Tag Archives: nhs

End of Year Blog: Reflections on my Time as a Non-Executive Director

I must apologise for the hiatus in blogging. This coincided with the Collaboration for Leadership in Applied Health Research and Care (CLAHRC) grant application – a £10 million grant from the National Institute for Health Research (NIHR), with over £20 million of matched funds. Following this, I successfully applied for a job to lead a Centre for International Research at the University of Warwick, and so I have been a bit busy.

I have had the privilege of serving as a non-executive director on the Sandwell and West Birmingham Hospitals NHS Trust Board for the last year and a half. Regrettably, I now have to resign this important post to pursue the above opportunities. This is a good time to reflect on my time on the Board.

Seventeen years had passed since I last served on a hospital board – the United Leeds Teaching Hospitals Group. I was an executive director in Leeds and this is, of course, a different role to that of non-executive director. The biggest change, however, was in the balance of topics discussed in the board.

Firstly, discussion of finance makes up a relatively small proportion of the business of a current board whereas it was a principle topic for discussion in the earlier epoch. Secondly, quality metrics now take up a large portion of board time and this was certainly not the case two decades ago. Ironically, the number of external groups who scrutinise the hospital has also increased dramatically. The Care Quality Commission, Monitor (or the Trust Development Authority), Litigation Authority, Health and Wellbeing Boards, various types of commissioning organisation, and many other bodies scrutinise hospital ‘performance’. The hospital is now a veritable goldfish bowl, and so the board is but one of many organisations providing ‘assurance’.

I shall return to my own views on the implications of all this external scrutiny in just a moment. In the meantime, I can report that during my brief 18 months on the Board, two very important developments took place, which many board members may not encounter during a complete period of tenure.

Firstly, our Chief Executive, John Adler, moved to the big and turbulent Leicester Teaching Hospital Group and so we had to find a replacement. Appointment of a chief executive is the biggest single decision that a board can make. It was fascinating to participate in this crucially important process, and very gratifying to watch the new Chief Executive, Toby Lewis, take control of the tiller. I think that to be a leader one has to want to lead and it has been a joy to watch Toby take charge. He is also an unusually, or should I say particularly, ‘cerebral’ chief executive. Intellectual curiosity is a safeguard against complacency and error. Hospital consultants are a clever lot (mean IQ above 125?) and they respect a leader who is more than a match for them. It was a delight to observe the constructive, but sometimes piquant, interaction between Toby and one of my peer non-executive directors, herself something of a force of nature.

The other big event was recognition, by the government, that a long-standing proposed new hospital scheme would be a suitable candidate for consideration under HM Treasury’s new model, Public Finance Initiative (PFI). With the exception of Chair Richard Samuda, who had previously been chief executive of a property company, my non-executive colleagues and I had to undergo a steep learning curve. The axioms behind the PFI are fiendishly complicated, yet it is essential for all non-executive directors to have a clear understanding of the decisions involved. Modelling future financial and clinical consequences of a new hospital obviously involves a large number of assumptions, including the amount of risk that can be transferred, whether the cost of transferring that risk is reasonable (given the alternatives), what would happen to ‘market share’, how much patient care will be transferred to the community (and with what financial and clinical consequences), and many other factors to which the model is sensitive. The important principle is that it is not just the future under the new building that must be modelled, but also the counterfactual under a scenario where the building does not go ahead – in other words there is no status quo. I came away with the idea that, quite apart from its impact on the nation’s financial position, PFI is not such a disastrous vehicle for hospital finance as many think, especially if, as expected, some Public Dividend Capital is added to the mix. Indeed, it was also prudent to model the consequences of methods to raise capital other than PFI. Architectural issues are also important. For example, I understand that time and motion studies show that single wards reduce staff efficiency by about 6%, compared to multiple occupancy wards. It is also extremely important that the design can accommodate future expansion. As our accomplished Director of Strategy and Organisational Development, Mike Sharon, put it, “the only thing we can be sure of is that we cannot be sure of the optimum size for a hospital 20 years hence.”

I will return now to the question of the role of the board in a time of increasing external scrutiny. To my mind, the corollary is obvious – the board needs to think less of itself as critical and more as friend. That is to say, it can (notwithstanding its statutory responsibility) place itself more on the side of the poacher than the gamekeeper, with respect to assurance. To my mind, executive directors need another scrutiny body like the proverbial ‘hole in the head’.

