Prosthetists as Managers Trained and Prepared for Management Duties - Essay Example

Prosthetists as Managers trained and prepared for Management Duties Table of Content Serial Number and Page Number 0 Introduction 02 2.0 Executive Summary 04 3.0 The Griffith Report 07 3.1 Reforms 08 4.0 Analysis 12 4.1 Training 12 4.2 Motivation 17 4.3 Reasons why Clinicians should become Managers 19 5.0 Conclusion 20 6.0 Bibliography 22 7.0 Referencing Harvard Style 23 1.0 Introduction Future health and health care will be shaped by the needs of the people, people who seek the need for professional guidance and assistance in supporting and correcting their physical, mental, and moral equilibrium. With advancement of science and technology, medical science too will be influenced by technologies and innovation that as are beyond one's imagination. Analogically, the health care needs of the people will be very different from those that challenge present health care professionals today. In this changing and evolving landscape there is one constant, the medical professionals, who work across a multitude of disciplines delivering care to patients and improving the health of the needy. The skilled workforce will need to keep abreast of developments and hone their skills and abilities. Flexibility, innovativeness, and efficiency will be the key to present and future challenges. Amputation is a curse. It leads an individual to ineptness. Misfortunes in the form of accidents, atrocity and violence, war, and diseases are attributed to parts of a human body being amputated. This action deprives the affected individual from doing the normal chores of a healthy person. Prosthetics help such people who have had to face the blade of surgeons on the operation table. Fitting limb prosthesis can help improve their quality of life. Even though such individuals may not be able to perform their ablutions like a normal individual, a properly fitted prosthesis can restore an individual's ability to walk, grasp, and manipulate objects, resulting in greater independence. These unfortunate individuals can get back on the road to financial independence, as they have the ability to return to work and participate in recreational activities, develop a better body image and improve self esteem. The prosthetic team comprises medical experts and members from nursing, prosthetics, physiotherapy and occupational therapy. Each member has a unique role in helping persons with amputations (The Rehabilitation Centre, 2004). Since 1948, doctors have in some sense been involved in management. Medical Superintendents were doctors who combined their clinical works with permanent management posts. Many government authorities had doctors as Medical Officers of Health which are similar to the general managers in today's trusts (Harrison and Pollitt, 1994). Some became directors of clinical programmes by virtue of their seniority. Senior doctors in specialties such as pathology or radiology were required to manage various non-medical staff in their departments and to co-ordinate with other departments in dealing with their patients. Should more doctors, and more generally clinicians, be involved in management (Chapter2, The Medical Director Phenomenon, groups.csail.mit.edu) Also to inculcate more participation and devotion to duty, do prosthetists make good managers This paper takes a closer look at the pros and cons that could well help define the logic behind such a move. The prosthetic service is contracted out of the NHS and the retention of the contract is often down to how successful the local manager is in providing leadership and motivating the team. Thus, if prosthetics are trained and prepared for management duties, they could help streamline operations that benefit the organisation, both financially, and professionally. In 1984, under the chairmanship of Mr. Roy Griffiths, an inquiry team was set up to review the management setup within the National Health Service (NHS). The Inquiry Team's report made a series of recommendations. The Government accepted the Committee's proposals, which included the inquiry team's proposal on general management functions, and on involving clinicians in the management process. 2.0 Executive Summary There is a preconceived notion that doctors don't make good administrators. This view was perhaps true 5-10 years ago. This has changed drastically, as doctors today have successfully fitted into their dual role of an efficient clinician and administrator. Today, medical directors provide more than useful medical input to the long term direction of their trust, play significant roles in board decision-making process, and hold potentially powerful positions in their respective organisations. Corporate responsibilities are a part of their portfolio in the well being and financial health of their trust. Along with this statutory responsibility is a strong leadership role. The smooth functioning of the clinical services and ensuring that his /her organisation heads in the right direction are responsibilities bestowed on him/her. The medical director can assess and understand the happenings within the organisation and make appropriate recommendations to correct flaws. On the whole, the medical director will be able to influence, persuade, and convince his or her colleagues of the appropriate way to bring efficiency and profit to his/her organisation (Simpson J, Moving into Management, 1997). Many hospitals have embarked on an initiative to involve clinicians in