health technology assessment in its local contexts: studies of telehealthcare

Social Science & Medicine 57 (2003) 697–710

Health technology assessment in its local contexts:studies of telehealthcare

Carl Maya,*, Maggie Mortb, Tracy Williamsc, Frances Maird, Linda Gaskc

aCentre for Health Care Services Research, University of Newcastle upon Tyne, 21 Claremont Place,

Newcastle upon Tyne, NE2 4AA, UKb Institute for Health Research, Lancaster University, Lancaster, UKcSchool of Primary Care, University of Manchester, Manchester, UKdDepartment of Primary Care, University of Liverpool, Liverpool, UK

Abstract

Health technology assessment (HTA) is one of the major research enterprises of late modernity, reaching into fields of

previously autonomous professional practice, and critically interrogating the organisation and delivery of health care.

The ‘evaluation’ of new health technologies within the field of HTA is increasingly a normative political expectation, as

discourses of ‘evidence-based’ practice run through health policy in the UK and elsewhere. Despite its importance in

governing the direction of innovation in health care delivery, there are hardly any empirical studies of HTA in practice.

In this paper, we draw on two ethnographic studies of telehealthcare implementation and evaluation in the UK to

explore the practical conduct of HTA, and we focus specifically on the social organisation and conduct of randomised

controlled trials of these new technologies. The paper examines how evaluation forms a mediating set of practices that

make the embedding or normalisation of a new technology possible; and present a simple model of the social and

technical contingencies within the evaluation process.

r 2003 Elsevier Science Ltd. All rights reserved.

Keywords: Telehealthcare; Health technology assessment; Evaluation; Contingency model; UK

Introduction

In late modernity, the institutional superstructure of

health care rests largely on the application of technol-

ogies to problems of understanding the nature and

distribution of disease, its diagnosis, treatment and

management, and the organisation of service provision.

These technologies may take the form of machines, or

systems, or of practices. Some are hardware, others are

software; some are embodied in people, others in

objects. Many take the form of hybrids and networks

in which the boundaries between the ‘social’ and the

‘technical’ are hard to locate, and when they can be,

seem often to be ambiguous or permeable. Indeed, the

point of distinction between technologies is itself

problematic, there is no concrete boundary between

the ‘technical’ and the ‘social’, but rather there are

practices of differentiation and demarcation on the basis

of agreements (or disagreements) about their properties

(Bloomfield & Vurdubakis, 1994).

This paper is about the social and technical transac-

tions through which such agreements are formed in the

field of Health technology assessment (HTA), and

specifically the evaluation of a new domain of informa-

tion and communications technology (ICT) in health

care—telehealthcare—in the United Kingdom. Evalua-

tion of new technologies, treatment modalities and

models of service delivery is a crucial component of

Research and Development in the national health

service (NHS) in the UK, and attracts significant levels

of government funding through an internal ‘tax’ on

NHS spending (the NHS R&D levy), and is formalised

through a variety of means—notably the NHS HTA

R&D Programme. Evaluation is therefore a normative

ARTICLE IN PRESS

*Corresponding author. Tel.: +44-191-222-7046; fax: +44-

191-222-6043.

E-mail address: [email protected] (C. May).

0277-9536/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved.

PII: S 0 2 7 7 - 9 5 3 6 ( 0 2 ) 0 0 4 1 9 - 7

political expectation that connects with the thrust

towards ‘evidence-based practice’ that increasingly

characterises health care systems across the developed

world, and which has become a deeply embedded feature

of the discourses of health care that circulate in the UK

(Harrison, 1996). Evaluation and adoption are inti-

mately drawn together by this political linkage, in which

the evidence base for a technology acts to discipline

qualitative decisions about policy and public spending.

Evaluation is neither a discrete asocial activity, nor is it

self-evident. HTA is one of the major research enter-

prises of our time. It is broad in scope, and defined by its

emphasis on formal—mainly quantitative—methods

and its focus on clinical and cost effectiveness; it is

therefore directed at the production of evidence about

the efficacy and utility of techniques and technologies of

health care delivery treatment modalities and ways of

working (Woolf & Henshall, 2000) that meet particular

criteria of adequacy. The formal proof of HTA is to be

found in the outcomes of the randomised controlled trial

(RCT), systematic review, and meta-analysis. The

questions that inform it tend to arise directly from the

thrust of health care policy (Faulkner, 1997), and the

outcomes of HTA practitioners’ work are specifically

intended to mediate between policy and practice.

So within the field of HTA, it is the method that is

prioritised either in the production of primary outcomes

data, or in the synthesis of existing knowledge. The

expository literature of HTA reflects the priority given

to methods, not theories, by locating them in a rhetoric

of political and social neutrality, and emphasising

applied investigatory technique over broader political

questions (Lehoux & Blume, 2000). None of this is

intended to imply that practitioners of HTA are

unaware of the political implications of their work, or

the wider social implications of their practice—the

reverse is certainly the case. But HTA emulates the

rhetorical form of biomedical science, constructing what

seem to be methodologically secure facts and so has, at

the outset, a defence against wider political critique

(Giacomini, 1999).

Work to conceptualise HTA to date has mainly been

directed at macro-level analyses of the relationship

between policy formation and evidence production.

More localised critiques have investigated the assump-

tions that underpin outcomes themselves, or the

methods by which they are reached. Much less work

has investigated the specifics of HTA as a field of

practice, the socio-technical networks in which knowl-

edge about efficacy is defined and generated, negotia-

tions about criteria for its adequacy, or the procedures

through which these are enacted in concrete practices.

The production of evaluative knowledge about the

utility and effectiveness of health technologies is socially

organised, and thus what the ‘facts’ are, is the product of

processes and practices of construction. This paper is

concerned with precisely this disciplinary field, exempli-

fied in the application of RCTs of telehealthcare

systems.

This paper has two objectives. First, we are concerned

to explore the practical conduct of evaluation and the

social organisation of RCTs of new technologies. Our

interest here is in the way that evaluation forms a

mediating set of practices that make the embedding or

normalisation of a new technology possible. Second, we

present a simple model of the social and technical

contingencies within the evaluation process. Our con-

cern here is to map the contingent points on the journey

between ideation (i.e., the emergence of ideas about the

value of a new technology to practice) and normal-

isation (i.e., the point at which it becomes possible for it

to be embedded in clinical practice). Understanding the

process of evaluation is important, for we actually know

little about the practical conduct of HTA, although

there is a large and expanding body of literature that

details either evaluation methods or the results of their

application.