So what is the role of non-executive directors, given that their scrutiny role has been, at least partially, subsumed by others? The obvious answer is to assist the executive directors in their tasks. This begs the question of whether the executives need such assistance! Here, I think the answer is somewhat nuanced. Firstly, there’s obvious need for a group who can hire and fire the chief executive. That indispensable role cannot be left to one individual. The second role of non-executives is in developing strategy for the organisation. Here, their primary role is to supply external ‘ballast’ in the form of clever and committed people who can contribute by increasing total brain power and by bringing in the perspective of someone who does not have their nose to the coal face. Their last role is to bring specialist expertise. However, I think that this is the least important role because expertise can always be brought in. Nevertheless, non-executive directors with legal and accountancy backgrounds definitely add something to discussions and may spot ‘unknown unknowns’. In my own small way, I tried to bring an academic perspective to bear and to form something of a bridge between the Hospital and the University. As a researcher, I pushed the Board to go beyond simply scrutinising data with which they were presented and scrutinise the method by which the data are collected. This is important to detect and mitigate bias. Statistical control charts should be used to allow for the play of chance. I hope these ideas have been taken to heart. In my opinion, however, too much is made of lessons that can be learnt from other industries – experience of commanding a ship at sea or running a biscuit factory is not much use in a hospital. Returning ambassadors and captains of industry are valuable because they are intelligent people (mainly) who naturally take a strategic perspective, rather than because they bring specific knowledge from these domains. Part and parcel of taking a greater role in strategy is the importance of finance. I do not go along with the fashion of criticising boards that emphasise money. Firstly, money is the language of choice and I would like to see more, not less, emphasis on value for money. Secondly, the surest way to undermine the care of future patients is to overspend in the current year. Maintaining financial probity is the bedrock of patient safety, as our excellent Director of Finance and Performance Management, Robert White, well understood.

Given my sense that boards of NHS hospitals should take a more prominent role in strategy rather than in simply conducting an assurance function, I was interested to see that this is precisely what is advocated in a new business book “Boards that Lead: When to Take Charge, When to Partner, and When to Stay Out of the Way” by Charan, Carey and Useem. These authors use a huge amount of experience and empirical observation to reach the conclusion that non-executives should be “strategic partners”. They also make the point that non-executives can subtract as well as add value to a company and a lot depends on the personality of the individuals concerned. Large egos, hobby horses, low intelligence and unwillingness to engage with detail can get in the way. For me, the hardest thing was finding enough time to fulfil my duties on the Board while holding down a highly competitive day job. But I leave with thanks to my Board colleagues, and a special “thank you” to our sure-footed Chair, Richard Samuda, and diligent Trust Secretary, Simon Grainger-Payne, who helped me settle in. I will miss working with such a committed and talented group of people, and wish them and the hospital all the very best.

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Thoughts on Culture

This week, Donald Berwick came across the Atlantic to tell us how to make the NHS safe.[1] Among the many expected things that he said was the ubiquitous concept of “the safety culture.” In fact, wherever I go I encounter this nebulous concept of culture; ‘It is a question of culture. We must change the culture. It’s all in the culture.’

A huge amount has been written, of course, about this concept of culture. However, organisational culture is usually treated as a discrete entity, disembodied from the broader society and from the subsections or departments that make up an organisation. If so many of the failures of the NHS are a question of culture, then part of the problem may lie not in the health service itself, but in broader society. So what can we say about British culture as a whole; are we a nation of high rectitude or turpitude?

It turns out that there is a scale of national morality. I refer to Fisman and Miguel’s paper on “cultures of corruption” from 2006.[2] These brilliant authors linked the New York Police Department database to that of the United Nations diplomatic corps. They were thus able to determine the extent to which diplomats from various countries violated their parking privileges. I knew that Norway would be squeaky clean, while there were other countries that I suspected would frequently violate parking restrictions under diplomatic immunity. I suspected that the United Kingdom would be down there in the middle grade. However, I was as surprised as I was delighted to see that we score among the highest probity countries, such as Denmark and Japan. In case you are wondering which country recorded the highest rate of violation per diplomat, this was Kuwait, followed by Egypt, Chad, Sudan and Bulgaria. High offending countries tended to have high scores on the international corruption index and also lower per capita GDPs (gross domestic product). As a fan of Max Weber I suspect that moral behaviour generates wealth rather than the other way round, and there is some evidence in favour of my position from John Kay.[3]

