Published: 10/03/2005, Volume II5, No. 5946 Page 29
Public health alert! We are in the midst of an epidemic. Its effects are pernicious and its symptoms are easily recognisable: widespread adoption of gimmicks, corny acronyms and poorly developed theories. It infects NHS colleagues, and is flourishing across the land.
Manifestations include the derision I encountered recently when I dared suggest that the applauded 'chronic-disease management triangle' (which depicts how to manage different levels of need, as developed by Kaiser Permanente in the US) was perhaps not quite the final word on such a complex problem.
My indolence provoked calls for flogging in the streets of Salford, such was the heresy of my position.
Or consider the scorn a colleague in London experienced because she wasn't prepared to express her views about supported self-care in the form of a series of interlocking circles, or map them onto a quadrant.
She was frustrated at the limitations of two-dimensional sketches, and even more frustrated at others' reliance on them. Bright colours and elliptical figures catch the eye, she argued, but they are not enough. It just ain't like that in the real world.
Triangles can be useful, and pyramids are attractive. Interlocking circles are easy on the eye. But images reminiscent of hastily painted murals on daytime makeover shows do not do our jobs for us. At the very best, they aid understanding. Nothing more.
do not misunderstand me.
Diagrams and figures have value. Of course they do. They have immense value if and when they help make sense of complex problems. They can help us manage our efforts. But they do not describe the world as it actually is. If we consider them as anything more than simplified representations, we give them an inflated status.
We cram the messiness of the world into beautifully crafted models. And in turn we start to see the world in terms of what they represent. So we miss the point.
'If the only tool we have is a hammer, ' wrote Mark Twain in Huckleberry Finn, 'then all our problems look like nails'. If we rely too heavily on trendy theory we will fail to understand the nuances of problems. Bullet points and clichés do little more than divert our attention away from the realities of the task. Sometimes we need blunt instruments. Sometimes we need precision engineering.
If we had more tools, and if we knew when best to use them, we would make headway. We might be guided by what communities need, rather than the latest mantra or witty acronym. We might be less worried about remembering the Four Cs (consult, compare, challenge...blast! I've forgotten the fourth), or the Five Ps (at the time of writing, they've slipped my mind too) or the 12 steps, or whatever.
And we might become strangely liberated to 'do' health improvement in ways that will make a long-term difference. Escaping from the tyranny of gimmicks might give oxygen to creativity.
Our yearning for quick fixes endures because public health practice remains underdeveloped.
Perhaps collective confidence in our ability to deliver is low. Maybe the deployment of poorly understood concepts creates the semblance of action.
In the midst of a crisis, doing nothing is not an option. I know that. But we have a long way to go.
Chronic-disease management is one of the greatest challenges we face.
But chronic-management disease might well be our undoing.
David Woodhead is deputy director of public health at Salford primary care trust and Salford city council.
He writes in a personal capacity.