management to improve the overall management of services in their hospitals. Can prosthetists too be trained to work as managers to bring more efficiency and profitability to their organization As mentioned a little earlier, the prosthetic team comprises medical experts and members from nursing, prosthetics, physiotherapy and occupational therapy. Each member of the team has his or her set of duties that they need to perform with conviction and interest to improve service. By having prosthetists trained and prepared for management roles, organizations may stand to benefit professionally and financially. Before proceeding to explore these possibilities, it is worthwhile to pause and retrace the duties of the prosthetic. In the words of Jenny Adams, a certified prosthetist-orthotist, "It doesn't get boring because you work with patients one at a time and each patient is different". He continues, "In O&P, we work with older people, kids, and all ages in between. For me a great day at work is a day that I fit a patient with something that I designed and it helps them to walk easier or be more functional." For the record, prosthetists perform the following tasks: Meet physicians, therapists and other members of the prosthetic team to understand a patients' rehabilitation plans Review prescriptions from physicians Examine patients to identify factors that could influence the fit of appliances Measure, take impressions, align, and fit orthoses and prostheses Design appliances to meet patients' needs Select materials and components and give specifications to technicians Adjust the appliances for comfort, alignment and appearance Counsel patients on how to use appliances Maintain and repair appliances Supervise orthotists/prosthetists assistants and technicians (Orthotists and Prosthetists, 2006) The Prosthetists are competent with the use of many hand tools and specialised machines in the fabrication of prosthetic devices. They make prostheses (artificial limbs), which are fitted to help rehabilitate individuals with disabilities. So challenging is this field that for every individual case, no two similarities are drawn. Prosthetists need to keep abreast of the latest developments in their field that include, new materials, techniques and controls to create an increasing demand for the numerous cases. They make prostheses from drawings, measurements and plaster casts using a variety of materials, such as thermosetting and thermoforming plastics, and leather. This calls for very high efficiency and knowledge. Thus, the service of highly trained and experienced personnel should be recommended to manage this department. What better than to have an experienced prosthetist manage the role of the manager There is therefore no doubt the importance of clinicians as managers for good management from a commercial business stance The reforms recommended by the Griffith report will help elucidate the statement whether prosthetists trained and prepared to become managers can fit in management (NHS Dumfries and Galloway Workforce Plan 2006, 2006). As doctors make most of the decisions for the commitment of resources within the hospitals, it can be concluded that control of costs must involve their co-operation (Griffith Report, DHHS 1983; Bruce and Hill, 1994). Doctors as managers can help break the barriers between professional groups and hierarchies, through the removal of distinction that doctors may have towards management (Dicken, et al., 1990). Clinicians Involvement in Management (CIM) can help clarify goals and objectives among members of the service provider (Walker and Morgan, 1996). Better budgetary control through improved planning with clinicians' co-operation (Heyssel et al., 1984; Walker and Morgan, 1996). Decentralise decision making process, leading to increased flexibility and faster response time (Dicken, et al., 1990). (Chapter2, The Medical Director Phenomenon, groups.csail.mit.edu) The dissertation also takes a look at The Defence Medical Education and Training Agency to understand what motivates clinicians to their duty. 3.0 The Griffith Report In 1983, an Inquiry Team under the chairmanship of Mr. Roy Griffiths was appointed to review likely management discrepancies within the National Health Service (NHS). After a detailed investigation, the inquiry team submitted a number of recommendations to plug some noticeable 'irritants' in the prevailing system. The report was sent to the Government for approval. The Government accepted the Committee's findings and approved the inquiry team's proposals. It wrote to Authority Chairpersons to present this proposal before a committee and canvass their opinions on the general management and on involving clinicians in the management process. The Committee held four public hearings. Prominent heads of medical associations, and the Secretary of State were involved in the hearing. The Committee found major discrepancies between Griffiths' report and the Secretary of State's view. The committee concluded that the Government introduces a substantive motion in the House, clearly stating its stand with regard to the report (Griffith's NHS management inquiry report, 1984). The period after the reforms announced by the government saw the emergence of 'Working for Patients'. The reforms began in earnest in 1988, following high levels of concern expressed about health service funding and its inadequacies. The Prime Minister announced a fundamental review of the NHS. The review took place quickly. The reviewing team comprised members of the Cabinet Committee that worked without public consultation and participation, a process followed by earlier Commissions. This turn-around attracted unprecedented levels of denunciation when the reforms were announced (Chapter 2- A Historical Background to the NHS, Bristol). 