Of course diplomats are not a random selection of the countries from which they emanate, but one has to consider the results as reassuring. To what extent does national culture determine the culture among particular services; doctors and nurses, teachers and the police, for instance? I don’t know; do you? And to what extent is a culture in an individual department a reflection of the organisational culture. On this latter point there is evidence from NHS staff surveys. Local culture trumps organisational culture and this is consistent with my own research work [4] and that of others [5] showing that standards of care are poorly correlated across organisations.

So what we have is people nested in departments, nested in organisations, nested in countries. It would appear that there is little correlation between culture in departments and in organisations, but the extent to which organisational culture correlates with national culture is more ambiguous. I suspect that national culture is more important than organisational and even departmental culture in determining the behaviour of individual clinicians. I would be extremely interested in any further evidence on these points.

In the meantime, we will carry on talking about culture, as though we understand it; and plan to change it, as though we could do it. What else can we do? And the evidence base does give us some strong clues. For example, we should be very leery about the use of financial incentives. I read a report on a paper recently that showed that performance following the withdrawal of incentives is worse than performance among people who never had the incentives in the first place.[6] What about targets? The situation here seems very nuanced; sometimes they seem to work well (infection-control) and sometimes they displace other worthwhile objectives (waiting times). I hypothesise that targets work best when the people at whom they are directed are convinced that the target is worthwhile. In any event, once the structure of a health service is well established it is through hearts and minds that objectives are achieved and, quite reasonably, we codify this idea through the concept of culture.

My research work shows that, from a technical point of view, the NHS has improved over the last decade or so.[7,8] The patient survey shows that there has been some improvement in the caring side of health, but not enough. Changing culture so that people become more caring in their attitude is a big challenge since behaviour in this regard depends largely on a person’s innate characteristics and on their upbringing. The NIHR recently elicited a call for research into this topic. Unfortunately I did not have time to apply and I look forward to reading about the results in due course. In the meantime I reflect that organisations are increasingly seeing the moral education of their staff as a worthwhile and important objective. As our churches empty, senior managers must assume the mantle of St Paul.

References:

[1] National Advisory Group on the Safety of Patients in England. A Promise to Learn – a Commitment to Act. Improving the Safety of Patients in England. 2013. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf [Accessed 9th August 2013].

[2] Fisman R, Miguel E. Cultures of Corruption: Evidence from Diplomatic Parking Tickets. NBER Working Paper No. 12312. 2006. Available at: http://www.nber.org/papers/w12312 [Accessed 9th August 2013].

[3] Kay J. The Truth about Markets: Why Some Nations are Rich, but Most Remain Poor. London: Penguin Books Ltd . 2004.

[4] Wilson B, Thornton JG, Hewison J, Lilford RJ, Watt I, Braunholtz D, Robinson M. The Leeds University Maternity Audit Project. Int J Qual Health Care. 2002; 14(3): 175-181. [Article link]

[5] Jha AK, Li Z, Orav EJ, Epstein AM. Care in US Hospitals – the Hospital Quality Alliance Program. NEJM. 2005; 353(3): 265-74. [Article link]

[6] The Economist. Making Pay Work. The Economist 25th May 2013. Available at http://www.economist.com/news/finance-and-economics/21578377-why-bosses-should-be-careful-when-using-performance-related-pay-making-pay-work [Accessed 9th August 2013].

