience, is told “Go and do your task, even though you know it’s wrong.” As an academic in public health I find myself in a dilemma. I have an interest in prevention of cardiovascular disease. My reading of the research evidence impels me to some quite clear conclusions about how to accomplish this. But I also have to teach. And I have to teach an orthodoxy that I don’t believe. I invite my readers’ thoughts on this dilemma.

The orthodoxy is that there is a condition called hypertension. We know there must be such a condition because there are societies and guidelines which embed this condition in very real societal structure.[1] [2] We have hypertension clinics and hypertension specialists. We have drugs licensed for hypertension. This condition must be diagnosed, which means categorising individuals as either hypertensive or normotensive. The most recent guidelines emphasise the need for technological gee-whizzery in the shape of 24 hour ambulatory blood pressure monitoring to assist this process. The condition must be treated: essentially with drugs. The drugs to be used are individually tailored to patients according to their age, sex and sometimes race. The patients are monitored and the drugs further tailored in the light of their response to treatment. The University of Birmingham helpfully runs a week long course for GPs to help them follow this orthodoxy. Case vignettes provided examples for clinical practice. These vignettes helpfully included discussion of the best treatment for a 22 year old woman with systolic blood pressure of 160 mm Hg. Multiple choice questions assessed the participants’ knowledge. I contribute to the teaching. Herein lies the dilemma.

Unfortunately most of the orthodoxy is nonsense. There is not really a condition called hypertension. Every living human being inhabits a continuum of risk of cardiovascular disease and blood pressure is just one of the factors influencing the continuum of risk.[3] Blood pressure alone does not offer any special insight into the chances of developing cardiovascular disease. The categorisation of individuals by risk would be arbitrary, but at least it has a clear relationship to something that matters: their chances of getting cardiovascular disease. The categorisation of individuals by their blood pressure is not helpful at all. We can trace this error back to the misty origins of medicine itself. Doctors categorise: sick and well. The categories are reified into diagnoses and shackled to treatments through the concept of “indications”. Specialists prosper. Indications become regulatory frameworks for medications and treatments. Pharmaceutical empires rise.

This matters. Nobody should care about their blood pressure. They should care about their chances of getting heart disease. Nobody should be given drugs to lower their blood pressure. They should be given drugs to reduce their chances of getting heart disease. It makes a big difference.

So what do we really know about blood pressure? We know that higher blood pressure is associated with a greater chance of getting cardiovascular disease. We know that drug treatments reduce that chance. But we also know blood pressure alone is not a great indicator of risk. Age is the strongest indicator of risk. If her blood pressure is really 160 mm Hg our 22 year old female has a probability of getting cardiovascular disease in the next 10 years of less than 0.2%. If treatment reduces her risk by a quarter we will treat 2000 such women for 10 years for one to benefit.[4]

Blood pressure is intrinsically variable. In essence this means that it is not measurable with any great degree of precision. So any categorisation of blood pressure also must include a measurement of mis-categorisation.[5] When high blood pressure is uncommon, the most likely explanation for a measured high blood pressure is chance variation. So anyone aged under 35 whose measured systolic blood pressure is >160 mm Hg after an average of three readings at separate clinic visits is much more likely to have had three chance high readings than to have truly raised blood pressure. The problem is slightly reduced, but not at all resolved by using ambulatory blood pressure monitoring.[6] First do no harm. There is no need to measure blood pressure in otherwise healthy young adults. It does little except put them at risk of misclassification. So it seems highly unlikely that our 22 year old female even has high blood pressure at all.

Put bluntly, our 22 year old probably does not have high blood pressure; any benefits from treatment are likely to be trivial; she would likely not have chosen to take treatment if anyone had told her this. Needless to say this was not the right answer helpfully provided by the hypertension specialists.

