Communicating Change in the NHS
A review of health communication campaigns,
media coverage of health care issues and
the process of public opinion and belief formation
David Miller* and Greg Philo#
August 1995
* Department of Film and Media Studies, Stirling University
# Glasgow Media Group
| Contents | Page Number |
| Summary | 1 |
| Introduction | 3 |
| Method | 3 |
| The Field of Health Communication | 4 |
| Determinants of Public Opinion and Belief | 6 |
| Media Coverage of Health Issues | 13 |
| Planning Communication Strategies | 23 |
| Policy, Professionals and the Media | 31 |
| Conclusions and Research Agenda | 32 |
| References | 36 |
Communicating Change in Acute Care:
A review of health communication campaigns, media coverage of health care issues and the process of public opinion and belief formation
David Miller and Greg Philo
Summary
This document reviews the current state of knowledge on the relationship between public opinion, the media and health care provision. The main findings are summarised below. A consequent research agenda is set out at the end of the document.
Public opinion and belief
· Support for socialised medicine appears to be a bedrock of public opinion.
· Opinion polls are limited in the complexity of the data they can supply.
· There is a need to go beyond assessing what people believe to find out why they believe it.
· It is important to understand public belief, rather than simply trying to change it.
· There is a complex relationship between experience, media and other information and the process of public judgement.
· The media can, in certain circumstances, have a strong impact on public belief.
Media coverage
· Coverage of health related issues has increased across the mass media in recent years.
· National media coverage of health service issues revolves around the rhythms of Whitehall and Westminster
· Press coverage varies with the political complexion of a news paper, although some stories may be attractive across the press.
· We have very little knowledge on the role of the local media and how they compare with national reporting.
· Media coverage of the NHS is not always 'negative' or 'positive' in a straightforward way.
· Hospital dramas are increasingly prominent in the schedules and tend to provide a forum for contemporary debates on the NHS.
· The media do not necessarily give the most prominence to the issues thought important by scientific or technical experts.
· Media coverage is determined by a combination of lobbying activities and media factors.
Communicating change
· Internal conflicts or lack of co-ordination in the NHS can (accidentally or deliberately) hamper communication efforts.
· Genuine public consultation may help communication efforts, but attention needs also to be paid to the content of what is communicated.
· Clarity on communication goals, audiences and messages is a necessity.
· Openness is a prerequisite for efficient consultation and is likely to play a role as a catalyst in securing staff involvement.
· Both decision making and communication strategy need to be understood in relation to the public sphere of political debate.
Policy and communication
· It is clear that the media now play an important role in policy making and implementation
Introduction
This report reviews the current state of knowledge on the relationship between public opinion, the media and health care provision. Specifically it looks at; 1. the process of public belief and opinion formation; 2. the way in which media organisations portray health services and why and 3. the development of health communication campaigns and strategies and their strengths and weaknesses. Finally, it identifies gaps in our knowledge and suggests an agenda for research. The bulk of this report refers to literature on general healthcare issues. This is because there is very little research on changes in acute care provision, partly because of the newness of this issue in public debate in the UK. Where there is research evidence in this area, we have specifically mentioned this.
Method
A few brief words on method are sufficient. The literature on which this review is based was culled from 1. a search (for items on health, communication/media, public opinion/perception/attitudes and marketing/public relations) of the Science Citation Index, the Social Science Citation Index and the medical database medline, between 1990 and 1995 . 2. A search of the literature in media studies which deals with health issues 3. consultation of books and articles on health policy in the UK 4. a secondary search of references obtained, following a preliminary examination, from the first three searches. We focused on the three main areas outlined above, and have discarded or ignored material that seems to us not to be relevant or to add little to understanding the complex relations between them.
The field of Health Communication
The field of health communication is a burgeoning academic sub-discipline, especially in the United States, where there is a journal (titled Health Communication),which specifically caters for it. However, writing on health communication has tended, unsurprisingly, to be strongly represented in medical and scientific journals. The 'dominant paradigm' in the field has been described as follows:
Communication about health occurs primarily in the formal health-care delivery system, between individual patients/clients who seek explanations and/or solutions to perceived symptoms and/or health conditions and individual health professionals trained to offer diagnosis, treatment, or other solutions to these symptoms/conditions. The effectiveness of the relationship and thereby the efficiency of the system may be enhanced to the extent that barriers to communication are mitigated, helping patients/clients to adopt recommended behaviours to alleviate the symptoms/conditions (Finnegan and Viswanath, 1990: 14-15)
A survey of the literature in four different databases between 1983 and 1987 found that the five most frequently appearing themes in writing on health communication were, in descending order:
· Professional-patient relations (interpersonal interaction in the health-care delivery system);
· lifestyle campaigns (the use of communication to improve health through preventive medicine or to inform the public about particular cures/treatments);
· interprofessional relations (the interaction of health care professionals);
· health professional training (programmes of training in communication skills);
· health information systems (the development of computer and other medical information systems to improve service delivery)(Finnegan and Viswanath, 1990).
Each of these areas are potentially relevant to this report and we will focus on particular aspects below. However, it should be readily apparent that the field of health communication has not been primarily concerned with external communication; that is with public opinion or media reporting. The exception to this is lifestyle campaigns which have targeted external audiences. However, this has largely been in relation to campaigns which are intended primarily to provide information about health and illness in the hope of encouraging behaviour change. It has not been concerned with the communication of changes in service provision. Similarly, much of the work in the other four areas relates specifically to health outcomes rather than to promoting or explaining changes in services. Nevertheless, there are some conclusions which can be drawn from this literature and applied to the issues under discussion.
Furthermore, we have uncovered a wide range of material which does shed some light on the topic and has enabled us to pinpoint gaps in our knowledge which could fruitfully be investigated in further research.
Determinants of public opinion and belief
Public belief and opinion on health care issues is complex, stratified and dynamic. However, there does seem to be a fairly coherent and steady bedrock of public support for the concept of a comprehensive National Health Service free at the point of delivery (Klein, 1985). A strong marker of that is the fact that Conservative ministers have felt the need to continually reiterate that the health service is 'safe in our hands'. The central question which needs to be answered is why are significant sections of the public so sceptical about changes in health care provision that they are seen simply as cuts?
Public Opinion
There is an extensive literature on public opinion and the NHS (see e.g. Blendon and Donelan, 1989; Bosanquet, 1988; Judge and Solomon, 1993; Judge, Solomon, Miller and Philo, 1992; MORI, 1991; Pfeffer and Pollock, 1993; Taylor-Gooby, 1990). However attempts to understand the relationship between opinion, political culture, personal or social experience and media content have rarely been a central focus in the literature. Furthermore, attempts to understand what people believe have been hampered by methodological and interpretative difficulties. Recently, as we put it in our work with the King's Fund:
there has been an unprecedented level of interest in public opinion about the NHS. Unfortunately, curiosity does not necessarily lead to greater clarity about what the reported views of citizens and consumers of health care actually represent. Findings have been seized and used with rather more alacrity than accuracy (Judge, Solomon, Miller and Philo, 1992:304).