3.1 Reforms 1. The White Paper, 'Working for Patients' rejected models of privately funded healthcare, and instead proposed an 'internal market' in the NHS. Health authorities would purchase services from independent NHS trusts. GPs would be offered the option of becoming 'fund holders', enabling them to purchase most services on behalf of their patients, thereby creating an incentive towards a more efficient use of resources, and more attention to the services that patients, or 'consumers' needed. 2. 'Medical Audit' required in principle that all clinicians should participate in review and audit of their practices, and that a professionally led Audit Advisory Committee should support medical audit at the regional level. Each district should establish a District Medical Advisory Committee to plan and monitor a comprehensive programme of medical audit, led by an advisory committee chaired by a senior clinician. 3. The concept of NHS trusts, each self-governing, would be headed by a trust board whose chairman was appointed by the Secretary of State. The board would be responsible for the management of the hospital. It would be required to submit an annual report to the Secretary of State; to ensure that revenue matched outgoings, and to achieve the financial objectives that might, from time to time, be set by the Secretary of State. The trust, providing services, would derive its income from contracts with purchasers, notably local health authorities and general practitioner fund holders. 4. As reforms were introduced, local health authority staff, hospital managers and clinicians were required to exercise discretion in deciding how they should take effect at a local level. This is the subject of contention to this dissertation. 5. In May 1989 the NHS Policy Board was created with the Secretary of State as the Chairman. It was chaired by the Chief Executive of the NHS. The reason; focus on responsibilities on the one hand, and management or implementation on the other. 6. 'Trusts will remain accountable to purchasers for the delivery of care through NHS contracts. They will be held to account by the provider arm of the NHS Executive regional office for meeting their statutory financial duties. Monitoring of Trusts' financial duties and approval of annual and strategic business plans will be undertaken by the provider arm of regional offices following the approach developed by the former outposts ' 7. The structure of the NHS in England, 1991-96 (Table 4, Page 41, Chapter2- A Historical Background to the NHS). Secretary of State for Health Department of Health including the NHS Management Executive - Regional Health authorities- Special health authorities- NHSME outposts Regional Health authorities- Family health services authorities & District health authorities. Regional health authorities- GPs, dentists, opticians, pharmacists & GP fund holders District health authorities- Directly managed units & GP fund holders NHSME outposts- NHS trusts 8. The regions were remodelled, by the appointment of board of executive and non-executive directors. The chairman of the board and the five non-executive members, including a person connected to the local medical school, was appointed by the Secretary of State. The strategic role of the region, in setting performance criteria and ensuring that plans were achieved is highlighted. 9. DHAs were required to place contracts with local NHS trusts for the purchase of services required by resident population. These contracts were not legally binding; and could be termed as 'service agreements'. 'Extra-contractual' referrals made, to cater for those patients who needed special treatment; an operation or package of care not already provided for in a contract. These additional costs had to be met by the DHAs on an individual basis. 10. Prior to placing contracts, the DHA is expected to assess what local health needs are, and to develop, with the assistance of its public health team, a strategy for meeting them. 11. In October 1991 the Patient's Charter51 was published as part of a national policy initiative to define standards of service within public services. It set out a list of rights or guarantees of service for patients (Chapter 2- A Historical Background to the NHS, Bristol). An initiative towards further training and management is seen in the endeavour by BSR, a charity, since its inception in 1984. With the increase in patronage, the society's programme of activities has expanded and so too has the support team. Most of these changes were to enable the Society to respond better to members needs. To ensure high standard in managing and supporting staff, BSR responded to government employment legislation and developed policies by further appraisal, training and induction to its staff (BSR: Aims and Objectives, Annual Report 2001). 