Blood pressure is hard to measure because it is so variable, but it is almost impossible to monitor reliably. By measuring blood pressure at two, three four or five consultations before treatment and again after treatment in the same individual, it is not possible to reliably know the effects of that treatment or even if the patient is taking their treatment.[5] [7] This is important. It means that every time blood pressure is measured and treatment changed as a result, chance has played at least as great a role in the change in treatment as any other factor. Yet the fact that we can’t monitor treatment accurately does not even matter much, because the effects of drug treatments vary little from one individual to another. The differences between different treatments at standard doses are trivial.[8] When it has been investigated it appears that almost all of the effects of treatment are attributable to drug dose and pre-treatment blood pressure and almost none to individual patient variation.[9] So the effects of treatment may be unmeasurable, but paradoxically they are largely predictable. As for tailoring treatments by age and sex and race, this hardly matters. The differences in response to treatment are too small to be detectable through measurement. Since almost everyone can benefit from two or three drugs it is irrelevant which drug class we consider “first line” since everyone will get drugs from two or three classes.

The solution is simple. Remember our purpose: to prevent cardiovascular disease, not to normalise blood pressure. We can identify who is most likely to be at risk using the most reliably recorded information we have: age and sex. These are untroubled by measurement error. We can refine that risk estimate with additional information: smoking and diabetic status. So far all of this is already recorded in the patient’s records. We can refine it further with more unreliable measurements like blood pressure and cholesterol levels, but often this is not necessary. Those unlikely to be at high risk (otherwise healthy young adults) need no blood pressure measurements, as no level of blood pressure will be worth treating. Those likely to be at high risk will benefit from treatment. We should prioritise them for action. We just need to reassure ourselves that their blood pressure is not so low that treatment will render them symptomatic. Precision is not necessary. Only those in the intermediate risk group might benefit from a more accurate estimate of their risk. Finally we can forget about all that monitoring of treatment effects. The drugs will work if patients take them. The measured blood pressure will vary during treatment. This makes for a rather different therapeutic relationship with the doctor.

And back to my dilemma. Do I continue to teach something I don’t believe? In the novel, the protagonist tries to evade the problem only to be told “You will be required to do wrong no matter where you go. It is the basic condition of life.” So what do I do? Should I go on teaching what I don’t believe or should I rock the boat?

–Tom Marshall, Deputy Director CLAHRC WM, Prevention and Detection of Diseases

[1] British Hypertension Society. British Hypertension Society. 2012.
[2] National Institute for Health and Care Excellence. NICE Guidance – Hypertension (CG127). 2014.
[3] Lewington S, Clarke R, Qizilbash N, Peto R, Collins R, Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002; 360: 1903-13.
[4] ClinRisk Ltd. QRISK®2-2013 Web Calculator. 2013.
[5] Marshall T. When measurements are misleading: modelling the effects of blood pressure misclassification in the English population. BMJ. 2004; 328: 933.
[6] Marshall T. Measuring blood pressure: the importance of understanding variation. Rev Bras Hipertens [Braz J Hypertens]. 2005; 12(2): 75-82.
[7] Hayen A, Bell K, Glasziou P, Neal B, Irwig L. Monitoring adherence to medication by measuring change in blood pressure. Hypertension. 2010; 56(4): 612-6.
[8] Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ. 2009; 338: b1665.
[9] Bell KJ, Hayen A, Macaskill P, et al. Monitoring initial response to Angiotensin-converting enzyme inhibitor-based regimens: an individual patient data meta-analysis from randomized, placebo-controlled trials. Hypertension. 2010; 56(3): 533-9.

Road traffic collisions

People often do not realise what a high proportion of deaths are caused by trauma. In fact 10% of all deaths world-wide result from trauma – more than malaria, TB and HIV/AIDS combined. By 2030 road traffic collisions alone will be the fifth highest cause of deaths in the world.[1] Road traffic collisions are the single most common cause of death in people between 15 and 29 years of age, and leave a trail of disability, as well as death. They particularly affect emerging economies – Kenya is a classic example. Here many perish in small minibuses, called matatus, even though these vehicles are regulated.[2] The CLAHRC WM Co-Director, Tom Marshall, found a recent RCT of about 1,000 such matatus, randomised to have, or not have, stickers displayed prominently to motivate passengers to take demonstrative action against the driver to avoid dangerous manoeuvres.[3] Insurance claims and deaths dropped by about a half in the difference in difference analysis.[3] Too good to be generalisable? The Director would like to replicate the study, perhaps in a factorial design – any takers?

