Abstract

Abstract: 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.