4.0 Analysis This section of the dissertation first takes a look at the commonalities between managers regarding, induction training and ongoing support, and areas managers who think they require training. In order to understand the common induction training and support required, the following case study gives ample proof of its necessity for both managers and area managers in line of duty. 4.1 Training Case Study No.1 Coming to terms with disability: Mothers' reactions to their child's diagnosis of cerebral Palsy: Parents of children with disabilities are prone to psychological distress during their child's diagnosis. A study to produce a qualitative account of a parent's experience and feelings of having their child diagnosed with cerebral palsy (CP) was undertaken. In order to complete this study, interviews were held with the mothers of those, whose children were affected by CP. The interviews were then analysed using interpretative phenomenological analysis. The findings were quite perturbing. Mothers became anxious when their child began to have problems; at the time of birth, or more often during infancy. The dreaded diagnosis followed, fearing the worst, they were left shocked and dumbstruck on hearing their worst imagination. Stress in the form of diagnosis, the fear by new medical information, continuous appointments, coming to terms with the loss of their lifestyle, the uncertain future of their child, and frustrations at lack of support from disability services keep them on tender hooks and depressed. This is where managers and area managers need to bring in their expertise to mitigate a mother's mental agony. Psychology plays an important part in rehabilitation. They must be able to console the mothers and make them aware of the adjustments and accept their child's disability. They can put in place appropriate practical coping strategies; educate the mothers on corrective therapy and support for their child. This will help the mothers to move forward and come to terms their child's condition (Proceedings of the British Psychological Society, 2006). Case Study No.2 The war in Iraq has seen soldiers being put to extreme physical and mental torture. Soldiers have been targeted by human bombers who have successfully managed to pierce through the tight security cordon and blown themselves up, in the process, killing and mutilating soldiers and innocent civilians. However, the army has to an extent been able to manage and minimise fatalities. Body armor, used to protect the upper-body, have minimised deaths, but at the expense of severe injuries to the proximal upper extremities. The record reads thus: Twenty-six above-elbow amputations, including three shoulder disarticulations, have been performed. Even the torso-protecting body armor has not been able to protect the axilla, which remains vulnerable. Sensing this, a physician assistant and a surgeon from a forward surgical team invented a device to cover the axilla and upper arm. Test performed on it proved to be a success, and the army ordered 50,000 of these to be sent to Iraq (Beyond the Purple-Heart-Continuity of Care for the Wounded in Iraq, Peake J.B, 2005). By November 2004, the cumulative figure of U.S soldiers injured and underwent major amputation in Iraq and Afghanistan was 203. Sadly, this figure continues to grow by the day. The U.S. military has sought the paramilitary medical team's assistance to stress for continuity of care, and revive and return each soldier to their highest possible level of functioning. This approach includes far more than the use of computer-assisted prostheses, custom-built hip sockets, and multiple types of limbs. It involves a lot of personal attention and care. It's a job for the highest personnel on board. This is the time when their management qualities are put to test. Prosthetists must learn to be managers. They should be respected and be heard. Here, it's not just the physical attributes of a soldier that needs to be set right, but the emotional effects of war and wounds must be tended to as well. Psychological barriers need to be broken, the behavioral health components of care is the key (Peake J.B, 2005). Summary: We saw in case study No.1 that, the mothers of cerebral palsy children were subjected to great mental stress and strain, the same is the case with the families of the soldiers, who were amputated. Counseling is an integral part of rehabilitation, and this service must be administered to not just the victims, but to their near ones as well. The families of these soldiers also require support as they begin to participate in rehabilitation (Beyond the Purple-Heart-Continuity of Care for the Wounded in Iraq, Peake J.B, 2005). Considerable work was undertaken during 2004 and 2005 to develop the new Ministry of Defence Hospital Units (MDHU) Concept. This period saw the culmination of the implementation of a new concept and formalisation of the new contractual arrangements with NHS and the Department of Health. The implementation of these arrangements has had two key components: the introduction of a revised C2 structure at all MDHU with the appointment of full time Commanding Officers to manage the MDHU, and establishment of Military Clinical Directors for Clinical Outputs, medical training and development, supported by senior Nursing Officers (Officers Commanding Nursing) The second component has been the introduction of new business relationships with NHS. DMETA in its first year as an Agency, with its current arrangements with NHS Trusts for the placement of clinical staff, was not meeting the business needs of DMETA, the aspirations of its clinical staff or, indeed, those of its NHS partners. In addition the forecast growth, most noticeable in Nursing and Consultation, but also affecting other specialties and trades could not be accommodated within the existing arrangements. In order to address