–Richard Lilford, Director of CLAHRC WM

[1] World Health Organization. Injuries and violence: the facts. Geneva: World Health Organization. 2010.
[2] Chitere PO, Kibua TN. Efforts to improve road safety in Kenya: Achievements and limitations of reforms in the Matatu industry. Discussion Paper DP/081/2006. Nairobi: Institute of Policy Analysis and Research (IPAR). 2006.
[3] Habyarimana J, Jack W. Heckle and Chide: Results of a randomized road safety intervention in Kenya. J Public Econ. 2009; 95 (11-12):1438-46.

Importance of Talking to Babies

CLAHRC Birmingham and Black Country (the precursor of CLAHRC WM) has studied the effect of perinatal support on mother-child bonding. This work is right on the money according to this year’s meeting of the American Academy for Advancement of Science. It is well known that by the age of four, children born into professional families have heard 30 million more words than those from alternative backgrounds.[1] Differences are apparent as early as 18 months of age and the words need to be spoken directly to the child – television will not do.[2] There are reasons to believe that neurons form more connections when stimulated through speech.[3] [4] Professor Christine MacArthur and Dr Sara Kenyon – main architects of the CLAHRC BBC study – will now follow-up children to see if those in the intervention group have better neuro-cognitive outcomes than those in the control. It would be fascinating to observe the effect of social interventions, such as the one we have implemented, on verbal interactions between parent and child. Our work focusses on early development because it is difficult for education and affirmative action to overcome disadvantages arising in the first years of life.

–Richard Lilford, Director of CLAHRC WM

[1] Hart B, Risley TR. Meaningful Differences in the Everyday Experience of Young American Children. Baltimore, MD: Paul H. Brookes Publishing Co., Inc. 1995
[2] Fernald A, Marchman VA, Weisleder A. SES differences in language processing skill and vocabulary are evident at 18 months. Dev Sci. 2013; 16: 234–48.
[3] Noble K. Socioeconomic Disparities in the Structure of Language Areas in the Developing Brain. AAAS 2014 Annual Meeting. 14 Feb 2014.
[4] The Economist. Child Development: In the Beginning was the Word. The Economist. 22 Feb 2014. pp 67-8.

Theory and practice of knowledge brokers – Diffusion, Leadership and Patient Fellows in CLAHRC WM

Knowledge brokering is increasingly seen as a panacea for the problem of translating evidence-based innovation into practice. More specifically, a ‘knowledge broker’, someone who, “gets the right knowledge into the right hands, at the right time,” is prescribed as a solution to the translation problem, not just in health and social care,[1] but as a longer standing phenomenon in the private sector.[2] [3]

The concept of knowledge broker provides the starting point for the design of CLAHRC WM processes and structure to ensure effective collaboration across research and practice. Within CLAHRC WM, we have developed three types of knowledge broker:

  • Diffusion Fellows
  • Leadership Fellows
  • Patient Fellows.

Each of these types have distinct, but interdependent roles, in translating evidence-based innovation into practice. This is not a new idea, nor is it distinctive to CLAHRC WM. All CLAHRCs commissioned 2008-13 encompassed knowledge brokers in some form. For example, within CLAHRC Birmingham and Black Country (CLAHRC BBC) (forerunner to CLAHRC WM), John Middleton’s facilitation of the programme linking data on home improvement with data on hospital admissions to drive improvement in service, represented a classic example of an effective knowledge broker.

What is different this time, at least within CLAHRC WM, is understanding that the presence of knowledge brokers is necessary, but not sufficient, for translation of evidence-based innovation into practice. First, knowledge brokers tended to be limited in number; e.g. one or two connected to each of the studies within a CLAHRC. As such, they generated no more than a ripple in any regional healthcare system, and this was only within the discrete service to which they are attached. Second, they were commonly limited to the middle of a healthcare organisation; e.g. a senior nurse or doctor in a service domain that CLAHRC intended to impact [4]; and so exerted less influence upon strategic levels of the organisation than was required to scale up interventions and learning. Responding to these limits, CLAHRC WM has extended the number and range of knowledge brokers, to encompass not just those in the middle of healthcare organisations (Diffusion Fellows), but those at senior levels (Leadership Fellows), and those receiving care (Patient Fellows).