This said, it does appear to be the case that widespread public support for socialised medicine remains a foundation of public opinion. This is by way of contrast with opinion in the US (Jacobs, 1993) although there is some evidence that US opinion has shifted in recent years (Jacobs and Shapiro, 1994).
Problems of interpreting public opinion
In our earlier work with the King's Fund it was apparent that answers to opinion poll questions, besides varying according to the precise wording of the questions, were being interpreted in a variety of different ways (Judge, Solomon, Miller and Philo, 1992). One key example related to public satisfaction or dissatisfaction with the NHS. Low levels of reported dissatisfaction were being interpreted by some as indicating acceptance of, or support for, the NHS reforms. Yet there is an inherent ambiguity in the questions being asked. Are people being asked if they are satisfied with the concept of socialised medicine, with the ongoing reforms or with their own personal experience of treatment? It seems reasonable to suppose that the relatively low overall level of dissatisfaction with the NHS found in the OPCS and other surveys may be partly related to an uncertainty in peoples minds about whether the question refers to the running of the NHS or the concept of universal health care. If we compare the levels of dissatisfaction with some of the other poll evidence the difference is marked. The British Social Attitudes (BSA) and National Association of Health Authorities and Trusts (NAHAT) surveys of 1991 show dissatisfaction at 47% and 12% respectively. Similar questions in an ICM survey for the Daily Express in May 1991 showed '88% of patients were "satisfied" with the general efficiency with which their case was handled by the NHS' (Daily Express, 22 May 1991). This is not very different from the NAHAT survey and seems to be related as does the NAHAT data to the phrasing of the question in cueing people in to talk of their 'personal' experience. However, in the same survey, the results of which were carried on the inside pages of the Express (in contrast to the '88% happy with NHS' front page headline) it was revealed that 58% disagreed that hospitals were inefficiently run, 84% thought that nurses were overworked and 83% disagreed that doctors 'don't work hard enough'. Huge majorities of people were also very satisfied or quite satisfied with the standards of care from nursing staff and doctors (91% and 89% respectively). The overwhelming support for the staff of the NHS and the way it is run are instructive. This translates disproportionately into support for the Labour Party. 42% in this poll thought Labour would 'best protect the NHS' compared with 20% for the Conservatives. Although there was a large degree of support for the services supplied by the NHS, there was also a large majority of people (83%) who thought that NHS hospitals needed 'more money to run efficiently'.
More recently both Gallup and MORI conducted polls in the last quarter of 1991. MORI asked 'Do you think that the Conservative Party has plans to privatise the NHS if they win the next election, or not?' A majority answered yes in all cases but there was some decline in the numbers. (Oct. 3-4 62%, Oct. 18-21 50%, Nov. 22-25 56%).
Consistent majorities of the population seem to have negative views on government policy on the NHS. This is found in tandem with high 'satisfaction' ratings for the standard of care within the NHS. It is sometimes suggested that the high ratings of satisfaction with the Health Service indicate that government reforms are popular. However this ignores the fact that a key part of the opposition to current government policy emphasises the heroic qualities of NHS staff and the benefits of NHS treatment. It seems reasonable to suppose that the 'wonderful' (Daily Mirror, 15 January 1992) treatment available in the NHS might lead to respondents being 'satisfied' with the NHS and yet still opposed to change in health service provision.
Culbertson and Stempel have attempted to explain similar opinion poll evidence on health care in the USA. They note the tendency of respondents to 'evaluate their own medical care favorably but to be quite critical of American health care as a whole' (Culbertson and Stempel, 1985: 180). They explain this by suggesting that people 'rely more heavily on media coverage in assessing society-wide care than in evaluating their own lives'. Besides the problems of interpreting the meaning of levels of 'satisfaction' noted above, we can note that the two sets of questions asked in their study are of different orders. An assessment of the experience of health care (in the first set) does not ask for a judgement on health care provision, government policy or broader questions of citizenship and justice, whereas these are being asked in the second set of questions.
Culbertson and Stempel link negative perceptions of the health care system with media coverage, by asking their respondents to rate media coverage of health care issues as positive, negative or neutral and correlating this with opinion on health care. At the methodological level, such a technique is unable to reveal the connections between various influences or the process by which people evaluate information. A key weakness of this research is that the researchers are unable to isolate the meanings attached to their questions by their respondents and moreover, do not know the meanings promoted by the mass media, since they do not analyse media content.
The limitations of opinion polling
Aside from the limitations of some opinion polling in distorting public belief (in whatever way) the major problem with opinion polling per se is that it does not reveal why people believe what they do. It entirely ignores the process by which we all constantly make judgements about the world based on our encounters with new information or experience. At best a series of opinion poll data can be matched with patterns of occurrence in other spheres such as news coverage, political events or personal experience of health care services. Yet this may provide only a possible correlation between changes in public opinion and changes in, say, press reporting. What is needed is an approach which asks about the sources of public belief and tries to retrace the process by which new information and experience are incorporated as people change or make up their minds.
Because of these problems of interpretation we would strongly argue that the available opinion polling data is not sufficient for grounding further research.
Formation of public belief and opinion
There are a series of key issues in this area which include: 1. How do people make up their minds about the health service?; 2. Why is British public opinion on health care so different to that in the US?; 3. Why is there such strong support for the concept of the NHS; and 4. Why is the public so critical of governments reforms of the NHS.?
Much of the concern about public opinion and belief in health and medical professions as elsewhere centres on the distance between scientific, technical or administrative assessments of and those of the public. It is often assumed that public beliefs are constructed by irrational or uncontrollable forces, such as media sensationalism or public panic or emotion. Such views are common participants in the politics of scientific wisdom or technical decision making (Miller, 1995; Nelkin, 1987). From the attempted dumping of the Brent Spar by Shell, to nuclear energy, from AIDS to Coronary Heart Disease, experts have decried the seeming inability of the public to agree with expert judgements on the magnitude of health or environmental risks. The solution to such perceived problems has been to attempt to either change media representations (get the media to be more 'responsible') or to increase 'public understanding' or both, as in the exhortation to improve the 'Public Understanding of Science'. However, an increasing number of social scientists have come to the view that rather than an increased public understanding of science, it is more important that scientists and other technical decision makers understand the media and the public (Beck, 1992; Davison et al, 1989; Dunwoody and Neuwirth, 1991; Miller, 1995; Wynne, 1989). Furthermore, understanding needs to be complemented by communication between the public and policy makers:
Health and health policy first depends on communication among providers and patients, not dictation by experts or the best organised interest group, about what health care or health policy should be (Logan, 1991: 58)
In other words the public should be involved in policy making rather than simply being its object. Greenberg, for example concludes that communicating openly is one way to improve relations between scientific and technical elites and the public:
We need to get on with making a case for scientifically informed policy that does not dismiss public perception. One challenge is to get scientists, government and corporate officials to interact with the public rather than hide from them. Scientists are beginning to accept the public's reactions to hazards as measurable and therefore real rather than calling them 'irrational'. They are also beginning to understand that failure to acknowledge public perceptions increases public outrage and reduces chances of making science understood (Greenberg, 1992: 537).