[7] Benning A, et al. Large scale organisational intervention to improve patient safety in four UK hospitals: mixed method evaluation. BMJ. 2011; 342: d195. [Article link]

[8] Benning A, et al. Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase. BMJ. 2011; 342: d199. [Article link]

The doctor/patient relationship: revolution or evolution

A few weeks ago, the theme of the British Medical Journal concerned the ‘patient revolution’, complete with a rather Stakhanovite image of empowerment on the front page. The so-called patient revolution was the main feature in the editor’s column, the first editorial1 and an article by Ray Moynihan2. Let me say at once that I am entirely signed up to doctrines of patient autonomy, patient-centred care and involving service users and citizens in the decision-making apparatus of healthcare. And yet, and yet – there was something rather censorious about these articles. The articles implied that doctors are a bunch of remote, self-serving, pompous, Lancelot Spratt-type characters. There was an insinuation that doctors habitually ride rough shod over patients’ sensitivities, that patients are not involved in decision-making, that doctors override patient autonomy and that the idea of involving the public in decision-making is totally novel. What nonsense! I was a member of the Maternity Services Liaison Committee in my days as a gynaecologist back in Leeds – some 25 years ago. And let me tell you, the members of the committee were no shrinking violets.

In my current role as a National Institute for Health Research Collaborations for Leadership in Applied Health Research and Care director, service users and members of the public interact with researchers and care providers at every stage of the process – from deciding on priorities, to advising on the design of new services. I am certainly not holding myself up as a paragon of virtue; heavy user consultation is a feature of the entire research landscape. Indeed, it is not just a feature but a requirement for access to National Institute for Health Research funding. Medical students have extensive education on communication with patients, and on medical ethics. Here in Birmingham we have a ‘mini medical school’ which is an educational resource for the general public, and in which I lead a discussion group on medical ethics. I believe I created the first medical ethics course at the University of Leeds, in collaboration with Jennifer Jackson, from the Department of Philosophy, and that was now 25 years ago.

Fiona Godlee tried to defend her war metaphors in the context of patient engagement/empowerment but I wasn’t convinced by the argument. A friend of mine recently started the process of converting to Judaism. I met her a few years later and asked her if she was now Jewish. She turned to me and said: “Richard, it is a journey, not an arrival.” In my opinion, that is a far more apt metaphor for the ongoing relationship between our caring profession and those for whom we care.

References
1. Godlee F. BMJ 2013;346:f3153
2. Moynihan R, BMJ 2013;346:f2789

Public inquiries versus systematic collection of the evidence

The Francis Report1 has had a great influence on British public life – from the Cabinet, through the boardroom and down to the shop floor. The report will be widely quoted for many years to come. The report is 1,782 pages long and contains no fewer than 290 recommendations. But how much can one really learn from such an in-depth analysis of just one site? Contrast the Francis Report with a recent systematic overview of the evidence on quality improvement from the Agency for Healthcare, Research and Quality (AHRQ) in Washington, recently summarised in Annals of Internal Medicine2. This AHRQ study is based on a systematic and intellectually grounded analysis of the entire high quality, world literature. It builds on a similar review conducted on behalf of AHRQ by the Stanford Evidence-based Practice Center over a decade ago. And a very interesting and active decade this has been with an exponential increase in research in the areas of quality and safety of healthcare.

Service delivery interventions to improve quality and safety can be divided, from a methodological point of view, into two classes3. Interventions applied close to the patient, with a specific objective in mind, are ‘targeted interventions.’ Interventions applied more upstream of the patient, with multiple objectives in mind are called ‘generic interventions.’ Generic interventions have much broader or diffuse effects on quality. An example of a targeted intervention is the use of ultrasound to guide the placement of intravenous cannulae. Examples of generic interventions include improving the nurse-to-patient ratio or changing the human resources policy.

Targeted interventions are much easier to study – for example they are much more amenable to evaluation through randomised trials. The AHRQ report shows that a number of targeted interventions are effective, including use of peroperative checklists, outlawing use of hazardous abbreviations, medication reconciliation and various types of guideline such as those concerned with ventilator-associated pneumonia, prolonged use of urinary catheters and thromboembolism prophylaxis.

