Personal Reflections On The Welsh Aspirin Group 2003 – 2008
Abstract
The Welsh Aspirin Group existed from 2003 to 2008 and consisted of an informal network of health service professionals and academics. The Welsh Aspirin Group might be considered to be an interest group and it has delivered a number of products, including a conference and a survey of aspirin taking in patients at high risk of experiencing a vascular event. Although interest groups sometimes work through lobbying and direct action, the Welsh Aspirin Group had a strategy of positive engagement with the Welsh Assembly Government. This has led to an ongoing dialogue with the Welsh Assembly Government about the public health potential of aspirin. The wider lessons of this work include the potential value of the ‘contingency theory’ for interest groups and also the importance of inter-personal dynamics. Leadership qualities, such as reflective practice and collaborative working, are also discussed.
Aspirin is an easily obtainable and inexpensive medicine that is widely used to treat a number of conditions. The medicine was first synthesized in 1899 by Bayer Pharmaceuticals in Germany (1) and mass produced under the commercial name of aspirin. In 1974, the first randomised controlled trial on aspirin and vascular events was published by Professor Peter Elwood and colleagues from the United Kingdom Medical Research Council (2).
Today, aspirin is widely used in low-doses of 75-150 mg per day to reduce the risk of vascular events by about 30% (3). There is also suggestive evidence that the medicine might reduce the risk of developing cancer (4), however, the exploitation of the public health potential of aspirin in the population is limited by undesirable effects. These effects include stomach irritation and bleeding which can occasionally be serious or even fatal in rare cases (5).
The Welsh Aspirin Group
Wales is one of the constituent countries of the United Kingdom and it has a population of about 2.9 million residents. Wales is the first and only country to date that has established a group with the specific aim of influencing policy to convert the public health potential of aspirin into a reality.
The Welsh Aspirin Group existed from 2003 to 2008 and consisted of an informal network of health service professionals and academics with an interest in the public health potential of the medicine. The aims of the Welsh Aspirin Group are shown below:
-
to collect, critique and organize aspirin literature
-
to debate and discuss aspirin research and policy
-
to stimulate and co-ordinate research projects of aspirin use
-
to disseminate information on aspirin and publish papers
-
to correspond with interested bodies from outside Wales
-
to influence aspirin health policy and practice in Wales
A number of antecedent events, including several papers on the public health potential of aspirin (67), led me to form the Welsh Aspirin Group and also take on the role of Secretary. Also of relevance is that one of the antecedent papers involved collaboration with Professor Elwood who agreed to be the Welsh Aspirin Group Chairman.
Welsh Aspirin Group Products
The inaugural meeting of the Welsh Aspirin Group was held on September 23rd 2003 and there were two important matters discussed. The first was plans for a conference on the ‘Public Health Potential of Aspirin in Wales’ while the second matter was a survey of aspirin taking in patients at high risk of experiencing a vascular event. The conference, held on May 6th 2004, was well attended and launched by the Welsh Assembly Government Minister for Health (8). At the conference, the survey results were reported providing evidence of a 50% under-use of aspirin for vascular event prophylaxis in Wales (9).
As well as the conference and the survey, another original product of importance was published in 2005 in the British Medical Journal with the title ‘Aspirin for all over 50 years?’ (10). In this paper, evidence on the potential benefits of taking low-dose aspirin from 50 years of age was put forward. A counter argument (11) advised caution on the basis that the benefit versus risk balance of aspirin in older people had not yet been clearly established.
With other professionals, Welsh Aspirin Group members made a substantial, indeed essential, contribution to the proposal, planning and delivery of the Citizens' Jury which was held in Wales in October 2006 with a overarching title of 'My health : whose responsibility?'. A Citizens’ Jury is a pseudo-legal framework in which 16 community members selected at random from the general public receives and debates evidence in order to offer recommendations on policy matters. Out of the 16 jurors, 13 agreed that members of the public should be given the opportunity to make informed choices on whether to take aspirin (12).
The results of the Citizens’ Jury led to renewed correspondence and dialogue with the Welsh Assembly Government Minister for Health. Arising from this, the Chairman and Secretary met with the Chief Medical Officer for Wales in September 2007 to discuss the public health potential of aspirin. Following this positive meeting, a Welsh Aspirin Group consultation document titled ‘Converting the public health potential of aspirin into a reality in Wales’ was widely circulated across the country. This set out proposals grounded within the Welsh policy context, namely the possibility of using health service contracts (13) and locally sensitive strategies (14) to promote the appropriate use of aspirin across the country.
Although the response to the consultation was limited, those received did offer a basis for further discussion with the Chief Medical Officer for Wales at a follow up meeting in April 2008. The discussion about the public health potential of aspirin has subsequently continued with a senior staff member from the Office of the Chief Medical Officer for Wales. In an unrelated development, my own appointment to a Welsh Assembly Government post as national Project Manager for an older person programme during 2008 required my withdrawal from the Welsh Aspirin Group, due to potential conflict of interest. After five years of work, the Welsh Aspirin Group was disbanded in September 2008 but the active interest of some members continues.
Some of the final products of the Welsh Aspirin Group included an ethical commentary on aspects of aspirin use (15) and also how the medicine might contribute to cancer control programmes (16). These products are of relevance to the ongoing discussions with the Office of the Chief Medical Officer for Wales. So overall, the work of the Welsh Aspirin Group has provided a number of original contributions to the literature. Furthermore, the products might also be helpful to the ongoing development of a public health strategic framework by the Welsh Assembly Government.