Understanding Public Understanding
People do not make up their minds about changes in NHS service provision in a vacuum. New information about the NHS has to compete with previously held views and beliefs as well as with other information and experience. Clearly, differing groups of people have access to different and varying sources of information and experience on the NHS. Those with special knowledge of the NHS, whether they be managers, clinicians, nurses, porters or patients may come to quite different judgements on the state of the NHS and how it should be run from those who don't have such experience. Indeed, it appears to be the case that differing professional groupings can come to quite different conclusions on the basis of their own experience. It is unhelpful to see the interpretative processes by which we all make up our minds simply as evidence of a lack of rationality. Instead we need to investigate the constituent elements of public and professional beliefs and the interpretative process by which some information is assimilated and believed and some discarded or disbelieved.
Once again there is very little material which examines the relative role of the varying constituents of public opinion. Some research has attempted to 'read-off' the impact of the media on public belief and health behaviour from simply examining media content (e.g. Fan and Norem, 1992; Fan et al, 1994; Kristiansen and Harding, 1984).(1) This is inadequate, since it ignores the fact that people actively interpret media messages and may reject some of them. The real question is why do the public reject some messages and not others? The most relevant piece of published work in this area is our earlier work with the Kings Fund (Judge, Solomon, Miller and Philo, 1992).
We showed, for example, between August and November 1991 that the number of people 'dissatisfied' with the NHS declined from 25.2% to 17.6%. This coincided with a shift in debates around the NHS as reported in the media. In particular the government achieved some success in shifting the media agenda onto more favourable territory.
In other areas of public debate it is clear that the media can, under certain circumstances influence public opinion and behaviour. Deacon and Golding have recently shown the
powerful impact of media coverage of the poll tax on its salience as an issue for the public. Table 1 reproduces their comparison of media coverage and public salience.
Table 1: Source, Deacon and Golding, 1994:194
They argue that this data shows the impact of the media on public opinion rather than the other way around:
The opinion poll data was collected at the end of each month, whereas the media data quantifies the cumulative coverage for each month. The almost identical convergence of the two patterns confirms that news priorities shifted before any equivalent change in public concerns had been empirically established (Deacon and Golding, 1994: 195)
The media can also impact on public belief in relation to health information. A clear example of this is the Salmonella 'scare' of 1988/89, in which junior health minister Edwina Currie stated on television news that 'most of the egg production in this country, sadly, is now infected with Salmonella'. Within days there was a dramatic decline in egg sales in Britain, which can be directly attributed to media coverage of the Salmonella story. A similar, though not so dramatic, process occurred around BSE ('Mad Cow Disease') in cattle in 1990, with a resultant slump in beef sales (Miller and Reilly, 1995).
Such media impacts are atypical in that they are more dramatic and short term than observable changes in belief around the NHS. However, in recent research we have examined a number of public issues, such as industrial disputes, the conflict in Northern Ireland, child sexual abuse and HIV/AIDS ( Kitzinger, 1990; 1993; Kitzinger and Miller, 1992; Miller, 1994a; 1994b; Philo, 1990; 1994). In each of these cases we have found that public beliefs and opinions are diverse and very complex. However, there are a number of factors which we have identified which can explain the process by which people come to make judgements on particular issues. The importance of each of these will vary between topics and between different groups of people, but it is in principle possible to identify the sources of information which people use in the process of judgement.
It does seem likely that people make up their minds on health care by using their own experiences and the experiences of friends and relatives in the light of other information, from the media (or other sources) and their prior political and social views. This mixture of information, views and beliefs is subjected to a greater or lesser interpretative and contextualising process by people, either individually or in groups, and judgements are arrived at. Such factors will also be influenced by socio-demographic factors such as age, class, gender, ethnicity and region. Furthermore such factors are likely to vary between different topics of public debate. What needs to be explained is the role of public experience of health care in relation to other factors, in the construction of opinion and belief on health care priorities and policies in particular.
Summary
· Support for socialised medicine appears to be a bedrock of public opinion
· Opinion polls are limited in the complexity of the data they can supply.
· There is a need to go beyond assessing what people believe to find out why they believe it.
· It is important to understand public belief, rather than simply trying to change it.
· There is a complex relationship between experience, media and other information and the process of public judgement.
· The media can, in certain circumstances, have a strong impact on public belief.
Media Coverage of Health Issues
There is a quite extensive literature on media portrayals of health issues, and a lesser amount on the production of media account of health issues. However, almost all of this focuses on the portrayal of particular types of ill health or disease, rather than on the representation of health care or health services (see Chapman et al., 1994; Clarke, 1992; Fisher et al, 1980; Klaidman, 1991; Lupton, 1994; Modolo, 1995; Simpkins and Brenner, 1982; Simonds, 1995). However, there are some aspects of this material which are useful in understanding a. the changing pattern of media coverage of health b. the general limitations of media portrayals of health issues and c. the ways in which some health care situations/professionals are portrayed.
Media coverage of health care provision
There is very little material on British media coverage of health care provision. We have located a handful of pieces dealing with news and current affairs coverage and nothing in academic or scientific journals on fictional coverage. However, it is clear that both factual and fictional programming and print coverage of health have increased in recent years (Entwistle & Beaulieu-Hancock, 1992; Karpf, 1988).
Kristiansen and Harding found that ‘Diseases were given the overwhelming amount of newsplay, followed by prevention, medical advances, the NHS and environmental influences on health’ (1984:367). (2) Their study found an average of 90 items per month in the press. Even so it seems clear that the NHS has increased in media visibility in the past fifteen years. In 1992 for example, news coverage of the Health Service was one of the most prominent issues on the media agenda (British Press and television items on the NHS; August 1991, 119; November 1991, 257; February 1992, 290; May 1992, 118) (Miller et al, 1992). However, it is also clear that the volume of coverage of the NHS does vary quite considerably over time. In a more recent study of the British press, during March 1993, Chapman and Lupton (1994: 72) found that coverage of 'hospital funding cuts' (28 items) came tenth in frequency. By contrast AIDS was covered in 148 items, followed by Health insurance (47 items).