Generic interventions with diffuse effects, are more difficult to study than targeted interventions. Nevertheless, a compelling case for or against generic interventions can often be built systematically by triangulating various sorts of evidence between and within studies.3 It is in this way, for example, that the authors of the overview conclude that improving the nurse-patient ratio leads to better outcomes (including hospital mortality). The report also produces reasonably convincing evidence in favour of rapid response teams, which can be called out from the intensive care unit to attend patients who are deteriorating on the wards. There is very strong evidence for simulation training, especially for complicated technical procedures, but the case for specific team training (as opposed to training in teams) was somewhat less convincing. There is evidence that surgical ‘score cards’ – that is to say a system where surgeons collect detailed data on their cases – leads to improved care when this is owned by the surgical societies and where individual hospitals are put in charge of improvement efforts. This result would seem to vindicate my recent post on how the outcomes of surgical procedures should influence practice. One ‘old chestnut’ is a question of top down cultural change. The evidence that top down cultural change can be produced through ‘heroic’ leadership is extremely unconvincing. A dispersed model of leadership, combined with bottom up specific improvement practices, seems to be the way to go. The report does not treat safety interventions as a black box, but seeks to understand what makes an intervention work or fail. For instance, rapid response teams are dependent on both good monitoring of patients’ conditions on the ward (the afferent arm) and a rapid, efficient response (the efferent arm). Many guidelines, such as checklists, will merely elicit ritualistic displays of compliance unless practitioners have first been convinced of their rationale.

The above are just a small sample of the extensive evidence in the overview. It is a rich source of high quality evidence, based, wherever possible, on comparative studies. It should be essential reading for clinicians and health service managers.
References

1. Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. Available from http://www.midstaffspublicinquiry.com/report. Accessed 14 March 2013.

2. Shekelle PG, Pronovost PJ, Wachter RM, Taylor SL, Dy SM, Foy R, Hempel S, McDonald KM, Ovretveit J, Rubenstein LV, Adams AS, Angood PB, Bates DW, Bickman L, Carayon P, Donaldson L, Duan N, Farley DO, Greenhalgh T, Haughom J, Lake ET, Lilford R, Lohr KN, Meyer GS, Miller MR, Neuhauser DV, Ryan G, Saint S, Shojania KG, Shortell SM, Stevens DP, Walshe K.. Advancing the Science of Patient Safety. Ann Intern Med.2011;154(10):693-696

3. 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 doi: http://dx.doi.org/10.1136/bmj.

Management of the NHS

Even more people than normal are commenting on this subject in the wake of the publication of the Francis Report into the problems at Mid Staffordshire Hospital. Articles are written, blogs are promulgated, and animated discussions take place at dinner parties. I have been struck in all this material by the confidence with which the various commentators stake out their position. It seems that everybody has a remedy; they all know what to do. Many of the solutions are extraordinarily anodyne and of the ‘we need to change the culture’ type. Many others invoke more specific remedies which always make great sense to the commentator but for which empirical evidence is in very short supply.

It seems to me that we are massively ignorant about how to improve the health service. Much management research is of very little help, since it is not designed in a way that can reliably lead to cause and effect inferences.1 It seems to me that much more rigorous quantitative research is required and I would refer readers to a paper that will be coming out in Annals of Internal Medicine in the first week of March2 which points the way to overviews of quantitative evidence on service improvement with particular reference to patient safety.

References
1. Lilford RJ, Dobbie F, Warren R, Braunholtz D, Boaden R. Top-rated British business research: Has the emperor got any clothes? Health Serv Manage Res. 2003;16(3):147-154.

2. Shekelle et al. The Top Patient Safety Strategies That Can be Encouraged for Adoption Now. Annals of Internal Medicine – imminent.

NHS reorganisation – rearranging deckchairs or game changers

When Tony Blair’s Labour Government came to power in 1997, the health service was reorganised. Lots of people changed jobs but the changes were superficial and (as it turned out) mostly ephemeral. The Labour Government certainly left one great monument to health – the National Institute for Health and Clinical Excellence (NICE). When the Coalition Government came in, they rearranged the furniture with a vengeance and, it might fairly be said, without permission from the owners. We are now settling down to do the same work in our new chairs, but what about a legacy from this reorganisation? Has the Coalition Government left behind something enduring, controversial, bold, and potentially game changing? In my opinion, insufficient attention has been paid to a radical and exciting change which, when all the dust has settled, may stand as a signature for the Coalition Government’s reforms. Unlike the creation of NICE, reaction to this policy has been somewhat muted. Could the transfer of responsibility for preventive public health from the health service to local authorities turn out to be a master stroke?