these problems a review was undertaken resulting in the MDHU Concept Paper3. As a consequence of the review, a great deal of work was done to rewrite the NHS Circular, which has now been agreed and published by the DoH, as NHS Guidance. The new arrangements formally introduce the concept of clearly defined Military Protected Time (MPT) and Trust Protected Time (TPT). The continued growth in DMS Consultants and the demands of increasing sub-specialisation has led to the number of consultant placements outside of MDHU increasing (Sustaining Military Secondary Care Capability, DMETA Annual Report 2004-05, Page 23, 2005). Improving health, and the delivery and effectiveness of social care services is dependent on the support and active engagement of all doctors, irrespective of their seniority, not only in their practice but also in their managerial and leadership roles. Whilst not always recognised, doctors and clinicians need to perform managerial functions to upgrade their services and facilities. A number of studies e.g. Firth-Cozens and Mowbray (2001), Shortell (1998), McNulty and Ferlie (2002), Ham (2003), Spurgeon (2001) and Dowton (2004) have highlighted the positive link between effective clinical leadership and improved patient care. Doctors and clinicians can make very good administrators as well in their respective field. The Griffith report emphasised the importance of clinicians being thrust with more responsibilities. They are very knowledgeable and can negotiate on behalf of the management on technicalities and purchase (Clark J & Morgan D.G, Improving the Effectiveness of Health Services: The Importance of Generating Greater Medical Engagement in Leadership, 2006). Modern health care is becoming increasingly complex. Doctors and clinicians need to be highly skilled and extremely competent to deliver high quality clinical care whilst working as part of a multidisciplinary team in an organisation. Periodic medical training designed to help them deliver safe and effective care, is paramount to the establishment's success. Such training focuses on clinical skills, but with the focus shifting to team-work, delivered within a managed system, it becomes increasingly important for doctors to, not only become competent clinicians, but also to function efficiently and effectively within the complex health care system. To be competent, clinicians and doctors must be able to manage themselves and their time, work within a team, be able to set an example to others, and be able to mark their influence on management decisions. Management skills to improve on prevailing practices in wards, OPD, operation theatres, and managerial qualities in negotiations with vendors, implementation of government gazettes, will serve to streamline operations and increase the exchequer. CCST is the basic qualification required by doctors to apply for a consultant post. The primary focus of this training is on organisational skills needed to manage a clinical firm. However, clinicians must inculcate the importance on upgrading of leadership and managerial skills from time to time (Clark J & Morgan D.G, 2006). 4.2 Motivation: Ham (2003) draws on an evaluation by Browns and McNulty (1999): "Significant changes in clinical domains cannot be achieved without the cooperation and support of clinicians; their support is associated with process redesign that reverberates with clinical agendas related to patient care, services development and professional development. To a large degree, interesting doctors in re-engineering involves persuasion that is often informal, one consultant at a time, and interactive over time.clinical commitment to change, ownership of change and support for a change constantly need to be checked, reinforced and worked upon". Dowton (2004) contends that the nature of the profession of medicine has changed over the years. He identifies a number of external influences that have now altered doctors' autonomy and the hierarchies within which they practice. Greater accountability for the safety of patients, quality and efficacy of healthcare, and public access to medical information has made the profession more challenging. Leadership roles are seen as being more critical, attention is paid to developing individual leaders and new models of leadership within the medical profession (Clark J & Morgan D.G, Improving the Effectiveness of Health Services: The Importance of Generating Greater Medical Engagement in Leadership, 2006). In the UK, many of the medical professional regulatory and training organisations are attempting to develop fresh paradigms that would lead to new models of medical management and leadership within the NHS. The Griffith Report also gave many clinicians and doctors the opportunity to enhance their reputation by being more 'extrovert'. Replacing 'consensus management' by general management' lent credence for equal growth opportunities. 