A key area of interest is to isolate the factors which combine to move the NHS up and down the media agenda. But we also need to know how the NHS is covered.
News and Current Affairs
The earliest study of coverage of the NHS appears to be that carried out by Best, Dennis and Draper in 1976/77. They concluded that television and the press tended to concentrate on curative medicine at the expense of preventive medicine. The media tended to see the NHS as a drain on the economy and the promotion of structural changes which would improve health as 'interfering' in peoples lives. Kristiansen and Harding reported similar findings from their 1981 study. According to them the press evaluated the NHS 'negatively' (1984: 370). Both these studies emphasised that media coverage of the NHS tended to be critical of socialised medicine, to play down 'socio-economic influences upon health' (Kristiansen and Harding, 1984: 370) and to reproduce what Best et al call the 'predominant interpretative framework' around health (Best et al, 1977: 59). By this they mean that the media tended not to be fundamentally critical of the government perspective on health. We might remember that this was in the period of office of the last Labour government, prior to the current reforms of the NHS. This is significant in that the coverage of the NHS was 'negative' in a quite different sense than coverage in recent years.
More recently we conducted a study for the Kings Fund Institute which found that news coverage of the NHS was closely tied to the rhythms of Whitehall and Westminster (Miller et al, 1992). This is to say that the issues on the NHS which got the most coverage were those which originated with government (particularly) or opposition statements or information and with the response to them from relevant stakeholders such as the BMA (Miller et al, 1992).
Press coverage of the NHS reforms
Unlike television, the press is not legally bound to be objective, balanced or impartial. Accordingly the stories which papers report are influenced by the political line of the paper and its assumptions about its own audience. These can shape the stories which are covered, the angle which is taken, the sources of information which are used and the way that information is presented.
The Mirror and the Sun are quite clear on the political line that they pursue on the Health Service and this often means ignoring inconvenient stories or not reporting them prominently. For example, the Daily Mirror ran regular stories on the Health Service, in contrast to the Sun which ran far fewer.
The political complexions of the papers also influence who is quoted in news stories. Overall the four most commonly quoted people were the representatives of the government and the opposition, although with the emphasis firmly towards the government.
Our argument here runs counter to that found in Anon, 1995 which suggests that 'among the national [press] there was no discernible difference between so-called "right wing" and "left wing" newspapers in their propensity to report (and preference for) negative stories. It is, of course, generally the case across all media that "bad" news makes bigger headlines than "good" news'(p2).
One problem here is the distinction between 'bad' news and 'good' news, which tends to simplify the ways in which the news agenda on health might change. There is no intrinsic reason why information with a high news value ('bad' news) should be news which suggests that change in the NHS is negative.
However, some of the difference between the two arguments is attributable to the fact that our analysis was conducted in the year leading up to the 1992 election. This is a period when the editorial priorities of the press tend to be most clearly visible. It was clear in our study that the conservative supporting newspapers were anxious to print 'good' news about the NHS (and especially about the reforms), but were unable to find enough. Having said this, it is also the case that stories about failures in service provision, especially as the affect young children may prove too tempting to the news values of some (especially tabloid) newspapers. In such cases 'news values' may take priority over the political line of the paper.
The orientation of the media to the parliamentary cycle means that the NHS debate in the media will largely echo the parameters of political debate. Waiting lists, activity levels, hospital cuts and closed beds will tend to displace debate on other factors such as demographic change and the increasing expense of 'High-tech' (and high cost) medical advances which might put a ceiling on the amount of GNP that any society can spend on health. In the periods which we studied such arguments were not strongly emphasised by either the government or the opposition. Indeed it was very hard to find either of these arguments anywhere on television or in the press.
This analysis is supported by a study of coverage of waiting lists in The Times between 1980 and 1992 which found that reporting ‘fails to include consideration of all the factors that we believe affect waiting list size’ (Anand, 1992: 16). Specifically, there was ‘no consideration in the media of the possibility that technical cost-increasing improvements could be a factor in the long-term growth of waiting lists’ or that ‘increasing demand has any role in the lengthening of queues’ (Anand, 1992:17).
Such coverage can mean that approaches to health policy, outside of those pursued by the main political actors and stakeholders (i.e. not only political parties) will be marginalised and get little coverage and certainly very little front page/headline coverage. This is only likely to change when such debates are given prominence by political parties or other prominent stakeholders such as the BMA.
The role of the local media
It has been suggested that the 'local press' is less likely to report the NHS 'negatively' (Anon, 1995). This would be an interesting area to explore further. Certainly, recent media research has pointed to the distinctive role of the local press (Franklin and Murphy, 1991). However, local media have been found to be more critical than the national press of government policy on other issues, such as the poll tax (Deacon and Golding, 1994). At present there is very little research on the role or significance of the local press (or for that matter local and regional television and radio) in reporting change in health care. This is certainly an area which would repay future research.
Fictional television coverage
Along with police series, hospital dramas have become a mainstay of television fiction (compare the dearth of soap and drama series on other public servants such as Social Workers or Teachers) in Britain. A similar situation is evident in the US where medical drama has increased markedly over the last forty years from an average of less than one hour per week in the 1950s to an average of between two and five hours in the 1970s and 1980s (Neuendorf, 1990: 120).
We have only to think of the US hospital and medical dramas screened on British television in recent years ( Marcus Welby, M*A*S*H*, St Elsewhere, ER, Chicago Hope etc.) to appreciate the relevance of this. As with factual coverage, fictional representation of hospitals have become more frequent on British television, resulting in a recent Radio Times feature 'Doctor, I think I'm addicted to hospital dramas'(Berkman, 1995). The increase in frequency has been complimented by a change in the way in which hospitals and their staff have been portrayed.
The portrayal of hospitals seems to have hardened especially since the 1980s (Karpf, 1988), during which, the politics of the NHS rode up the political agenda. Part of the new social realism of the hospital dramas was an increased profile for the politics of the NHS in programmes such as 1983's single play The Nation's Health, the BBC's long-running series Casualty (broadcast from 1986) or the more recent Cardiac Arrest. The Nation's Health was perhaps the most critical, but it raised issues which have also been covered in other fictional representations. The Nation's Health writes Anne Karpf: 'showed the hospital as a workplace with problems of industrial relations and steaming kitchens of a gross, Fawlty Towers kind. And the cuts to the NHS were ever present, the pressure to find beds constant, the long waiting lists routine, and the closure of a hospital wing depicted as an act of official vandalism' (1988: 200). Such portrayals have on occasion led to conflict between the government/NHS and broadcasters and to condemnation of the broadcasters from sections of the press. Karpf reports that as early as winter 1986 Casualty 'attracted Conservative Party wrath: "If you listen to Casualty", their spokesman claimed, "it is like a Labour Party meeting. the general patois used throughout is so-called health service cuts"' (1988:192).