What do different types of knowledge broker do? As in CLAHRC BBC, those in the middle, Diffusion Fellows, work into and out of specific research studies within a service theme. Working into the research study, they may help define the problem in the first place, co-produce the design of the research, and/or comment upon emerging analysis in the course of the research. Working out of the research study, they help engage stakeholders important to translate evidence-based innovation into practice, through developing communities-of-practice [5] and facilitate the often complex management of change (e.g. in workforce roles and leadership arrangements) necessary for service improvement. Meanwhile, Leadership Fellows are responsible for maintaining visibility of CLAHRC WM at strategic levels of health and social care organisations, and ensuring the efforts of CLAHRC are aligned and integrated with organisational strategy where relevant. For example, if a CLAHRC WM partner is bidding for ‘new business’ in an area within which CLAHRC studies are taking place, then this should be invoked in support of the bid. My previous experience in another CLAHRC suggests this is not always the case. Meanwhile, Patient Fellows ensure that the patient and carer experience is considered (and actioned) as an important source of evidence in improving service, and potentially helping scale-up service improvements. Their role is likely to prove wide-ranging as they work into academic teams and practice partners to ensure that the patient and carer experience is not marginalised relative to evidence related to cost considerations, clinical effectiveness or frontline professional experience, when pursuing service improvement.

Third, CLAHRC WM is not just about ‘knowledge brokers’, but about ‘knowledge brokerage’. This is not just a semantic difference, but an important practical one. Effective translation of evidence-based innovation into practice, despite the extension of numbers and levels of knowledge brokers within CLAHRC WM, depends upon more than the agency of individuals, however influential such individuals are within health and social care organisations and systems. The organisations and systems themselves represent an infrastructure that may inhibit or facilitate translation. For example, professional organisation can be fragmented or hierarchical in a way that retards the translation of evidence-based innovation.[6]  Meanwhile managerial organisation might be one orientated towards compliance with policy pressures, rather than towards organisational learning necessary for service improvement.[7] So, at the same time as we introduce ‘knowledge broker’ into the CLAHRC WM system, we need to introduce ‘knowledge brokerage’ to mediate the effect of professional and managerial organisation upon translation of evidence-based innovation into practice. This is a matter of ‘absorptive capacity’ [8] [9] and ‘co-ordination capability’,[10] but that’s enough ‘management speak’ for one blog.

–Graeme Currie
Deputy Director CLAHRC WM, Implementation & Organisation Studies Lead.


[1] Currie G, White L. Inter-professional barriers and knowledge brokering in an organizational context: the case of healthcare. Organ Stud. 2012; 33: 1333-61.

[2] Hargadon AB, Sutton, R.  Building an innovation factory. Harvard Bus Rev. 2000; May-June: 157-66.

[3] Verona G, Prandelli E, Sawhney M. Innovation and virtual environments: Towards virtual knowledge brokers. Organ Stud. 2006; 27: 765-88.

[4] Rowley E, Morriss R, Currie G, Schneider J. Research into practice: Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Nottinghamshire, Derbyshire and Lincolnshire. Implement Sci. 2012;7: 40.

[5] Lave J, Wenger E. Situated learning: Legitimate peripheral participation. Cambridge: Cambridge University Press. 1991.

[6] Martin GP, Currie G, Finn R, McDonald R. The medium-term sustainability of organisational innovations in the National Health Service. Implement Sci. 2011; 6:19.

[7] Burgess N, Currie G. The knowledge brokering role of the hybrid middle manager: The case of healthcare. Brit J Manage. 2013; 24(s1): s132-42.

[8] Cohen WM, Levinthal DA. Absorptive capacity: A new perspective on learning and innovation. Admin Sci Quart. 1990; 35: 128-52.

[9] Zahra SA, George G. Absorptive capacity: a review, reconceptualization, and extension. Acad Manage Rev. 2002; 27: 185-203.

[10] Volberda HW, Foss NJ, Lyles MA. Absorbing the concept of absorptive capacity: How to realize its potential in the organization field. Organization Science. 2010; 21: 931-51.