Telehealthcare as a case study

Telehealthcare offers an important and relevant focus

for understanding the social contexts and practices

involved in evaluation, since there is not only disagree-

ment about the utility and efficacy of the technological

systems involved, but also about the most appropriate

means to assess them (Holle & Zahlmann, 1999).

Telehealthcare systems are politically attractive, but

clinically contentious technologies that promise new

kinds of links between clinicians and patients separated

by time and space. These technologies are unstable in

clinical practice: they are not widely used, and there are

doubts about their efficacy (Roine, Ohinmaa, & Hailey,

2001; Hersh et al., 2001), acceptability to patients

(Williams, May, & Esmail, 2002) and cost effectiveness

(Whitten et al., 2002). Nevertheless, they have proven

attractive to policy makers, because they seem to offer a

technological ‘fix’ for some of the structural problems

that affect access to health care. In particular, they seem

to offer the potential to speed up referral to specialist

clinicians in an environment where a key criterion by

which governments themselves are measured is their

capacity to speed patient throughput. Against the

background of this policy impetus, we need to under-

stand evaluation as a constructive stabilising process,

which in the case of new and rapidly developing

technologies, involves debates about evaluation metho-

dology and professional dynamics that conceal more

fundamental difficulties in conceptualising a technology

in play, and which are difficult to resolve in practice.

These debates represent struggles within specific profes-

sional communities of practice to develop ways of

ARTICLE IN PRESSC. May et al. / Social Science & Medicine 57 (2003) 697–710698

conceptualising, as well as measuring, systems and their

effects.

In the evaluation of telehealthcare, the means of

production of knowledge typically emulates biomedical

research procedures. Proponents of telehealthcare re-

cognise this, and make it explicit within their literature.

But more than this, they also emphasise the limitations

on the value of evidence produced through these

practices (Holle & Zahlmann, 1999). Such views run

through debates about the construction of macro-level

knowledge about telehealthcare (Filiberti, Wallace,

Koteeswaran, & Neft, 1995; Grigsby, Schlenker,

Kaehny, Shaughnessy, & Sandberg, 1995; Huston &

Smith, 1996). Within this literature, attempts have

been made to divide up the ‘field’ of telehealthcare in

ways that make it more amenable to the practices

and procedures that drive other domains of biomedical

research. But the impetus is still to do the kinds

of research that ‘fit’ with the wider pattern of normative

expectations about the reliability of health care knowl-

edge. In this context, quantitative techniques for knowl-

edge production, such as the RCT, are paramount.

The problems that stem from the normative metho-

dological expectations of biomedical research are ex-

emplified in the discourse of HTA. In the British

context, one example of this may be found in the UK

government’s HTA Programme’s report on the evalua-

tion of rapidly developing technologies (Mowatt et al.,

1997). It wrestles with the problem of applying the

conventional techniques of biomedical research to fast

developing technologies, but which reaches no firm

conclusions about alternatives. But however much this

discourse seems to specify asocial and acontextual

products of evaluation work—particularly, the develop-

ment of generalisable quantitative measures of efficacy

and utility—the business of understanding the practices

that underpin it relies on a critical interrogation of social

and technical processes. These relate to the practices

through which ‘facts’ are constructed and agreement

about them reached (Bartley, Smith, & Blane, 1997).

Study group and method

This paper draws on analyses of ethnographic data

drawn from two studies. In the course of these studies,

we examined the development, implementation and

evaluation of 10 telehealthcare interventions between

1997 and 2002. These are described in Fig. 1.

ARTICLE IN PRESS

Code Research Site – Description TM1/S1 Synchronous telepsychiatry service between primary and secondary care

providers. Pragmatic service evaluation, survey and qualitative study of ‘users’ views. (Non-academic setting, successfully completed)

TM1/S2 Synchronous internal medicine service. Randomised controlled trial.Non-academic setting, failed to develop beyond protocol design)

TM2/S3 Asynchronous teledermatology service. Randomised controlled trial followed by pragmatic service evaluation. (Academic setting, successfullycompleted)

TM2/S1 Asynchronous system between primary and secondary care: pragmaticservice evaluation; survey users’ views. (Non-academic setting, projectsuccessfully completed)

TM2/S2 Asynchronous system between primary and secondarycare: RCT; qualitative study of users’ views (Academic setting, project continuing).

TM2/S3 Synchronous system between hospital department and community: RCT ; economic evaluation; qualitative study of users’ views (Academic setting, project continuing).

TM2/S4 Synchronous system: RCT; qualitative study of users’ views (non-academic setting, project continuing).

TM2/S5 Synchronous system: service evaluation (non-academic setting, projectfailed)

TM2/S6 Mixed system: RCT (academic setting, project continuing).

TM2/S7 Synchronous: service evaluation (academic setting, project continuing).

Fig. 1. Description of telehealthcare evaluations in TM1 and TM2.

C. May et al. / Social Science & Medicine 57 (2003) 697–710 699

Study TM1 was a qualitative formative process

evaluation of the implementation of three telemedicine

services in an English Region, and focused on the

professional and organisational dynamics of their

implementation and evaluation. Between 1997 and

1999, we examined services providing telepsychiatry,

internal medicine, and teledermatology (May & Ellis,

2001; May et al., 2001a; Mort, May, & Williams, 2002).

In each case, formal semi-structured and unstructured

interviews were undertaken continuously with key

informants (clinicians, technical experts, evaluators,

managers, and in psychiatry and dermatology with

patients; participant observation was undertaken in

clinical and management meetings and other settings;

documentary analysis was conducted upon archives of

service documentation and correspondence, including

email archives and log files at individual computer

terminals. Data interpretation followed the precepts of

constant comparison (Strauss, 1987) formed through

inductive, rather than deductive, analysis.

Study TM2 was an ethnographic study focused on the

conduct of evaluation of telemedicine services. The

study aimed to identify and explore those factors that

promote or inhibit the effective evaluation of telemedi-

cine systems, and was specifically concerned with the

practices and processes involved in the social construc-

tion of reliable knowledge (May, Mort, Williams, Mair,

& Shaw, 2001c). We purposively sampled telemedicine

evaluations (four randomised controlled trials and three

pragmatic ‘service’ evaluations) commencing between

the autumn of 1999 and summer of 2000. The study

group conformed to a maximum variation sampling

strategy, in which the study groups distinguished by

service type (‘store and forward’ delayed data transmis-

sion versus ‘real time’ interactive video links); by service

site (academic versus non-academic link), and by

evaluation type (randomised versus non-randomised).