There is no systematic research which reveals the extent to which such representations are still typical, whether, 'health service cuts' are ever dealt with in a positive way in fictional representations or on the significance of drama for public belief.
Portrayal of Health care professionals
Doctors, like scientists, have a very high status for the media. One researcher has suggested that 'repeated exposure to fictional images' of doctors, might well 'foster what one might term a Marcus Welby Syndrome, an unusually strong tendency to believe that physicians are all-powerful and all-good' (Neuendorf, 1990: 126). However the development of social realism in television coverage of the NHS has paralleled the decline in the image of the Doctor in the media. Several researchers have pointed out that the image of doctors and consultants in the media has suffered in recent years (e.g. Samra, 1993), but, Karpf argues that 'however much medical drama changed in the mid 70s and 1980s, and no matter how bleakly it represented medical practice and bureaucracy, one character endured. The good doctor, repository of all hopes we invest in medicine and the ideals we hold dear, remains an invariable component of even the most abrasive medical fiction' (1988: 201; see also Turow, 1989). The enduring truth of this statement is supported by the characterisation of the junior doctors in the recent series Cardiac Arrest. While it is clear that Doctors and medical personnel retain a significant cachet for the news and entertainment media and possibly for the public, it would be a mistake to assume that the media and especially the public will believe anything so long as it comes from the mouth of a doctor in a white coat. Only part of the reason for this is the slight tarnishing of the image of the physician in recent years. The content of the message in its political and historical context is also likely to be important. After all, the British Medical Association vehemently opposed the introduction of the National Health Service in the late 1940s, leaving them severely adrift from public opinion which was overwhelmingly in favour (Jacobs, 1992:194-196).
There is very little material on the portrayal of hospital managers, executives or policy makers. In one study, however, Turow concluded that images of health care executives on US television were predominantly negative showing them as 'obstructions' to good medicine (Turow, 1985). It may be that a similar pattern is evident in the British context and this may have serious implications for public perceptions. However, there are at present, no data on this.
Explaining Media Coverage
It is clear that most of the daily press is hostile to the Labour Party and to their policies on Health. The Sun, Mail, Express, Times, Telegraph and their Sunday equivalents are all generally supportive of government policy. The Mirror with the Guardian and the Independent tend to give alternative views.
Yet, the Health Service is not a strong area for the government and public opinion polls consistently show that opinion is against them. In 1992 the government attempted to foster the impression that the Major government was quite different from the previous years under Thatcher. Yet some government allies saw this as a problem. An Express leader writer was worried:
Ministers and Central Office mandarins are at such pains to avoid referring to Mrs Thatcher, save in the most ritualistic terms, that they cannot extol the Government's record with the unbuttoned enthusiasm it warrants... This uncertainty is reflected in an inability to spot good news and beat the drum about it. A good example is the way the Government made so little of this week's survey showing overwhelming satisfaction with the NHS - a story given its proper due only in the Daily Express. (Editorial, 16 November 1991)
The problem for the Conservatives in winning the debate in the media is that the arguments that they use on health are comparatively unattractive in terms of both news values and public tastes. Winning the argument in the public sphere is determined not only by the rationality or evidential base of a proposition, but on political considerations about presentation, assessments of the news media and the current state of public sympathies. The main government arguments have centred around convincing the public that the NHS is safe in their hands, that it is not being privatised and that reforms will improve efficiency and cut waiting lists.
Given the lack of discussion of the impact of demographic and technological change in the media it is hardly surprising that the public does not believe the government when it says that it has increased spending on the Health Service in real terms. Indeed some supporters of the government in the press have pointed to wider reasons why the government was losing the health debate. These relate both to public experience of the Health Service and to the working practices of the media.
The problem is that the intricacies of these reforms are dull, they are too recently introduced for their good effects to be visible, and the public are not in the mood to listen to the arguments. (Daily Telegraph, 12 November 1991)
On the one hand it is argued that the benefits of the reforms cannot be seen either by patients or journalists and on the other the reforms themselves are too dull to trumpet in the newspapers or to interest or convince the public. This is a tacit acknowledgement that the opposition case which emphasises wards closed and operations cancelled is much more to the taste of both the public and the press and it is this rather than the intrinsic strength of the argument which is important in winning the public debate.
In this context the most powerful images are of people (especially children) being refused treatment, of wards closed and beds lying empty. In the period between August and the end of November 1991, the Daily Mirror printed many front page and double page stories on the health service vilifying the government over its health policy. In contrast the only front page banner headline in the other tabloids in August and November was in the Daily Express which reported an opinion poll as indicating that nearly 9 out of 10 people had received 'excellent' treatment as in-patients, under the headline 'WE LOVE NHS, SAY PATIENTS' (14 November 1991). The lack of positive news about the NHS also worried the Sun. They ran a small news item appealing to their readers to ring the Sun with good news stories about the NHS. 'Did the NHS treat you well?... Knockers are forever moaning about service and complaining treatment is poor. But the Sun wants to hear the other side of the coin. Perhaps your life has been saved or you have another reason to be thankful. Call us with your NHS good news today... We'll ring straight back.' (27 February 1992)
The plight of the sick (especially children) is much more likely to be remembered by the public than the latest figures on activity in hospitals or waiting times. However, it is not at all clear that the public inevitably sees change in NHS provision as negative. (3) This depends very much on other factors such as whether the change is seen as positive by stakeholders and the media. The interaction of these actors with public sentiment create and recreate the political climate in which debates on policy change are won or lost. Understanding the way in which such interactions work is essential and can be informed by future research.
Explaining media coverage
Media coverage can be understood as being the result of two sets of factors. First, media priorities, which might include, the need to boost circulation/profit, the influence of the proprietor/editor/ editorial hierarchy, the political line of the newspaper, news values etc. Second there are source factors, which are the priorities of social institutions and stakeholders. The media require sources of information and comment to provide them with 'information subsidies' (Gandy, 1980). The importance of this is that it means that the priorities of the media are not wholly antagonistic to those of stakeholders and institutions (or of the NHS). The NHS remains a highly prized institution for the British public, politicians and the media. Such disagreements as exist, are about priorities for the NHS, not its disbandment. While it may be felt that media coverage of changes in the NHS does not properly deal with its complexities or tends to simplify and sensationalise, this is in part due to the information supplied by the social institutions with which the media interact. It is obviously the case that there is competition between stakeholders to gain access to the media and to push policymaking in different directions. Such strategies might result in media coverage which disrupts, blocks or ignores attempts to communicate change in the NHS. But it is equally possible that the strategies of other groups or of the NHS itself might facilitate and enhance attempts at change. The point is that media coverage would be different if the information they received from a variety of sources was significantly different.