Inter-Personal And Organisational Aspects Of The Welsh Aspirin Group
The products of the Welsh Aspirin Group were achieved with little funding and this owed much to the inter-personal aspects of the members who were all individually approached. The personal selection of individuals for the Welsh Aspirin Group was crucial since team cohesion (17) and harmony (18) is important. The selection may also have contributed to the avoidance, at least in part, of the second element of the 'Tuckman stages of group life'. The stages have been suggested as Forming, Storming, Norming and Performing (19). Although matters were debated, there were no disruptive inter-personal tensions between any Welsh Aspirin Group members. The Welsh Aspirin Group experience therefore raises questions over the circumstances in which the 'Tuckman stages of group life' applies.
In the 'contingency theory', there is no one optimum state for an organisation to exist or to make decisions and the best approach is the one that fits the circumstances (20). The structure of an organisation and the success it gains are dependent and contingent upon the nature of the tasks with which it is designed to deal. 'Contingency theory' therefore encompasses a broad literature concerning the contextual factors that influence the structure and management of organisations (21).
The 'contingency theory' does not seek universal principles that can be used for every situation but instead attempts to explain how one attribute or characteristic depends on another. So it may be likened to an IF-THEN matrix based on factors such as inter-personal aspects of the members and working style. The predominant working style of the Welsh Aspirin Group was that all arrangements were informal yet products were still delivered. This experience might suggest that the 'contingency theory' might be a helpful modus operandi to small and informal interest groups that have a flat management structure.
Fulfilling a range of team roles, such as those proposed Dr Meredith Belbin (Table 1), has also been suggested as being crucial for the effectiveness of a group (22). In the case of the Welsh Aspirin Group, individual members might not have completely fulfilled all team roles so my work as Secretary needed to be flexible and versatile, which to a certain extent gave me a leadership remit.
Leadership Reflections
Whilst recognizing the importance of authority and competence (23), it has also been suggested that leaders creatively move towards a difficult goal using a minimum specification involving a few simple flexible rules (24). In 2003, it was not clear how the Welsh Aspirin Group would progress yet no complex business plan or strategic document was prepared. My minimum specification was the 6 aims coupled to a collaborative approach with other Welsh Aspirin Group members.
Being knowledgeable about a topic (25) is perhaps a further key element of leadership and my contribution to the products of the Welsh Aspirin Group, based on my long standing interest, was essential. A related issue is capability, namely the extent to which individuals can adapt to change, generate new knowledge and continue to improve their performance (26). My increasing capabilities led to a constantly expanding range of products being delivered and this might be considered to be 'situated learning' (27).
Reflective practice has been suggested as a leadership quality (28) helpful 'for the development of personal knowledge or self-awareness' (29). In an analytical review of the process of reflection, 3 elements have been suggested, namely a trigger event followed by critical analysis and the subsequent development of new perspectives (30). All of the Welsh Aspirin Group products had the potential to be trigger events for critical analysis and new perspectives which was helpful to drive the work. Also of relevance is the associated self-awareness arising from reflection which further links with the concepts of emotional intelligence (31) and authentic leadership (32)
Leadership styles also include transformational leadership which inspires and motivates colleagues, whereas transactional leadership is based more on reinforcement and exchanges (33). My leadership approach to the Welsh Aspirin Group, however, perhaps extended the 'contingency theory' and might be termed 'situational leadership' (34). Also, my approach as Secretary always tried to take account of the wider public health and policy context in Wales. Such 'situational awareness' (35) helped the work by ensuring that the Welsh Aspirin Group was in harmony with health priorities and the local realities, which has been suggested as a key determinant of policy effectiveness (36)
My experience suggests that interest groups constituted on the basis of the 'contingency theory' need to be driven forward by a leader with a number of personal and professional qualities. Furthermore, working in collaboration has been suggested as a key element of public health leadership (37) and this sometimes requires working across professional disciplines. This might be termed as 'boundary spanning' (38) (Table 2) and my work as Secretary required working with cardiologists, health economists, statisticians, public health professionals, an epidemiologist and a paramedic.
Closing Remarks
It has been stated that ‘worldwide, aspirin used more widely and appropriately would avoid many deaths’ (39). In Wales, the products of the Welsh Aspirin Group might lead to original policy developments that compliment other public health initiatives. Figure 1 summarises how aspirin might further contribute to the prevention of chronic disease in the community.
Although interest groups sometimes work through lobbying and direct action, the Welsh Aspirin Group had a strategy of positive engagement with the Welsh Assembly Government. Whilst acknowledging that the Welsh Aspirin Group might have worked differently, the products and the ongoing discussion with the Welsh Assembly Government might not then have occurred. To quote Donald Berwick, the President of the USA Institute of Healthcare Improvement ‘Every system is perfectly designed to achieve the results it achieves’ (40). In the case of the Welsh Aspirin Group, it started as an outsider group and by working constructively with members of the Welsh Assembly Government, it appeared to have achieved insider status (41). Whilst noting the complexity and subdivisions of insider and outsider groups, Welsh Aspirin Group members continue to be in dialogue with Welsh Assembly Government officials on this matter of significant public health potential.
Table 1 : Nine Belbin types
Table 2 : Boundary Spanning Competencies
Figure 1 : Possible Role of Aspirin in Chronic Disease Prevention