African centres for Service Delivery Research

The CLAHRC WM Director returned yesterday from a three week trip to African centres for Service Delivery Research (see here for a map).* He visited:

The launch of the CHSSRD
The launch of the CHSSRD

CLAHRC WM is establishing collaborations with these centres of excellence in South and East Africa. Some of the health problems that African centres are tackling are very different from those in the West Midlands (malaria and infant malnutrition), while others are similar (type 2 diabetes and hypertension). However, although the specific problems may vary, at the generic level there is startling similarity in objectives (improving access, identifying problems before harm is done, improving implementation of care standards and so on – examples are given in Table 1). Likewise the methodological issues in carrying out evaluations are, if not identical, then very similar across continents. These observations reinforce the idea that we have a lot to learn from each other and that the North-South divide is a barrier more in our minds and on maps than in the problems we face and methods used to address them.

One very generic issue concerns the question of whether hospitals and hospital departments fail in the specific or in the general – that is to say are rates of adherence to the tenets of good practice correlated within hospitals and their departments? This is a crucial issue for managers, since if they are only very poorly correlated, as found in some studies,[1] [2] then efforts at improvement may need to be focussed on each standard, one at a time. However, if they are strongly correlated, then a generic approach might get more purchase. The issue is also important scientifically, since high correlation within hospitals/departments reduces precision in comparative studies (the so-called “design effect”) meaning that larger numbers of clusters are needed to achieve a given level of statistical power. CLAHRC WM is proposing to investigate this issue in primary and secondary research studies. This project will be greatly enriched by collaboration across high- and low-income countries, allowing the role of context to be more thoroughly explored.

We would be grateful for comments from readers, along with enquiries about future collaborations, which can be made “without prejudice.”

*As an aside, he also completed the gruelling 109km Cape Argus Cycle Tour for the Amy Biehl Foundation, riding alongside famous cricketer Allan Lamb, and finishing the course in 4:21:51 despite dealing with a late puncture and headwinds of up to 45km/h.

Table 1

Triage Surges in demand for admission to labour ward Sick children may wait up to 3 hours to be seen in long queues outside health facilities
Workforce training and continuing
Physician assistants, nurse and doctors Clinical officers, nurses and doctors
Case-finding Undetected high-risk in the community Nutritional deficiency and hypertension in villages and urban
informal settlements
Implementation of
effective care
– identifying and then overcoming barriers
Uptake of home haemodialysis /
improving holistic trauma care for elderly people
Management of adult
diabetes and paediatric emergencies
Cost-effectiveness of Service Delivery Interventions ePrescribing systems and increasing
consultant cover over weekends
Increasing high-
dependency bed
availability under
different constraints
Non-allopathic care for mental illness Providing a platform (“YouthSpace”) for young adults with
mental illness
Exploring the role of the traditional healer

–Richard Lilford, Director of CLAHRC WM


[1] Jha AK, Li Z, Orav EJ, Epstein AM. Care in U.S. hospitals — the Hospital Quality Alliance program. N Engl J Med. 2005;353:265-74.

[2] Wilson B, Thornton JG, Hewison J, Lilford RJ, Watt I,  Braunholtz D, et al. The Leeds University Maternity Audit Project. Int J Qual Health Care. 2002;14:175-81.

Unfinished business

Readers of this News Blog will know that the NIHR CLAHRC WM has a strong mental health theme. Professor Swaran Singh (University of Warwick) drew the Director’s attention to a recent provocative paper by Wunderink et al.[1] This is a seven year follow-up of a randomised controlled trial (RCT) comparing standard maintenance antipsychotic chemotherapy with an early dose reduction/ discontinuation strategy in patients with first-episode psychosis. While the reduction/ discontinuation strategy resulted in a higher relapse rate within two years, this difference had disappeared at seven years and patients in the reduction/ discontinuation arm had better functional status. Since exposure to antipsychotic drugs has been shown to be associated with reduced brain volume in humans (even after trying to control for illness severity),[2] and in normal primates,[3] [4] this study has potentially massive implications for the future research agenda in schizophrenia. For instance, it would be informative to understand the effect of these medicines, which cross the placental and blood-brain-barriers with ease,[5] on the foetal brain.[6]

–Richard Lilford, Director of CLAHRC WM


[1] Wunderink L, Nieboer RM, Wiersma D, Sytema S, Nienhuis FJ. Recovery in Remitted First-Episode Psychosis at 7 Years of Follow-up of an Early Dose Reduction/Discontinuation or Maintenance Treatment Strategy: Long-term Follow-up of a 2-Year Randomized Clinical Trial. JAMA Psych. 2013; 70(9): 913-20.

