This paper examines some of the ways in which scientific evidence influenced the development of the policy for the payment of general practitioners for coronary heart disease (CHD) prevention in the UK, in particular the introduction of 'health checks'. The specific policy events which are examined are the 1990 and 1993 contracts for health promotion by general practitioners. Data for this paper were provided by oral history interviews with key informants including general practitioners, public health doctors, civil servants and academics. The study shows the way in which complex scientific evidence interacted with other, professional and political, factors to produce a policy for which there was variable scientific evidence. The relationship between science and policy was complicated and tortuous but two aspects were particularly salient, the way in which scientific uncertainty influenced the content of the policy and the contribution of expert advice to policy making. The existence of social and technical uncertainty about the effectiveness of health checks allowed different players to hold different views depending on their professional affiliation or other agendas. The mechanisms by which scientific advice was given to policy makers were primarily by medical civil servants and through informal contacts and networks. There was no independent systematic formal system to assess and disseminate scientific advice to policy makers, for instance by an expert committee. These factors in turn allowed policy makers to ignore or misinterpret scientific evidence according to other policy imperatives.

Coronary Disease↗

PubMed1998

Influencing national policy; public health medicine and coronary heart disease prevention by general practitioners.

BACKGROUND: Public health medicine has a potentially important role to play in influencing national health policy. This study examines the role of public health medicine in the development of the policy on coronary heart disease prevention in general practice, exemplified by the 1990 and 1993 general practitioner (GP) contracts. METHODS: The methods of the study were qualitative. There were two sources of data: interviews with 33 key informants and analysis of documents relating to the policy process. RESULTS: Public health medicine as an organized medical specialty had little involvement with the development of the policy. The reasons for this include a closed policy process which tended to exclude those not from a primary care background, the role of political factors, the predominance of secondary care concerns by public health medicine in the early 1990s, and differences in perspective between primary care and public health medicine. Public health medicine structures did not have systematic links with the policy process. Public health physicians working in research had more influence, but this was also limited by the absence of any systematic scientific advisory links. CONCLUSIONS: To influence national policy it is necessary to have formal and informal systematic links with the policy-making machinery at all levels of the specialty.

Coronary Disease↗

PubMed1996

Barriers to evidence based policy.

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Evidence-Based Medicine↗

PubMed1996

Effects of the phenylurea herbicide isoproturon on periphytic diatom communities in freshwater indoor microcosms.

The toxic effects of the phenylurea herbicide Isoproturon -IPU: (3-(4-isopropylphenyl)-1, 1-dimethylurea)-were studied on the colonization of periphytic diatom communities, within indoor microcosms consisting of a mixed biotope (water column and natural sediment) and two biological species-rooted macrophyte cuttings (Elodea densa) and benthic bivalve molluscs (Corbicula fluminea). The periphyton, essentially composed of diatoms, was collected on artificial substrata (glass slides) in the upper layers of the water column, after two periods of exposure (34 and 71 days). IPU was initially added in the water or in the sediment compartment, at two nominal concentrations (L1 and L2 levels) for each contamination source-5 and 20 microg litre(-1) and 100 and 400 microg kg(-1) in sediment (w/w) respectively. The effects of IPU on the density and community structure of periphytic diatoms are described. A marked reduction in the diatom density was observed after 34 days exposure to the lower concentration of IPU in the water (5 microg litre(-1)). For the L2 levels, the very small number of live cells present did not permit quantification of the diatom density. After 71 days, recovery in community parameters occurred for the two contamination levels of the sediment and water column sources. Samples collected in the experimental units contaminated with the L2 levels were dominated by heterotrophic and smaller diatom species, such as Sellaphora seminulum. Data treatment based on factorial discriminant analysis enabled us to distinguish the different contamination conditions, with only 11 species from the 130 taxa identified.

Journal Article↗

PubMed1994

Decisions about cardiopulmonary resuscitation.

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Attitude of Health Personnel↗

PubMed1993

'Do not resuscitate' orders: the need for a policy.

The use of 'do not resuscitate' (DNR) orders is widespread in UK hospitals, but until recently there has been no formal policy for this practice. The decision not to resuscitate should be made on ethical and medical grounds. The ethical implications for such decisions are explored. A review of current practice reveals considerable variation in the way in which DNR orders are made. Patients are rarely involved in the decision. There have been failures of communication between doctors and nurses, and between consultants and their juniors. These issues have now come to public and professional attention. There is a need for coherent national and local resuscitation policies that should take into account the medical, ethical and practical aspects of DNR decision making.

Ethics, Medical↗