Once again, ethnographic methods were employed: with

key informants (between 5 and 15 key informants in

each study) were interviewed continuously; other data

was drawn from participant observation at meetings and

on other occasions, and the textual analysis of project

documentation.

The two studies provided a wealth of data. This

includes 120 transcripts of formal semi-structured inter-

views with clinicians; technical experts; evaluation

researchers; policy actors; and patients. It also includes

field notes of observations (and also some transcripts) of

project and other meetings; conferences; and also of a

session of the UK Parliamentary Select Committee on

Health. Other data includes archives of written and

email correspondence; study protocols and other doc-

umentary material. Analysis of this material has been

guided by the precepts of the ‘constant comparative’

model of qualitative research practice set out by Glaser

and Strauss in The Discovery of Grounded Theory

(Glaser & Strauss, 1967). Each of the authors conducted

fieldwork, including formal (and informal) interviews,

participant and non-participant observation. Interviews

and field notes were transcribed, and we worked

together to develop a coding strategy which was then

collectively applied to the data at ‘data clinics’ when we

met to interpret data and develop our analysis. Some of

the data from these studies is reproduced in this paper,

but given the volume of this material it is necessary to

present this in an illustrative rather than systematic

form. Our fieldwork in study TM2 has been founded on

a guarantee to our respondents that neither they, nor

their specialisms or institutions will be identified in

reports on our work: we have therefore removed details

that might compromise their anonymity from the

transcribed materials presented here. Respondents are

therefore identified by codes that indicate (a) the study;

(b) the research site; and (c), their discipline or grade.

The contingency model

Our purpose in this paper is to understand the

production of evaluative knowledge in HTA—and to

do this we use the development of telehealthcare systems

as a mediating example. Telehealthcare is intrinsically

interesting, for the use of ICTS as intermediaries

between clinicians and patients is a highly unstable field

of activity, where evidence is by no means certain, and

where proponents of these technologies have not found

it easy to penetrate health care systems (Bashshur 1997;

Pelletier-Fleury, et al. 1999). The field of telehealthcare

research and development is dominated by a mass of

often small-scale evaluations and technology demon-

stration projects (Roine et al., 2001). More recently,

however, development of telehealthcare systems in the

UK has seen a number of major evaluation studies

coming into play, that accord broadly with the

methodological precepts of HTA, and which particu-

larly employ RCTS or other techniques which ‘fit’ the

production of evidence that meets the assumptions of

adequacy that circulate within the field of HTA as a

specific (if heterogeneous) community of practice—even

though these methods are by no means ideal for the

evaluation of new ICTs.

As we have already noted, one of the principal aims of

our work has been to conceptualise the evaluation of an

innovative health technology in context. By this we

mean, the networks and practices through which it is

formed, and the normative expectations of these

practices and intervening political processes (at both

macro- and micro-levels) that run through the networks

in which they are located. There are a number of general

approaches to this, which include classical diffusion

theory (Carter, Jambulingam, Gupta, & Melone, 2001;

Miller & Garnsey 2000), and the analysis of technological


regimes (Hadjilambrinos, 1998). These both operate

at a macro-level of analysis. There are far fewer

such analyses of telehealthcare, although work by

Whitten et al. (Whitten, Sypher, & Patterson, 2000;

Grigsby et al. 2002; Whitten & Collins, 1997). is an

important example of the application of diffusion theory

to the field. Policy level analyses of telemedicine also

include that by Rigby (1999) which stresses the manage-

ment level problems that may be encountered in

telemedicine service provision. An important socio-

logical contribution, by Rappert and Brown (2000) has

explored the configuration of innovation processes in

telemedicine and contrasted these with technology

innovation in genetic diagnostics, in an attempt to

illuminate the defining ‘moments’ of the two technolo-

gical fields.

Our approach has been somewhat different. Because

we have had a unique opportunity to observe and

compare the development and evaluation of specific

services over their lifetimes, we have been able to

establish the levels of activity within which new

technologies are evaluated in terms of the kinds of

knowledge and practice that circulate within them.

Importantly, our work has been situated within the

communities of practice in which attempts have, and

are, being made to stabilise and normalise these

technologies. The model that we offer in this paper

(see Fig. 2), therefore distinguishes between the norma-

tive components of the technologies of evaluation

practice, and the discourses through which telehealth-

care systems are applied to practice; and divides research

and clinical practice. But the boundaries between these

are permeable. We have observed four such levels of

activity.

(1) Ideation: where general notions of the definition

and production of both a new technology and

reliable knowledge about it are formed and

circulated (cells 1.1–1.4);

(2) Mobilisation: in which models of evaluative knowl-

edge and clinical practice are translated into a

specific field of technological development (cells

2.1–2.4);

(3) Clinical specification: which disciplines the contin-

gent processes through which reliable knowledge is

produced, and clinical practices enacted (cells 3.1—

3.4), and;

(4) Specific application: in which the procedures that

form both knowledge production and clinical

practice are made concrete at a micro-level (cells

4.1–4.4).

Our purpose here is to develop an analytic framework

that connects the social and technical construction of

‘evaluation’ with that of ‘technology’. It focuses on the

social processes and networks through which these are

worked out and understood. Some caveats need to be

made in respect of this framework at the outset.

Although our model appears to be hierarchical (working

from diffuse normative expectations, through to specific

concrete practices and applications), it is not: the

boundaries between these levels are permeable and

negotiable. The framework therefore does not set out a

sequential model of activity, for each level may run

concurrently in interaction with the others. Nor are we

concerned to develop a specific critique of methods of

evaluation. What the model does provide, however, is a

conceptual framework that elucidates a set of contingent

points on a map of social practices. The model locates

actors and activities against these contingent points—

and in doing so, sets out the points of resistance and

constraint that appear as new technologies are brought

into the play of service development and evaluation

practice, as well as the points at which strategic and local

expansion of opportunities are situated.