[2] Ho B, Andreasen NC, Ziebell S, Pierson R, Magnotta V. Long-term Antipsychotic Treatment and Brain Volumes: A Longitudinal Study of First-Episode Schizophrenia. Arch Gen Psychiatry. 2011;68(2):128-137.

[3] Dorph-Petersen KA, Pierri JN, Perel JM, Sun Z, Sampson AR, Lewis DA. The influence of chronic exposure to antipsychotic medications on brain size before and after tissue fixation: a comparison of haloperidol and olanzapine in macaque monkeys. Neuropsychopharmacology. 2005;30(9):1649-61.

[4] Konopaske GT, Dorph-Petersen KA, Sweet RA, et al. Effect of chronic antipsychotic exposure on astrocyte and oligodendrocyte numbers in macaque monkeys. Biol Psychiatry. 2008; 63(8): 759-65.

[5] Masud Iqbal M, Aneja A, Rahman A, et al. The Potential Risks of Commonly Prescribed Antipsychotics. Psych. 2005; 2(8): 36-44.

[6] Bodén R, Lundgren M, Brandt L, Reutfors J, Kieler H. Antipsychotics During Pregnancy: Relation to Fetal and Maternal Metabolic EffectsArch Gen Psychiatry. 2012;69(7):715-721

Changing Human Behaviour Through the Fast-Thinking Part of the Mind

Culture change improvements target the slow-thinking conscious mind. But human behaviour can also be influenced subliminally in the fast-thinking mind – by making the “right thing to do the easy thing to do“.

For an excellent account of the state of the science on unconscious influences on behaviour, the Director recommends a recent article in Scientific American. (Bargh JA. How Unconscious Thought and Perception Affect Our Every Waking Moment. Scientific American. January 2014:22-7.)

–Richard Lilford, Director of CLAHRC WM

On the high prevalence of mental disorders

There are a very large number of different mental disorders, at least according to the recent American Psychiatric Association diagnostic classification. More to the point of this blog, certain mental disorders are also extremely common – in particular, depression.

A recent study compared exercise treatments with anti-depressants or cognitive behaviour therapy in a meta-analysis of head-to-head trials.[1] Each of these modalities has been shown to be better than nothing, but they appear to be of similar effectiveness.

What are we to make of this? Presumably, people should be given the choice. Also, the dose of the medication is reasonably well standardised. That of exercise is very variable. I am training for the world’s largest bike race (the Cape Argus Cycle Tour) and have been doing a lot of exercise at the limits of my endurance. This has a euphoric effect, which was probably not replicated for the average person in the trials. Exercise also has other health benefits, apart from the mind.[2]

But what if we stand back from these rather instrumental results, and consider the matter from a more anthropological perspective? The really interesting thing at this distance is the observation that mental illness is so extraordinarily common and depression affects approximately a quarter of all human beings at some point in their life.[3] Of course, the 25% incidence threshold is a choice – society could use a higher or lower cut off if it wished. Nonetheless 25% of people endure one or more extended periods where their answers on a pro forma indicate that they feel pretty miserable.

This invites the question as to why such a feeling is so common. There seem to be two possible aetiologies for this phenomenon. Firstly, it may be the case that being a human being is very hard, irrespective of the society or time in which one dwells. Alternatively, living in a modern market economy, for all the comforts it gives us, may be particularly psycho-toxic. I think this question is near unanswerable. However, I offer the hypothesis that some societies offer their citizens greater opportunities than others, but these opportunities come at a price. This price is exacted because opportunity entails the risk of failure. The United States, at the moment, is a wonderful habitat for the liberal cognitive elite, sitting in Boston, Chicago or Palo Alto, but the meritocracy has a down side. It seems plausible that people brought up to have no great aspirations, perhaps in a communist or feudal world, might be at lower risk of depression than those exposed to competition with their peers. I would be very grateful if anyone can supply some empirical evidence on this point, though I suspect the results will always be contestable. My observation is that people will always tend to migrate from less free to freer societies, even though they are not so poorly informed as to think that this will necessarily take them to the top. It is hope that projects them into the liberal maelstrom. Like Candide,[4] I would certainly make such a trade-off.

