Public health practitioners in NHS hospital trusts: the impact of 'medical care epidemiologists'.
BACKGROUND
In the late 1990s, one NHS region created posts of 'medical care epidemiologists' (MCEs) to employ public health skills in NHS Trusts in pursuit of the 'evidence-based medicine' agenda.


METHODS
A qualitative interview study and documentary analysis of MCEs' activities were carried out, followed by case studies of selected activities with plausibility of claims assessed by a 'counterfactual panel'.


RESULTS
Most MCEs were centrally involved in the following: Trust committee structures related to clinical effectiveness; service review and evaluation; development of information systems or of access to existing systems to support clinical effectiveness; training in critical appraisal or similar skills; local development of clinical guidelines. A minority adopted narrower roles; only one had concentrated on identifying usable clinical outcome measures, an original objective of the MCE initiative. Case studies of selected activities showed the following: the government's clinical governance agenda created a receptive context in which Trusts connected their MCE's appointment with an external policy agenda; the activities undertaken were nevertheless chosen and shaped by the MCEs themselves, leading to a close fit between the activity and their individual skills and interests; the main impact of MCE activity resulted from deployment of these in ways that transmitted messages about changing organizational culture, rather than from the formal output of their activities.


CONCLUSIONS
It is unrealistic to expect individuals to change the culture of whole organizations. In the right policy context, a real contribution can be made by individuals with appropriate skills and strong personal agendas consonant with, but not determined by organizational agendas.
Harrison
Stephen
S
University of Manchester s.r.harrison@man.ac.uk
Keen
Steven
S
D002983:Clinical Competence; D003195:Computer Communication Networks; D004813:Epidemiology; D019317:Evidence-Based Medicine; D006302:Health Services Research; D006779:Hospitals, Public / Q000458:organization & administration*; D006801:Humans; D019982:Organizational Case Studies; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000592:standards; D024382:Professional Role; D015980:Public Health Practice; D013222:State Medicine / Q000458:organization & administration*; D006113:United Kingdom; D000078329:Workforce