Ideation

At the outset (cells 1.1–1.4) we can identify practices

of ideation. Put simply, this is the field in which

proponents of a new technology set out its possibilities

and work to persuade other actors of these, by

articulating its potential to resolve institutional or

clinical problems within health care systems. This

persuasive activity constructs a set of expectations about

its efficacy and utility. In telehealthcare, the key product

‘champions’ have initially tended to be policy entrepre-

neurs, who have seen these technologies—and their

associated clinical techniques—as a means of resolving

structural problems of access and of the uneven

distribution of expertise. There is abundant evidence of

this in the British context (Klecun-Dabrowska &

Cornford, 2000), and equal evidence of such actors at

work in other health care systems—notably the US

(Sinha, 2000).

The discourse that runs through networks of actors at

the level of ideation is one of technocratic optimism, and

they seem to be ‘evangelists’ for telemedicine. A crucial

problem for these actors, however, is that they are

caught between two contending policy streams (May,

Mort, Mair, & Williams, 2001b). The first, explicit in

modernisation policy as it relates to the UK health care

system, is dealt with through discourses of technological

development and strategic expansion (cells 1.1 and 1.4).

On many occasions we have heard key policy makers

and clinicians arguing the case for generalised tele-

healthcare systems on the grounds of modernisation. At

a meeting of the British Association of Dermatologists,1

ARTICLE IN PRESS

1British Association of Dermatologists, Symposium on

Telemedicine. Royal College of Physicians of London, 1 June

2001.


for example, a representative of the NHS Information

Policy Unit asserted that: ‘We want to see telemedicine

and telecare fully integrated into health care delivery

ðyÞ so that when you’re planning new services

telemedicine is just something that is delivered as part

of it’ (Preston, 2001). Modernising discourses open up a

field of practice, defining its possibilities, but they run

against a less optimistic and more parsimonious set of

positions (cells 1.2 and 1.3), that are drawn from a

contending policy stream that asserts the importance of

the evidence base from which policy interventions

should be derived, and which we find evinced in

discourses of knowledge production and technological

containment. In ideational practices, then, we find

political contests between proponents of modernisation

and HTA. These are particularly well represented in the

accounts of senior clinicians who are themselves critical

of the quality of evidence available to them. For

example:

TM1/S3/Consultant Dermatologist: [F]requently, the

studies are quite small and they tend to be done by

ARTICLE IN PRESS

Level ofanalysis

Mode oftechnological development

Mode of knowledgeproduction

Mode ofcontainment

Mode of strategicexpansion

Ideation 1.1 Idea of newtechnology:expectation ofapplications of newtechnology to clinical settings, concepts ofutility and effectiveness.

1.2 Notion ofresearch/evaluation: normative expectations about the production and circulation ofgeneralisable and reliable knowledge

1.3 Judgementsabout value: expectations ofintellectual and otherkinds of capital, andconstructs of the social worth of a technology (what’s better, what works?)

1.4 Key actors: work to championtechnology and construct apersuasive field ofpossibilities; link into policies and programmes of R&Din design and manufacturing sector.

Mobilisation 2.1 Constructs ofappropriate design and operation:translation of expectancies intoplans, technicaldecision making, systems thinking.

2.2 Constructs ofresearch/evaluation methodology: normative models of transferable knowledge circulatingwithin communities of practice, subject to the elision of contingency.

2.3 Selective enrolment into communities of practice: recruitmentand integration ofactors into networks; entry criteria andcontrol overactivities; contextualisation of fields of agreement and disagreement.

2.4 Emergentpractitionercommunities: organise expectancies intoprogrammes ofwork; contest patterns of infrastructure organisation and resource allocation; organise the market-place toreceive technology.

Clinicalspecification

3.1 Technical implementation:system intended tostructure contingent practice within aframework of reliable clinical knowledge.

3.2 Research/ Evaluation protocol:specific instrumentintended to structure otherwise contingent processes of knowledge production within aframework of reliable practice.

3.3 Structural constraints ondynamic instability:fixes technologiesand techniques inplace, forces theelision of contingencyof interpretation.

3.4 Practitionergroups reifypossibilities of technology: construct ideal forms of specific application;organise resources and infrastructure;situate dynamicactivities in specific settings.

Specific application

4.1 Clinical intervention:activities leading tothe organisation ofclinical proceduresabout which claims of reliability can bemade, and which are intended to meet thenormative expectations ofexternal adjudicators.

4.2 Research/ Evaluation application:activities leading to the production of knowledge about which claims of reliability can be made,and which are intended to meet normativeexpectations of externaladjudicators.

4.3 Attempts toprevent interpretiveflexibility: act to place restrictions on creative modificationof systems in play,intended to frame standardised and generalisable products of clinical evaluation and practice.

4.4 Possibility of Normalisation: conventional processes ofreporting andpublication; informal diffusion through networks of practitioners; socialconstruction of localisedpossibilities.

Fig. 2. The contingency model.

C. May et al. / Social Science & Medicine 57 (2003) 697–710702

people who are particularly enthusiastic about

telemedicine. There’s no doubt at all that when you

have great enthusiasts doing something, they will

make it look better than when the average person has

to use the system. And the fact is that often the type

of patients enrolled in the studies has been selected to

a great degree, which is not always apparent from

what’s been published in the papers.

What is important about the field of ideation is that it

is formed primarily through discourse. This is an arena

where the possibilities for expansion and containment

are formed through ways of speaking strategically about

a technology, and where expectations are general, rather

than specific. At this level, telehealthcare can be shown

to be a valuable and persuasive means of service delivery

precisely because the problems of developing and

engineering systems hardware—and of re-engineering

the organisation of clinical practice—are placed in the

background. Because of this elision of health care

practice, complex alliances of policy makers, clinicians,

technical experts, and manufacturers can form around

persuasive possibilities. They act as policy entrepreneurs

(Miller & Garnsey, 2000), asserting that systems will

work and will be shown to work, and calling on

resources to develop and prove them in practice. The

triumphalism of ideational discourse is vital: it cements

heterogeneous groups of actors into alliances by the

promise of a common trajectory. However, there is

nothing monolithic about these alliances, and one of the

key features of the development of telehealthcare has

been its fragmentation and limited scale. Unlike the

major developments that take place around genomics, or

pharmaceutical developments, for example, there is no

large-scale sponsor at work here, and industrial

resources are profoundly limited. At the Parliamentary

Select Committee on Health session2 devoted to

telemedicine, for example, a succession of industry

representatives argued that (in the words of one of

them), ‘the time for research is over, these systems work

and we have shown that they work’. This is true, in the

sense that the hardware can be shown to function, but it

is equally clear that questions about the capacity of such

systems to deliver effective clinical services remain.