A century ago, public health was largely about the containment and prevention of infectious diseases. Massive gains were achieved through public works, such as provision of water-born sewerage. Health services played a direct role by increasing vaccination. Of course, legislation continues to have a role in public health, for example making people to wear seatbelts or pay more for their cigarettes. Health professionals continue to have a role in prevention, largely by encouraging their patients to adopt healthier behaviour, an idea embodied in the ‘Making Every Contact Count’ (MECC)1 doctrine. But these factors aside, primary prevention really turns on services and policies carried out largely under the jurisdiction of local governments. Education, especially education in the early years is arguably the biggest determinant of health,2 since much of the social, psychological and even neurological substrate for further responsible citizenship is laid down in the first three years of life. Right ‘up there’ with education, we must mention crime prevention – indeed the underlying conditions for poor educational and social achievement and for criminal behaviour are one and the same (or at least largely overlapping)3. Child Support policy is also crucial, both for accident prevention and for encouraging exercise. Lastly, local authorities are responsible for social services, a service which has potential large impacts on education (as mentioned above) and directly on health.

All of these services – education, crime prevention, transport and social services – have effects that lie outside health and in all cases the main intended effect is not a health-related one (unless health is given a very wide definition, but when a word is made to mean everything, it starts to mean nothing, and so I am using health in the colloquial sense). It could, of course, be very cogently argued that policy can be adequately guided to take health considerations into account, and give them their due weight, without bringing part of the public health function into the local government. Moreover, it must be conceded that there is, as yet, no evidence that the policy will work. I know of no international comparisons that provide empirical support for the policy.

It could be argued that a minimal condition for this radical shift in policy should be demonstrable deficiency in the existing system – we should not repair something that ‘ain’t broke’. However, there is plenty of headroom for improvement. Britain incarcerates more of its citizens than most European countries; in 2009, it had the second highest prison rate in Western Europe behind Spain. We seem to have a particularly large proportion of homes with a single unemployed parent which perpetuate themselves to generate a vicious cycle of deprivation.

Of course, the origins of crime and poverty lie deep, and it is far from clear that inculcating public health physicians to local authorities will significantly ameliorate the problem – why should it?

Well, I think I can make an argument as to why the policy has a chance of success. So I’ll start with an ‘Enlightenment’ premise that, insofar as policy can be successful, this can only be achieved by policies which maximise the probability of achieving desired objectives. This in turn can only be achieved by generating, collecting and using evidence about what works. And it just so happens that, at this moment in history, expertise in generating, assembling and analysing evidence is resident mainly within health. This is somewhat ironic because the evidence-based movement – based on synthesising evidence from multiple sources – started in education4. Nevertheless, when I recently attended the Campbell Colloquium (where evidence concerning crime, education, social services, transport and microeconomics is assembled each year) I found that over half the presentations were given by health professionals.

I have the privilege of directing a large National Institute of Health Research funded centre, a network known as a CLAHRC (Collaborations for Leadership in Applied Health Research and Care). For many years now I have been working with local authorities (most notably Sandwell through John Middleton and Worcester through Richard Harling). Our aim has been to collaborate with policy makers and thereby integrating evidence from the international literature, with the particular circumstances prevailing at a local level – a melding of knowledge, sometimes referred to as knowledge management. Collaboration at the heart of local government offers a powerful voice within the local authority and a chance to promote evidence-based policy. My colleagues and I in the CLAHRC will seek to capitalise on this new policy, both for knowledge management purposes and also to design studies to generate new knowledge. I enclose a short synopsis (a CLAHRC BITE) to give an example of the kind of collaborative work that we now propose to carry out with local authorities.

Use of knowledge management to design a service delivery intervention and the research agenda BITE

References:
[1] Health Committee – The Government’s Alcohol Strategy Written evidence from the NHS Confederation (GAS 64). Available from http://www.publications.parliament.uk/pa/cm201213/cmselect/cmhealth/132/132vw60.htm (accessed on 22 January 2013).

[2] Hallam A. The Effectiveness of Interventions to Address Health Inequalities in the Early Years: A Review of Relevant Literature. Scottish Government. 2008. Available at: http://www.scotland.gov.uk/Resource/Doc/231209/0063075.pdf (Accessed 24 January 2013)

[3] Middleton J. Crime is a public health problem. Medicine, Conflict and Survival. 1998; 14(1): 24-28

[4] Glass, N. Sure Start: The Development of an Early Intervention Programme for Young Children in the United Kingdom. Children and Society. 1999; 13: 257-264