4.3 Reasons why Clinicians should become managers: In practice, districts were under enormous time pressure to complete annual contracting rounds. Health authorities had problems with the lack of medical information required to do proper assessments. This hampered efficient and positive results. It was necessary to reconcile results of needs assessments with spending budgets to produce a set of actual purchasing priorities. Although a needs assessment revealed a "need" for medical care and treatment, it did not reveal anything about how one particular need should be met in preference to another.' The 'internal market' was slow. The information needed to compare services and their costs often did not exist. If it did, it was in the hands of the providers rather than the purchasers, and many services were not readily amenable to 'competition' from alternative providers. The Griffith Report recommended the appointment of general managers for planning, implementing, and controlling centre performances. This system could clarify responsibilities for carrying out policies, for providing better leadership and for enhancing the motivation of the staff. This then could be entrusted to only qualified clinicians. The recommendation for the development of management for budgeting at the hospital unit level could also be done only by a person who was well-informed or practitioner. Clinicians too could handle financial budgets and resource allocations, as they were well aware of the system they worked in. This would be directly related to clinical workload (Chapter2, The Medical Director Phenomenon, groups.csail.mit.edu). 5.0 Conclusion Since the beginning of the NHS in 1948, doctors were involved in management. Medical Superintendents and Medical Officers of Health performed the duties of a doctor and handled management. Then there were those, who by virtue of their specialties managed various non-medical staff in their departments as well as coordinated with other departments in dealing with their patients. Good health and social care services are dependent on the support and active engagement of all doctors, irrespective of their seniority. Whether recognised or not, doctors and clinicians have to perform managerial functions to upgrade their services and facilities from time-to-time. The Griffith Report urged the involvement of doctors in management and budgeting. This, Griffith termed, as 'natural managers'. Health authorities had problems with the lack of medical information required to do proper assessments. This hampered efficient and positive results. The Griffith Report also gave many clinicians and doctors the opportunity to enhance their reputation by being more 'extrovert'. Replacing 'consensus management' by general management' lent credence for equal growth opportunities (Chapter2, The Medical Director Phenomenon, groups.csail.mit.edu) 6.0 Bibliography 1. The Rehabilitation Centre, http://www.ottawahospital.on.ca/rehabcentre/servicesclinics/pando-e.asp 2004 2. James B. Peake, Beyond the Purple Heart-Continuity of Care for the Wounded in Iraq, The New England Journal of Medicine, http://content.nejm.org/cgi/content/full/352/3/219, 2005. 3. Dr. Jenny Simpson, Moving into Management, Career Focus, http://bmj.bmjjournals.com/cgi/content/full/314/7080/S2-7080, 1997 4. BSR: Aims and Objectives, www.rheumatology.org.uk/publications/annualreport/annualreport 2001. 5. Griffith's management inquiry report, BOPCRIS, http://www.bopcris.ac.uk/bopall/ref21676.html 1984. 6. Orthotists and Prosthetists, http://www3.ccps.virginia.edu/career_prospects/briefs/pdfVersions/Orthotists.pdf 2006. 7. NHS Dumfries and Galloway Workforce Plan 2006, http://www.nhsdg.scot.nhs.uk/dumfries/files/Final%20Workforce%20Plan%202006%20with%20appendices.pdf 2006 8. DMETA, Annual Report 2004-05, Defence Medical Education and Training Agency, http://www.mod.uk/NR/rdonlyres/D78EA9FC-5F0B-4D8F-A2A3-DB40CFB663D6/0/dmeta_ara_04_05.pdf 2005. 9. John Clark & Dame Gillian Morgan, Improving the Effectiveness of Health Services, www.institute.nhs.uk/NR/rdonlyres/8FD5327E-C9ED-4379-8A7E-481F6B8D30E1/0/MedicalLeadershipReport11thMay.doc 2006 10. Chapter 2- A Historical Background to the NHS, http://www.bristol-inquiry.org.uk/final_report/chapter_2_.pdf 11. Proceedings of the British Psychological Society, Volume 14 No 1 _ February 2006, Coming to terms with disability: Mothers' reactions to their child's diagnosis of cerebral palsy Page 19, http://www.bps.org.uk/downloadfile.cfmfile_uuid=2F70C091-1143-DFD0-7EB0-EAA9CC86A0DA&ext=pdf 2006 12 Chapter2, The Medical Director Phenomenon, groups.csail.mit.edu/medg/people/lmui/MedicalDirectors/MD_thesis/Chap2_background.DOC 7.0 Referencing Harvard Style 1. Authorship unknown, BRI Inquiry Final Report (2004), Chapter 2- A Historical Background to the NHS, Bristol. Electronic Media 2. Career Prospects in Virginia (2006), Orthotists and Prosthetists, Virginia University. Print Media 3. DOC, Involving Doctors in Management, Document, UK Electronic Document 4. Authorship Unknown, Division of Health Psychology Annual Conference (2006), Coming to terms with disability: Mothers' reactions to their child's diagnosis of cerebral palsy, The British Psychological Society, ISSN 1350-472X. 5. Dr. Jenny Simpson (1997), Moving into Management, BMJ 7080 Volume 314: London, BMJ Journal. 6. HMSO (1984), Griffith's NHS management inquiry report: House of Commons, British Government Publications, London. 7. James B. Peake (2005), Beyond the Purple Heart-Continuity of Care for the Wounded in Iraq, The New England Journal of Medicine, Volume 352: 219-222, Journal 8. John Clark & Dame Gillian Morgan (2006), Improving the Effectiveness of Health Services, Institute for Innovation and Improvement, Research Paper 9. NHS Dumfries and Galloway (2006), Workforce Plan 2006, Scotland, Report 10. BSR President's Report (2001), Developing our Staff Team, Annual Report. 11. DMETA (2005), Sustaining Military Secondary Care Capability, Annual Report 2004-05 12. Prosthetics Services (2004), Who are the Members of Prosthetics Services Ottawa Hospital, Canada. Read More