Mobilisation

The technocratic optimism inherent in discourses of

ideation begins to break down once members of its

component alliances and networks begin to translate

expectancies and plans into concrete activities. Eviden-

tial knowledge becomes crucially important here (cells

2.1 and 2.2.) offering a means of leverage—shifting

ideation towards practice—and a means of meeting

normative policy requirements related to the construc-

tion of the ‘evidence base’. Evidential knowledge serves

a stabilising purpose for ideational claims. But to build

these, specific communities of practice have to be

developed, and new actors enrolled into an emergent

field of technical development (cells 2.3 and 2.4), around

agreed notions of what facts are (Bartley et al., 1997).

Once again, the inherent conservatism and methodolo-

gical parsimony of HTA runs against modernising

impulses in health care systems development. A senior

clinician drew out this tension clearly:

TM2/S4/Consultant physician 1: I think there are

two points: not a lot of research has been done; but

also—the other one—it seems that the nature of

current telemedicine programmes will not alter this

dynamic very quickly. And, it always interests me

that as a medical profession we think we’re being

incited to practice evidence based clinical practice,

but when it comes to policy we have a policy of

rolling this out in five years, when perhaps since the

1997 publication things haven’t changed that drama-

tically.

This speaker represents clearly the collision between

HTA and modernising policy. HTA requires stable

knowledge production (cell 2.2) that accords to the

normative modes of clinical evidence—but modernising

policy (cell 2.1) is inherently unstable, driven by political

forces outside of the clinical arena and thus forcing its

way into health care practice at an organisational level

(Moran, 1999). A specialist consultant observed that

‘politics’, rather than ‘clinical need’ drove the develop-

ment of telehealthcare as a field:

TM2/S4/Consultant physician 1: As far as [tele-

specialism] is concerned, I am firmly of the belief that

it will be part of the way that we practice [specialism].

I can’t see it going away. I think that we in

[specialism] should be willing to work with the people

who are developing these technologies, because y

they are not going to stop doing it. They are just

going to go ahead regardless and we should be able

to shape the service that’s provided.

The ‘politics’ here relate to a good deal more than the

organisation of health care delivery. The notion of

politics reflects the constitution of forms of professional

engagement that actively shape the form and direction

of telehealthcare systems as they are drawn into practice.

This engagement itself comes about through the

emergence and solidification of alliances between

specific groups of clinicians (often organised around

clinical specialties) and non-clinical proponents of

telemedical services (cells 2.3 and 2.4). In this context,

ARTICLE IN PRESS

2Portcullis House, Palace of Westminster, London, 26 April

2001.


ideas about evaluation are formed at a contingent point

where resistance to telemedicine can be framed. One

specialist asserted that:

TM1/S3/Consultant Dermatologist 1: [I]f it works,

that’s great. If it doesn’t, you’ve got the evidence

that it’s no good. But that’s what you need—you

can’t just go to the health authority and say, ‘‘sorry,

we’re not going to do [tele-specialism] because

it’s no good’’. They’re just going to say, ‘‘how do

you know that?’’ And, we can say we’ve done the

study and 90% of the patients thought it was terrible

y personally, I think it’s probably going to be

useful, but what we’re trying to do is set the

parameters—set the limits as to what it should be

used for.

The actors enrolled into the emergent communities of

practice around telemedicine development are not,

therefore, exclusively ideational entrepreneurs. They

include sceptics, and so evaluation becomes one of the

sites on which contests about expansion and contain-

ment are worked out (May & Ellis, 2001). There is thus a

powerful tension between the activities and alliances that

appear in cells 2.3 and 2.4, even though their occupants

may sometimes overlap.

At the level of mobilisation, ‘uncommitted’ out-

siders—the service class of HTA—begin to enter the

field and circulate within the alliances that have emerged

at the level of ideation. In using the term ‘uncommitted’

we mean only that these actors are neither technology

entrepreneurs nor clinical proponents of telehealthcare.

Instead, we are pointing the wide array of actors upon

whose methodological skills the whole enterprise of

HTA depends. Crucially these are the technical experts

(statisticians, trialists, economists, psychologists and

sociologists), whose expertise is harnessed in the ‘field’

of health services research (Pilgrim & May, 1998). Their

‘commitment’ is to the ‘trial’, rather than the ‘technol-

ogy’. Later, of course, ‘uncommitted’ insiders become

important, when a wide range of (sometimes sceptical)

clinicians and managers are called upon to actualise

and accommodate the evaluation protocol translated

into practice. A statistician involved in the evaluation of

one of the telemedicine services that we examined

observed that the funding decision for his project

depended on the presence of these uncommitted out-

siders.

TM2/S4/Statistician 1: I think that’s probably one of

the reasons why it got funded—HTA is a multi-

disciplinary programme and basically [they] want to

give money to people who can prove that they can do

it [evaluate telemedicine] or have got the panel of

medical statisticians, health economists, public health

physicians, clinicians, nurses, GPs all on board. I

think we must have managed to sell them that from

the start.

The assumption here is that telemedicine is a

treatment modality rather than a way of organising

service delivery: the kind of group that is described here

is typical of any HTA project, but crucially technologists

and systems experts are already largely excluded from

the kinds of groups that are incorporated within this

specific field of HTA. The business of understanding and

evaluating telemedicine thus becomes thoroughly med-

icalised at the point of tension between cells 2.1 and 2.2.

Indeed, the kinds of evidential knowledge that are

proposed within this domain of practice are alien to the

technologists, even though they often remain enthusias-

tically involved in developing the ‘system’. But this is not

always the case, we have observed signal disagreements

between developers and manufacturers, and clinical

evaluators about whose knowledge ‘counts’ in ‘proving’

the hardware and its fitness for clinical practice (May &

Ellis, 2001). Such disputes can be bitter. For example, in

an exchange of correspondence with a funding agency

one technical expert argued that:

TM1/S2/Technical expert 5: Although we accept

[name] as having some clinical experience in clinical

research matters, we do not accept that this involves

technical expertise in the field. The technical team are

quite willing to accept external guidance ðyÞ but

only if that person is suitably qualified and experi-

enced in the field ðyÞ A technical co-ordinator

cannot present such people with a technical appraisal

from a technically unqualified medical practitioner

and expect them to accept it.

The division of authority and expertise in telemedicine

trials thus rests on the epistemological authority of

medical not technical research, and subordinates other

forms of knowledge and practice. This division consti-

tutes a powerful discursive position in the conduct of

telemedicine development, quite unlike other fields of

explicitly biomedical research, where the technical is

integral—for example, in genomics or pharmaceuticals

(Rappert & Brown, 2000).