All this reminds me of an article in the Times Higher written by the Vice-Chancellor of the University of Buckingham (Prof Terence Kealey), which likened people in a competitive society to a herd of wildebeest – yes, the gnu of the African plain. Male wildebeest compete to become the alpha male. They try hard, and then most eventually fail. At some point, survival of the herd is dependent upon the contest ending with the unambiguous emergence of the leader. At that point, the unsuccessful bulls become subdued; they lower their heads and graze quietly while the Vice-Chancellor among the gnu procreates to his heart’s content. Biochemically, the cerebral serotonin metabolism of the remaining herd has been altered – in short, they are depressed. But hey, they had their chance.

So let’s get back to treatment. Whether because our society is meritocratic or because it is just part of the human condition, many people will cross the threshold of clinical depression. If they do, they can be given the choice between exercise, anti-depressant drugs, or talking therapy. They can try one, and then switch to the other, although I suspect that cognitive behavioural therapy is by some margin the most expensive and might have to be rationed for that reason. I mean, if a quarter of the population get depressed, it would take a mighty big mental health workforce to provide behavioural therapy for all of them. As for prevention, even if the human condition is such that many people will warrant the label depression, it may be worth trying to mitigate the problem through public health means, such as tackling bullying in schools and targeting high risk groups, such as children who have recently been in care. Finding out whether or not these measures are effective is an aim of the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for West Midlands.

–Richard Lilford


[1] Cooney GM, Dwan K, Greig CA, et al. Exercise for depression. Cochrane Database Sys Rev. 2013; 9: CD004366.

[2] Larson EB, Bruce RA. Health Benefits of Exercise in an Aging Society. Arch Intern Med. 1987; 147(2):353-6.

[3] WebMD. Depression Health Center. Available at: 2013 [accessed 17 Dec 2013].

[4] Voltaire. Candide, ou l’Optimisme. Available at: 1759 [accessed 18 Dec 2013].

Business management

We are familiar with randomised controlled trials (RCTs) in healthcare, education, criminology, and social policy, but what about business management?

Many management interventions are generic,[1] covering the whole of an organisation. I came across a really interesting RCT of such an intervention recently where whole factories were randomised.[2] The factories were textile organisations in India, and the intervention was to have, or not have, management consultant support. I have always had a rather nihilistic impression of the consultancy industry, but it looks as though I might have been wrong, as the intervention sites performed slightly better than the control sites in terms of an increase in productivity in the first year (17%), and the opening of more production plants (0.259 on average) within three years.

–Richard Lilford, Director of CLAHRC WM


[1] Lilford RJ, Chilton PJ, Hemming K, Girling AJ, Taylor CA, Barach P. Evaluating policy and service interventions: framework to guide selection and interpretation of study end points. BMJ. 2010;341:c4413.

[2] Bloom N, Eifert B, Mahajan A, McKenzie D, Roberts J. Does Management Matter? Evidence from India. Q J Econ. 2013; 128(1):1-51.

New type of health professional

There is an international trend to create a new type of health professional to provide front line diagnostic and therapeutic care. Such clinicians are called Physician Assistants in the US, and Clinical Assistants in Africa, but there are many synonyms for this job. The motivations for creating this professional grade vary, but, in essence, the post has been designed make good a shortfall in medical manpower at lower unit cost. From a low-income country perspective such posts have the advantage that certification is not internationally recognised, thereby mitigating a potential ‘brain drain’.

A CLAHRC ambition is to study the role of such personnel, with special reference to continuing education, support and specialisation, and to measuring impact and safety. We would be interested to hear from other people who are undertaking similar work.

–Richard Lilford, Director of CLAHRC WM