Because media coverage is the result of media priorities interacting with the strategies of stakeholders, it is very unlikely to mirror objective changes in the NHS. This is not at all unusual or unexpected. It is widely recognised that media coverage of social and political issues does not mirror either objective conditions or expert assessments of those conditions (by scientists, doctors, or technical experts such as managers) (See Miller and Reilly, 1995; Nelkin, 1987). The media do not simply reflect the world, they provide an arena in which arguments are won and lost, brought centre stage and marginalised.
However there is a further sense in which the priorities of the NHS and those of the media might be said not to match. It is not at all clear that either the media or the NHS have one set of priorities. We have shown above that media coverage of the NHS varies quite dramatically between different newspapers, which means that some messages are more popular in some parts of the media than others. More importantly, it is not at all clear that the various parts of the NHS are all working to the same communication priorities. If they were this would be unusual given the sheer size of the NHS. Furthermore, there are clear political and economic limitations on decision making and communication. There is some feeling in the NHS that communication about change is impeded by political constraints which result in an inability to tell the whole truth. Such factors may have a major impact on the credibility of any attempt to communicate changes in provision. It would be very helpful to identify such limitations in order that they may at least be incorporated into communication strategies. Unfortunately, there is almost no literature on such problems in NHS communication systems.
Summary
· Coverage of health related issues has increased across the mass media in recent years.
· National media coverage of health service issues revolves around the rhythms of Whitehall and Westminster
· Press coverage varies with the political complexion of a news paper, although some stories may be attractive across the press.
· We have very little knowledge on the role of the local media and how they compare with national reporting.
· Media coverage of the NHS is not always 'negative' or 'positive' in a straightforward way.
· Hospital dramas are increasingly prominent in the schedules and tend to provide a forum for contemporary debates on the NHS.
· The media do not necessarily give the most prominence to the issues thought important by scientific or technical experts.
· Media coverage is determined by a combination of lobbying activities and media factors.
Planning Communication strategies
An understanding of both the media and the public (whether as a whole or specified sections such as staff or local people) are essential to the planning of communication strategies. However, even a sophisticated understanding of both will not guarantee the success of any communication strategy. One important reason for this is that the media or the public may not like the content of what is communicated. However, more fundamentally for present purposes, are the problems of communication in decision making and implementation. While there is a very extensive literature on health communication campaigns, specifically in relation to health education and health promotion (see e.g., Atkin, 1978; Atkin and Wallack, 1990; Backer et al, 1992; Hastings and Haywood, 1991; Lau et al, 1980; Ling et al. 1992; Salmon, 1989; Shaw, 1986; Tones, 1994; Wallack, 1994), the problems identified in relation to communicating about health care provision, seem to us to go beyond the attempt to change belief and behaviour in relation to particular health risk factors.
Internal and external communication in the NHS are seen as a problem by most commentators (Audit Commission, 1993; Butler, 1994; Hargie and Tourish, 1993a; 1993b; Hargie et al, 1994; Lloyd, 1994; NHS Management Executive, 1992; Sheaff, 1991; Wells, 1994). Among the problems identified are:
No clear sense of communication goals;
· lack of agreement on standards to measure NHS improvements;
· Communication often an afterthought in decision making;
· Jargon ridden communication; political constraints on honesty;
· different messages coming from different parts of the NHS (Centre, HAs, trusts etc.) as well as conflict between elements in the NHS;
· specific inability to communicate with the media and especially the public;
· overweening bureaucracy hindering communication efforts
There are a large number of issues here which would merit further exploration. For present purposes we will discuss these factors under the following headings:
1. Internal relationships in the NHS;
2. The process of decision making and the role of consultation;
3. Communicating change;
4. internal communication
Internal relationships
There are a number of ways in which internal variations and differences can impede the efficient communication of change. First, different Health Authority's and trusts may be putting out different messages without effective co-ordination. Second, information from the centre may not always meet the needs of local trusts or authorities, or more importantly, their publics. Thirdly, there may be conflict between various parts of the NHS either between professional groups and their representatives or between, for example, purchasers and providers. Wells has noted:
The purchaser-provider split moreover, has caused great confusion in the public's eyes, not least when they see the unedifying spectacle of two parts of the NHS criticising each other or, even worse, negotiating through the medium of the local press (Wells, 1994).
Divisions and internal conflicts are not unique to the NHS. In fact most large bureaucracy's, such as government departments, local authorities and even pressure groups are likely to be hampered by such differences (Miller, 1993; Miller and Reilly, 1995; Miller and Williams, 1993). At present there appears to be little research in this area on health care issues.
The decision-making process and the role of consultation
For some Health Service managers the problems of the health service are simply problems of communication (Wells, 1994). However, there are different models of communication in relation to decision making which may impact upon how decisions are viewed and communicated. For example, it is possible that the lack of public sympathy for changes in NHS provision may be due, at least in part, to the lack of public involvement in the formation of policy decisions (Wells, 1994); or it may be that the policy decisions themselves are unpopular. At present there is very little research on the relationship between such decision making and communication. Examining current decision making practice in the light of evidence on public beliefs and attitudes would be useful.
Consultation with the public
Assessing public opinion and perceptions of health needs has become increasingly popular in the NHS in recent years as part of a move to listen to local views (NHS Management Executive, 1992). There are at least two models of such consultations. First, is the approach which sees public consultation as a means to a preconceived end in which:
there is a failure to make a clear distinction between improving the planning of services and needs assessment, and using public opinion in a process that might result in the denial of health care to some groups... "rationing" and so called priority setting exercises masquerade as research into community "health care" values. This is dishonest when the same exercises are sold to the public as public consultation on developments of purported benefit to the respondents or local community (Pfeffer and Pollock, 1993: 751).
Others argue, citing experience from Oregon in the US, that 'public preference is being used selectively to justify cuts in services - when it accords with the views of the decision makers' (Scott-Samuel, 1992: 1058).
Second, is the approach which sees consultation with the public as being part of the decision making process, in which the policy process is opened up to public debate and influence. One model of public consultation is that reported by Knox and Chapman in New South Wales. Here 'members of the community, local government and other state government agencies' were involved in the 'identification and assessment of needs, the policy development process and planning of programmes and services' (Knox and Chapman, 1995: 111). In this approach the public are not just consulted but involved in the process. In the US, where questions about health care rationing are on the health policy agenda, the need to relate to public opinion is overwhelming because 'decisions about health care allocation are inherently public and, as such, public opinion is a relevant consideration, both politically and ethically' (Zweibel et al, 1993: 80). Here is the test of public consultation exercises; the extent to which the public are allowed a role in decision making rather than simply being 'consulted'.