The long timescale of the clinical trial, and so the

extent to which—as one manufacturer told us, ‘you

researchers are inhibiting the development of telemedi-

cine and the prosperity of the industry as a whole’—is

also a point of contention. We can see why they might

take this view when we consider the conventional

methodology of HTA. Central to the thrust of HTA is

the RCT, the ‘gold standard’ vehicle through which the

efficacy and utility of clinical interventions can be

normatively ‘proved’ (Tanenbaum, 1994). Even non-

randomised ‘service’ evaluations can take many months

from inception to the publication of results. The


extended temporal structure of the ‘trial’ fits badly with

the interests of outsiders to HTA, especially the

manufacturers and the policy modernisers, who seek to

champion systems over much shorter timescales, and to

penetrate the institutional contexts in which telemedi-

cine is expected to be located relatively rapidly. The

selective enrollment of actors into communities of

practice (cell 2.3) and the emergence of practitioner

communities (cell 2.4.) differentiates, then, between

those who produce particular kinds of normative

general knowledge, and those who enact telemedicine

in specific instances of health care practice. This

emphasis on quantitative knowledge derived from

processes that emulate the biomedical sciences is, as we

shall see, a problem for actors further down the line. In

short, the definitions of knowledge that count are

thoroughly medicalised, as networks and alliances

around telemedicine development shift their attention

towards proving a technology for practice.

The desired product of the alliances and networks that

emerge at the level of mobilisation is rarely a working

telemedicine system. Instead, it tends to be a document

or series of documents that are literally intended to

translate the generalised expectancies that appear in

ideational discourse into concrete practices. These

documents—study protocols—also set out possibilities,

but their emphasis is on trial design, and the status and

stability of the service and the technology, that are to be

tested are assumed. Throughout our work we have seen

that the objectives of the networks to be found in the

tension between cells 2.2 and 2.3 is the reproduction of a

model of practice that assumes that contingency does

not reside in the usability of the telehealthcare system

itself, or in the ease to which it may be applied to clinical

practice.

Clinical specification

So far, we have shown how actors and alliances that

operate at the level of ideation engender a set of

discourses that set out the possibilities for a technology,

and that are configured through technocratic optimism.

Following from this is mobilisation work that configures

these possibilities in relation to concrete practices of

knowledge production and service delivery. This is not

always systematic, but is sometimes opportunistic.

Where ideation is optimistic, mobilisation mixes belief

and scepticism. Crucially, the product of mobilisation is

the medicalisation of ideas about appropriate and

reliable knowledge, and the formation of alliances that

include ‘uncommitted’ outsiders. But at the level of the

implementation of a specific technology (cell 3.1) and the

application of a formal evaluation protocol (cell 3.2)

their activities become both focused and concrete.

Contention at the level of specific technologies is about

demonstrating reliability and eliminating contingency,

as well as defining and implementing systems of practice

that seem to ‘work’. The relationship between the

‘hardware’ and its associated clinical practices, and the

technology of evaluation, its protocol, and associated

practices of data collection and collation becomes the

point of contention within and between component

groups within practitioner communities. We find this

evinced in attempts to place constraints on the dynamic

instabilities of clinical practice (cell 3.3), for example, by

securing the recruitment of particular kinds of patient or

practitioner into a clinical trial, and in attempts to reify

the possibilities of a technology set out at earlier points

in the process by organising resources and reengineering

service delivery. Recognising this is itself a contingent

point:

TM1/S1/General practitioner 6: Whether they’ll

[specialists] cope with it themselves really. They are

used to traditional consultations where face-to-face

contact is important. You know, the body lan-

guage—the things that you pick up by being in the

room with them. ðyÞ I think that the clinical risks

are that it might frighten the patient really—that

they’re vulnerable and that they might feel thaty:It’s how to ensure that the patient is happy with the

consultation and do we—as GPs—have to check [on]

them really? You know—if you refer somebody to [a

specialist] they [the specialist] might say, ‘‘well,

I’ll see you [the patient] in two weeks’’. And you

feel satisfied that all has been done, whereas this

may leave the patient feeling a bit confused and

[feeling] that, ‘‘I didn’t talk to the doctor in the first

place’’.

Where complexity has previously been seen by our

respondents to reside in the production of a trial

protocol (in designing sampling and randomisation,

and defining procedures for statistical data analysis,

for example), or in the manufacture of a system that

works—at the level of specific application complexity

resides in integrating the operation of hardware, the

organisation of service, and the conduct of the evalua-

tion. Our interviews reveal the extraordinary effort

invested in standardising equipment and procedures,

organising recruitment, and developing recording prac-

tices that can make sense of the instabilities of service

delivery. Much of this work is directed at restructuring

existing clinical practices, and with this comes unpre-

dictable work around accommodating systems of

practice that are often alien to their users (Mort et al.,

2002). The difficulty here arises from the extent to which

the protocol is often assumed to be the stable ‘truth’ of a

sequence of activities and events—and work that takes

place around it is directed at trying to eliminate

contingency, and most importantly stabilise interpreta-

tion. For example, in an interview one ‘uncommitted

ARTICLE IN PRESSC. May et al. / Social Science & Medicine 57 (2003) 697–710 705

outsider’ working to develop an RCT in clinical practice

remarked:

TM2/S3/Non-clinical Researcher: The issue is the

nurses. They are already worried that their profes-

sional discretion about who to admit is threatened by

this. They can use the question of ‘safety’ to subvert

recruitment into the trial. It’s hard to see how this

can be stopped.

But a later email from this researcher shows this

issue of ‘subversion’ to have multiple points of deriva-

tion:

TM2/S3/Non-clinical Researcher: Some research

politics; Nurses have expressed concern this week

that we may show they’re not ‘cost-effective’ by the

research. Some more general concerns about [name

of service] itself have also been uncovered: for

example, that the criteria for acceptance of patients

by the [name of service] have become ‘relaxed’ over

time—pressure to take patients who are more ‘ill’

than before. Service not seen as sufficiently estab-

lished/proven to undergo close scrutiny or exposure

to the modification on which the trial is predicated.

Nurses’ (and patient safety) ‘on the line’. At the

same time there’s been development of specialist

nurses at [hospital] for other [type of disease]

conditions—with inevitable overlap with (and possi-

ble threat to) role of [name of service] nurses. The

study in this context becomes something of a match

for dry tinder!