Consultation and communication on health policy options could usefully take place at national, regional and local level. Local support for changes may not translate into national support and vice versa. One recent attempt to grapple with the issue of consultation in the NHS has been the use of health panels, currently under exploration by Somerset Health Authority (Richardson and Bowie, 1995). Reviewing such initiatives in the NHS would be a valuable aid to defining more detailed research questions and may also serve as a focus for investigating various attempts at communicating change. One outstanding problem is that it is not at all clear how public consultation should be incorporated into decision making in this area. Further research on this is needed, which might draw on the experience of public consultation in other spheres such as technological and scientific decision making.
Communicating change
The issues of, what is the message which is to be communicated? who does the communicating? Who is the communication aimed at; and for what purpose? are all questions on which there is very little research evidence. It is also very difficult to plan answers to these questions in the absence of information on public belief and its sources. However, the health communication literature does provide some pointers to operational and strategic research in this area. One example is the approach taken by the Centers for Disease Control in Atlanta, Georgia. As might be expected their approach is based on the communication of information about specific health risks, but their general research process guide is useful. It includes the following stages:
Review background information;
· set communication objectives;
· analyse and segment target audiences;
· develop and pre-test message concepts;
· select communication channels;
create and pre-test messages;
· develop promotion plan;
· implement communication strategies;
· conduct outcome and impact evaluation;
· feedback to improve communication (Roper, 1993). (4)
Because of its orientation towards health risk information, this approach is not straightforwardly transferable to communicating about changes in service provision. It has the drawback of failing to consider public consultation and the analysis of the current state of public belief in the planning of campaigns, but otherwise it describes some of the general process of communication planning.
As for the specifics of message communication, Wells has suggested that:
there is... a temptation for planning to concentrate on the negative, rather than to highlight the positive. For example, the changes in London are concentrated on the rationalisation of acute local services, whereas a plan to concentrate acute services, specialities and research into four or five major centres of international excellence, would have told a completely different story while effectively achieving the same thing (Wells, 1994)
This view sensibly directs our attention to the key role of communication in the decision making process. Not only should the public be involved in decision making from the beginning, but communication of change needs to be integrated into decision making from the beginning rather than tacked on at the end. What is being planned may have to be recast in the light of communication advice. An integrated approach to communication might also be beneficial in relation to debates on openness in the NHS. (5)
Openness
One significant problem for NHS communication is a perceived lack of openness. A preference for minimum disclosure is not uncommon amongst technical and managerial specialists who perceive themselves to be unfavourably regarded in the media (Miller and Reilly, 1995; Nelkin, 1987) (6). Hargie and Tourish argue that 'there is now abundant evidence to suggest that managers take a more optimistic view of the effectiveness of their communication practices than are warranted' (1993b: 277). This certainly seems to be the case in relation to openness in the NHS. According to research by the Office for Public Management:
one in four trusts and one in five HAs cited objectives for their internal communication strategies that were exclusively about informing staff, without also including objectives for consulting and involving them. Only 13% of HAs and 23% of trusts mentioned openness and honesty as key objectives (Lloyd, 1994: 19).
Furthermore, according to research carried out for the Audit Commission, 46% of directors of Health Authority's and trusts thought openness had improved following the reforms against 10% who thought it had worsened. In contrast 15% of other staff said it had improved against 24% who believed it had deteriorated (Brindle, 1995). One NHS staff respondent said 'if we knew of anything that was immoral we would never risk saying anything. We wouldn't risk our jobs. We've all got families to feed and mortgages to pay'. Such sentiments do not speak of an increased openness in the NHS. There have recently been several celebrated cases of 'whistle blowing' which have tended to reinforce media perceptions of increased secrecy and have been debated in the medical journals (e.g., Lennane, 1993; Smith, 1992: Warden, 1992)
Lloyd argues that openness is intimately bound up with the process of consultation:
Openness does not mean being outspoken in a critical way or seeking to blame others when problems arise. Rather, it ought to be an attempt to involve others at an early stage in the dialogue about the priorities, difficult choices and dilemmas that managers often have to resolve. This is a two-way process and entails listening and responding as well as being prepared to divulge more about aims and purposes (Lloyd, 1994: 20) (7).
It is self evident that a climate of fear and secrecy is unlikely to lead to NHS staff performing a role as catalysts for a more positive public opinion either with patients or in their own social milieu. It is possible that NHS staff are an especially important source of information for the public given that the NHS employs a very large number of people. Furthermore, the reporting of secrecy in the NHS may also influence the views of a broader public and affect the credibility of the information which does emerge from the NHS.
Finally, the potential for success of an efficiently planned strategy must be understood in relation to possible opposition in the public sphere. The public realm of political debate, dispute and electoral bargaining provides a key context which must be analysed when communicating about fundamental changes in health service provision.
internal communication
There is a very extensive literature on doctor-patient communication, together with the associated topic of assessing needs for health information (e.g. Epstein and Beckman, 1994; Orthner et al. 1994). Much of this literature deals with communication about clinical outcomes, rather than about quality and availability of care. In a recent review of the literature in the area Buckland argues that this may be a 'reflection of the narrow focus of much previous research and/or the limited availability of health information on access and quality' (Buckland, 1994: 82).
Whatever the reason, we have found very little relevant literature on communicating change inside healthcare organisations. One useful, though not directly comparable, piece of research centres on organisational change in a geriatric hospital in the early 1970s. In particular there was a move from bed-care to re-enablement in the hospital. The proposals for change
were discussed at a series of meetings [which]... served as a safety valve for stress engendered in the nursing staff by the changes in hospital procedures, and probably minimised staff turnover due to the transition, but their fundamental purpose was to reach and sustain agreement over goal objectives for the hospital... [The meetings]... seem to have been entirely effective in winning quite quickly the wholehearted co-operation of the nursing staff in the policy of re-enablement' (Topliss, 1974: 359)
It is important to note that internal communication here was both 'upward and downward (e.g., from ward sister to matron, or porter to hospital secretary, and reverse); and horizontal between all grades of nurses and between different staffing structures' (Topliss, 1974: 362). This facilitated 'in the staff as a whole, not only those attending the meetings, a confidence that each one mattered and had a contribution to make to the running of the hospital' (ibid: 362) (8). There is a clear relevance here for current debates about internal communication in the NHS. However, we should be cautious about taking the comparison too far, since the reforms currently taking place in the NHS are of a much greater magnitude and are much more of a public/political issue than the example above.