There is a struggle here, and it is organised around the

work that needs to be done to accommodate and

integrate (a) a new system of delivering care; (b) its

evaluation; and (c) existing patterns of service delivery,

and the professional identities and roles that are

integral to it. The mode of contention that is worked

out in this struggle is defined in cells 3.3 and 3.4.

Crucially, evaluation involves at least some profes-

sionals surrendering their clinical discretion and auto-

nomy.

TM2/S1/Nurse: I think non-medical people don’t

appreciate the problems you are going to have really.

They think the nurse can just sit there and do what

they have to do but it’s not the same when you are

actually with somebody. And they’re worried, if it’s a

lesion, they’re worried what it is. For some people to

wait two weeks is an awful long time if [the symptom

is worrying]. They might say ‘‘what am I going to do

until I hear?’’ That’s going to be quite a difficult one

for us really.

In this instance, and in others that we have observed,

the ‘non-medical people’ are often seen by their clinical

collaborators to fail to understand the obligations

inherent in clinical practice—the immediate demands

of dealing with the ill person. Here, the ‘protocol’ is an

abstract entity that works to govern conduct, but which

may also alienate the practitioner from the patient. This

is especially the case where the patient’s identity is

reformulated as that of an experimental subject,

randomly selected for entry into a trial. The clinical

director of a study, speaking about one of his physicians,

emphasised the impact of randomisation on clinical

discretion:

TM2/S2/Consultant 2: Yes, he [TM2/S2/Consul-

tant1] won’t be able to get out of it, he’ll just say I

don’t want to telemedicine this, they’re a very

[problematic case] blah blah blah, and I’ll say we’re

going to have to (y) well, do your best, on this

occasion I overrule you.

Randomisation, by virtue of its impersonal quantita-

tive logic, runs entirely counter to the deeply sedimented

notion of personal moral responsibility upon which, as

Jacob (1999) has observed, ideas about professional

identity in health care. Personal responsibility and

discretion can be mobilised explicitly to undercut

attempts to develop new systems of working—as the

interview extract above suggests. But it also constitutes

an implicit undercurrent of insecurity and instability

across the whole field of interaction between profes-

sionals, new technologies, and their evaluation. It is not

simply that the logic of impersonal randomisation

alienates professionals from practice; it also interrupts

stable patterns of work organisation and service

delivery. And, of course, it generates an additional

clinical load for practitioners:

Interviewer: Did it use more of your time than if you

had just seen a patient normally in clinic?

TM1/S1/Consultant Dermatologist: Oh, without a

doubt, because we set up separate clinics. It was, in

effect, an extra clinic that was taking place, so yes it

did but ½y� it was good because it then ended up

being, ideally we wanted the doctor who was

referring to see them. I think, on the whole, they

didn’t have a problem because the way we slotted it

in, we could tell them a time and they could typically

book out a session but it typically took about twenty

minutes and a normal consultation is ten minutes, so

yes, by that very nature it would take that. But one

would hope that, and I think what happened is that

you also then had a more complete solution, so

patients (and we didn’t do any work on this, but

often that’s the only problem) would probably come

back less often.

We can construe both the ‘hardware’ and the trial

design as intervening technologies. Both act to specify

and construct particular versions of adequate knowl-

edge, but both exert alienating forces on the social

identities of both professional and patient. The


telemedicine hardware, for example, separates the

patient from professional in time and space and

demands the intervention of proxies to organise and

manage their interaction. The trial protocol assigns an

abstract identity to actors, eliminating their specific

identity and reifying them as objects of externally

imposed procedures. Professionals and patients are

reconstituted in these procedures: for the normative

resources of knowledge production in evaluation are

quite different from those that are typically applied in

clinical practice. So, the definition and reification of

possibilities located in cell 3.4, is one that engages the

potential for resistance as well as promotion of a new

technology in practice.

Specific application

The construction of the trial protocol and its

integration with clinical service provision involve com-

plex negotiations about the application of procedures

that form both knowledge production and clinical

practice (cells 4.1—4.4). Accommodating these fields of

practice becomes both routine and highly problematic

here. First, the integration of new hardware and clinical

practice has to be accomplished in a relatively complete

way (cell 4.1); and second practices that meet the

normative demands of external adjudicators (cell 4.2)—

where the protocol is followed, and an abstract plan is

translated into concrete data collection (Mort et al.,

2002). We have already noted the importance of

suppressing professional discretion, and this is evinced

in the shift—at this level—to eliminating interpretive

flexibility and interactional contingency (cell 4.3). We

can see this in a manager’s account of the need for

‘structure’.

TM2/S3/Nurse manager 1: She’s very much going to

have to follow a very structured way of dealing with

the patient, because otherwise it could take two hours

a consult because of patients asking questions all the

time. Yes you encourage them to ask, so [they are

given the opportunity to ask] questions at this point

[but] then the nurse goes through the whole

procedure. But she will also have to explain to the

patient that ‘‘the questions I ask you are the ones that

I need you to answer, we can’t veer off that, you can

ask me some more afterwards but we need to get

those out of the way, these are the ones we need for

the doctors to make the diagnosis at the other end’’.

But they are going to be restricted to some degree in

terms of time because we can’t afford obviously a

couple of hours per patient.

To secure that standardisation of activities on which a

trial rests, it is necessary to place restrictions on the

creative modification of systems in play, and to keep to

the abstract plan set out in the protocol. While this is

intended to frame standardised and generalisable

products of clinical evaluation and practice, in practice

it is hard to achieve. To this end, a new, more rigidly

defined structure of professional work3 has to be drawn

up that places boundaries on creative resolution of

problems, and to constrain professional discretion. One

service manager told us that:

(TM1/S3/manager 1): [My role includes] developing

protocols to support the nurses in [location], to make

sure that they’re not doing anything they shouldn’t

be doing and that they’re not covered to do,

developing the operational policy ðyÞ And defining

the nurse’s role—a sort of temporary job description

if you like, just so that everybody knows exactly

where they fit in. We don’t want nurses dropping

themselves in it really in terms of going beyond what

they should be doing. ðyÞ In terms of the

operational policy we have to define that very rigidly,

this is what you tell them, you both tell them exactly

the same, if [the back-up nurse] steps in. So

information sent to patients before will be (a) (b) &

(c), information given to patient after appointment

will be (d) (e), following up will be, etc. You’ve got to

spell it out like that.

Restructuring, and fixing in place, professional

discretion and the material practices that stem from it

is the key problem across cells 4.1–4.3. Evaluation relies,

as we have noted, on the elimination of contingency,

while clinical practice itself—even in its most routine

forms—is characterised by contingency and the creative

resolution of the problems that this generates. Indeter-

minacy is a central characteristic of professional work in

health care, and maintaining indeterminacy is a resource

on which professionals can draw in negotiating, resisting

and transforming the field of practice that is set out by

the trial. Evaluation is not, then, simply the production

of a body of disinterested knowledge about the

application of a new technology to clinical practice. It

is also a field of contest about the potential for

integration into existing models of practice. In this

context, ‘evaluation’ and ‘practice’ are in an uneasy

tension with each other between each of the cells in our

model.

The purpose of evaluation is to produce determinate

and reliable knowledge that leads to generalisable

results—this is especially the case in the enactment of

formal techniques like the RCT. In this context, a

ARTICLE IN PRESS

3Our own work, and that of others, suggests the difficulties

involved in ‘reengineering’ the form of interaction between

clinicians and their patients. The clinical encounter takes a

different form when technological intermediaries come into

play (Lehoux, Sicotte, Denis, Berg, & Lacroix, 2002; Harrison,

Clayton, & Wallace, 1998; MacFarlane, Harrison, & Wallace,

2001).


‘successful’ trial suggests the potential to normalise the

technology in play, and so to constitute it as an

unremarkable possibility for clinical practice (cell 4.4).

We emphasise that the issue here is the potential for

normalisation—exactly the point at which we began our

analysis with the optimistic and technocratic discourse

(apparent in cell 1.1) that forms the general field in

which the development of telehealthcare is framed. But

in our model, the possibilities for normalisation are

transformed by the business of evaluation, and by the

variant tensions and contests that emerge at each

contingent point on the map of networks, activities

and identities that we have described.

Conclusion

The starting point for our analysis has been that

telehealthcare offers an important and relevant focus for

understanding the social contexts and practices that

appear at the points of contact between evaluation and

new forms of service delivery. We have emphasised its

instability, for it is characterised by disagreements and

contests about utility and effectiveness not simply about

the combination and interaction of techniques and

technologies involved, but also about the most appro-

priate means to assess them. The role of evaluation in

this new and emerging field of practice is complex: it is

both a field of technical practice and a field of

contention.4 Our work reveals a series of problems of

integration and accommodation that are evinced within

this complex arrangement of fields and networks.

The fluidity and complexity of fields of practice in

which new technologies emerge, are understood, become

stabilised, and perhaps ultimately become normalised is

one of the defining features of literature in the field

(Webster, 2002). A variety of approaches to under-

standing them have been proposed, ranging from crude

causal models, but more recently mainly divided

between processual and structural models in studies of

technological innovation (Edwards, 2000), and studies

of constructive actor networks drawn from the sociology

of science and technology (Pinch, 1996; Mackenzie,

1998). In the former field, studies of technological

development, diffusion and adoption have convention-

ally focused primarily on the technology itself as in some

sense being the central unit of analysis. Our analysis is

closer to the latter, and suggests that evaluation is not

simply the arbiter of success that moves telemedicine

from one position to another in a linear process towards

adoption or diffusion, but rather a key technology in

itself. Our analysis therefore emphasises a key group of

actors who are neither champions, entrepreneurs, nor

potential users of telemedicine systems in practice—the

‘uncommitted outsiders’ who are charged with the

production and processing of legitimating knowledge

about ‘effectiveness’ and ‘utility’. The politics of

relations between these different groups are crucial to

the potential stability of telehealthcare as a field of

clinical practice and are expressed in the different

normative structures in which they work. We find,

therefore, technologies (‘owned’ by different alliances)

interacting within complex institutional settings. So

‘evaluation’ should not be seen as a politically neutral

set of disinterested research techniques, but rather as a

complex set of social practices that are themselves

generative of a product—reliable knowledge—that

provides (but does not guarantee) leverage towards

normalisation.

The contingency model provides a map for under-

standing both processes and structures and defining the

spread of networks. It also suggests an alternative unit of

analysis in studies of the development of new ICTs,

which are contingent relations themselves. Contingencies

have multiple points of derivation: some are drawn from

policy and practice environments others arise out of

agency exercised by specific actors or groups; many are

functions of non-human actors (the epistemological

authority of the RCT as a way of working; and the

lack of epistemological authority of the hardware

deployed in practice, are two examples). The precise

identity of the specific technology in play becomes less

important, of course, once we see the business of

telemedical development as a product of interactions

between technologies evincing different degrees of

attributed stability.

Our objective in this paper has been to employ

telemedicine as an exemplar, or vehicle, through which

to develop an explanatory model of evaluation—and

thus enable us to understand the complex set of social

relations, discourses and practices that are implicated in

the shift from ideation towards normalisation of a field

of ICT in health care. The contingent relations model

gives a degree of priority to the political contests that

take place around the stabilisation of knowledge and

practice in a field or domain of activity, rather than

focusing specifically on the supposed trajectory or

diffusion of a specific artefact. This leads us to suggest

that the model has generalisable utility in understanding

the wider field of HTA.

Acknowledgements

The study from which this paper is drawn is funded by

the UK Department of Health (Grant ICT/032), and we

ARTICLE IN PRESS

4A key contest, but one that does not appear here, is between

those who propose that RCTs are the appropriate way to

evaluate clinical informatics technologies, and those who argue

that they are not. Within the field of informatics, there is strong

resistance to RCTs (Kaplan, 2001; Heathfield, Pitty, & Hanka,

1998).

C. May et al. / Social Science & Medicine 57 (2003) 697–710708

have also drawn on work undertaken in a study funded

by the NHS North West R&D Directorate (Grant

RDO/12/20). This support is gratefully acknowledged.

None of our work could have been done without the

support and co-operation of respondents in these

studies: we thank them for their time and considerable

candour. Theresa Atkinson, Helen Doyle and Nikki

Shaw undertook some of the fieldwork on which the

present paper is based, and we acknowledge their

contribution to the paper in this regard; we thank

Mrs. Denise Mukadam for her administrative support of

our work, and Tiago Moreira, Derek Hibbert and

Christine May for their helpful comments on a draft of

this paper. This paper presents the views of the authors

and not of the UK Department of Health.

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