Nevertheless, the approach to communication above is quite different to that advocated by one manager in a survey carried out for the Audit Commission. Asked if staff were encouraged to attend board meetings, the non-executive director replied: 'I hope you have not been planting ideas in their heads'(cited in Brindle, 1995) (9). Hargie and colleagues have also found that good relations can be enhanced by an open communication process (10)
In particular, staff were keen to report on initiatives taken in their area and wanted to be able to request any information they felt was necessary for them to do their job effectively. They also felt more action should be taken on the information they were providing. If, no follow up occurs, cynicism soon sets in. Another issue raised was the need for a climate in which bottom up communication was fostered and seen as positive, since there was a fear that if someone offered critical views, they might then be 'marked' by senior managers. It should not be difficult to foster such a climate... [but] benefits will only be forthcoming if follow-up action is seen to be taken by managers (Hargie et al., 1994: 27).
However, we would note that channels of communication, while important, can deliver different types of information. A second relevant limitation of research on internal and doctor/patient communication has been the tendency to focus on 'examining the way information is given' rather than on the content and meaning of the information itself (Tuckett and Williams, 1984: 571). This is particularly relevant to communicating changes in health service provision, since, the effectiveness of communication between different staff groups will in part depend on what is said, and not just on how it is said.
One current approach to internal communication problems is the communication audit advocated by Hargie and Tourish (Hargie and Tourish, 1993a; 1993b; Hargie et al, 1994). This approach deals solely with internal communication practices and concentrates on communication between managers and other staff. Whatever its merits, this leaves out a significant portion of what we might otherwise refer to as internal communication; that is communication within the NHS, between trusts, Health Authorities and the NHS Executive. It also brackets off external communications, with other non NHS organisations, the media and the public. The close interaction between internal and external communication and especially the impact of media coverage on NHS staff and hence on internal communication are difficult to account for in this model. Nonetheless, investigating staff beliefs and their sources in the context of internal communication, personal experience and media information would be a useful next step to the 'communication audit' approach. Future research needs to examine such linkages, economies of scale and the possible interactions between communication strategies planned for different audiences.
Summary
· Internal conflicts or lack of co-ordination in the NHS can (accidentally or deliberately) hamper communication efforts.
· Genuine public consultation may help communication efforts, but attention needs also to be paid to the content of what is communicated.
· Clarity on communication goals, audiences and messages is a necessity.
· Openness is a prerequisite for efficient consultation and is likely to play a role as a catalyst in securing staff involvement.
· Both decision making and communication strategy need to be understood in relation to the public sphere of political debate.
Policy, Professionals and the Media
Concern about the role of the media in influencing public opinions and beliefs often obscures the other major way in which the media have an impact. To the extent that the media provide the arena for public debates and for putting issues on the public agenda, they are themselves a part of the policy process (Miller and Reilly, 1995) (11). The very fact that the media are seen as an obstacle or potential ally in communicating change in the NHS, indicates that the media have a role in policy making. Otten describes a variety of ways in which the media can influence policy processes
One person says the all-powerful media essentially set the governmental agenda. No, says another, press coverage simply moves higher on the agenda an issue already growing at the grass roots. A third respondent suggests that the media act merely as a conveyor belt for interest groups seeking government action, while a fourth notes that by exposing shoddy or illegal behaviour, the media impel governments to corrective behaviour. One critic complains that media sensationalism often pushes the government into bad policies, while another charges that by ignoring a vital problem, the media permit the government to ignore it as well (Otten, 1992: 111) (12).
Media information may place information in the public arena on which policy makers may act or feel compelled to act. As Otten puts it: 'Every agency or congressional staffer knows how often the boss starts the day demanding to know more about an item in that morning's paper or on the previous night's news. The press puts information into the policy making process' (Otten, 1992: 113). Media representations may also influence the perceptions or morale of NHS staff (including managers) either in the same direction as the media messages or promoting scepticism about the role, value, agenda and worth of the media. However, the impact of the media on health service policy or provision is chronically under-researched.
The point is that the media are now central to the operation of modern societies. What is necessary is to understand the many and varied relationship between the media the public, professional groups and institutions such as the NHS.
Summary
· It is clear that the media now play an important role in policy making and implementation.
Notes
1. In fact Fan and his colleagues go further than this and claim that they can predict public opinion simply from examining media content. In reality the interactions between social institutions, the media, public belief and policy decisions are more complex than such a model could allow.
2. The sample here was seven British national papers between July 2 and September 2 1981 excluding 2 daily papers and all Sunday papers
3. Pettigrew et al, 1992 also make this point.
4. The British counterpart of the CDC, the PHLS does not use a similar procedure, but we understand that they are considering initiatives in this area. Other official bodies such as the Health Education Authority do use broadly analogous methods for the production of health education materials.
5. There are a variety of pieces on aspects of NHS public relations (e.g. Mitchell, 1985; Sheaff, 1991; Silver, 1985).
6. Although, there is recent evidence that medical researchers and public health officials, have somewhat more positive views on media reporting of their own work than on their field in general (Gellert et al, 1994a; Gellert et al, 1994b; Wilkes and Kravitz, 1992).
7. Sheaff argues that 'many NHS internal documents are dull even to their NHS readers but it is at least arguable that those which inform matters of public record... can reasonably be made public and that the onus of proof should be placed on those who wish to deny the public access to NHS records (except records containing medically or commercially confidential information) (Sheaff, 1991:140).
8. Similar findings can be found in the management and doctor/patient communication literature. Improved communication is generally deemed to improve relationships in health care settings as well as clinical outcomes (See e.g. Amsbary and Staples, 1991; Epstein and Beckman, 1994).
9. Topliss also found that the benefits of open communications were not always fully recognised by some hospital officials:
Unfortunately... while the communication system was functioning most efficiently, it was not consciously valued by many of the participants as a key feature of the hospital organisational structure. They welcomed the better staff co-operation and job satisfaction, ...which resulted from the meetings, but had not analysed the role of the meetings in securing these benefits nor were they able to regard discussion and talking over problems and possible solutions as constructive work. there is a real risk, therefore, that the hospital's very good communication system may be allowed to atrophy (1974:364).
10. See also Butler, 1994; Lloyd, 1994
11. As Walsh-Childers has put it 'The vast majority of research on the mass media influence on health has been devoted to studies of the impact of public health campaigns on individual behaviours... Despite at least twenty years worth of interest in the way the news media cover health-related issues, little if any research has been done to show how such coverage affects the development of local, state, or national government health policies' (Walsh-Childers, 1994: 820-821).
12. See also Klaidman and Beauchamp, 1986; Rettig, 1992; Walsh-Childers, 1994; Walt, 1994: 70-72.
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