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more information – www.cambridge.org/9781107648654
Evidence for Health
From Patient Choice to Global Policy
Evidence for Health
From Patient Choice to Global Policy
Anne Andermann
Associate Professor, Department of Family Medicine,
Associate Member, Department of Epidemiology, Biostatistics and Occupational Health, and
Research Associate in Public Health and Primary Health Care, St Mary’s Research Centre,
McGill University, Montreal, Canada
cambridge university press
Cambridge, New York, Melbourne, Madrid, Cape Town,
Singapore, São Paulo, Delhi, Mexico City
Cambridge University Press
The Edinburgh Building, Cambridge CB2 8RU, UK

Published in the United States of America by Cambridge University Press, New York

www.cambridge.org
Information on this title: http://www.cambridge.org/9781107648654

© A. Andermann 2013

This publication is in copyright. Subject to statutory exception

and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without the written
permission of Cambridge University Press.

First published 2013

Printed and bound in the United Kingdom by the MPG Books Group

A catalogue record for this publication is available from the British Library

Library of Congress Cataloguing in Publication data

Andermann, Anne, 1972–
Evidence for health : from patient choice to global policy / Anne Andermann.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-107-64865-4 (pbk.)
I. Title.
[DNLM: 1. Public Health. 2. Decision Making. 3. Evidence-Based Practice. 4. Health
Policy. 5. Outcome Assessment (Health Care) 6. World Health. WA 100]
362.1–dc23
2012024120

ISBN 978-1-107-64865-4 Paperback

Cambridge University Press has no responsibility for the persistence or

accuracy of URLs for external or third-party internet websites referred to
in this publication, and does not guarantee that any content on such
websites is, or will remain, accurate or appropriate.

Every effort has been made in preparing this book to provide accurate and up-to-date information which is in
accord with accepted standards and practice at the time of publication. Although case histories are drawn
from actual cases, every effort has been made to disguise the identities of the individuals involved.
Nevertheless, the authors, editors and publishers can make no warranties that the information contained
herein is totally free from error, not least because clinical standards are constantly changing through
research and regulation. The authors, editors and publishers therefore disclaim all liability for direct or
consequential damages resulting from the use of material contained in this book. Readers are strongly
advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that
they plan to use.
I have written this book for Lara and Ben, with the
hope that promoting evidence-informed decisions
will allow them to live in a healthier and more
equitable world.
Contents
Foreword page ix
Preface xi
Endorsements xv
About the author xvii
Acknowledgments xix

1 Introduction 1
2 Strategies for improving health 5
3 Understanding how decisions influence health 26
4 Producing evidence to inform health decisions 74
5 Facilitators and barriers to using evidence 121
6 Making evidence-informed decisions 146
7 Conclusion 175

Index 199

vii
Foreword
Tikki Pang
Visiting Professor, Lee Kuan Yew School of Public Policy,
National University of Singapore, Singapore and formerly
Director, Research, Policy and Cooperation, World Health Organization,
Geneva, Switzerland

In an age of financial crises, diminishing resources and competing priorities, Anne

Andermann’s book is very timely and fills an important gap in the critical area of developing
sound and sustainable health policies. While many books and manuals have been written on
the use of evidence in the development of clinical practice guidelines, there have been very
few attempts at a treatise on the use of evidence in policy formulation. Written as a practical
guide to evidence-informed decision-making, this book will be an invaluable tool for policy-
makers and others, including health practitioners, enabling and empowering them to make
rational decisions and better withstand vested interests and political, economic and even
ideological pressures, which are so pervasive in the policy sphere.
Based on her own extensive experience, the author takes us systematically through the
strategies commonly used to improve health, and the more difficult topic of how decisions
are made which impact health outcomes. She then tackles the practical issue of producing
evidence and the critical bottleneck which exists between the production and use of evidence.
Often, a major challenge is the lack of understanding between researchers and policy-makers,
which, I believe, can be overcome to a large extent by giving attention to the issues
highlighted in this book. In the chapter on evidence production, the author highlights, for
example, the increasing importance of implementation research, which aims to develop
strategies for optimising the delivery, uptake and use of new or existing interventions by
populations in need. This type of research is particularly important in supplying the kind of
evidence which policy-makers appreciate and understand more readily than basic biomedical
or even clinical research. The chapter also highlights the importance of evaluating the impact
of policy, and how such research can feed back into the “knowledge loop” in an iterative,
reinforcing manner. The final chapter cogently tackles the oft-neglected final step of how
evidence-informed decisions are actually made, highlighting the necessity of coming up with
various options which take into account ethical, social, legal and cultural issues, and the
sensitivities and concerns of interested parties who may be affected by the decision.
This book is valuable for three reasons.
First, is its pragmatic, realistic and empathetic approach. Relating her ideas to her own
personal experiences, which make the book feel vibrant and “alive”, the author highlights the
reality that policy-making is inherently complex and challenging, with evidence being only
one factor which has to be integrated with a myriad of others. In the words of Sir Michael
Marmot, the reality is that “scientific findings do not fall on blank minds that get made up as a
result. Science engages with busy minds that have strong views about how things are and
ought to be”.

ix
x Foreword

Second, is its implicit message that the need to understand the importance of evidence is
as relevant and important for a doctor, a nurse, or an individual patient and consumer, as it is
for senior policy-makers at national or global levels. All of these people must, ultimately,
make decisions pertaining to the health of human beings, be it at the level of an individual or
whole populations, both in developed and developing countries.
Third, is that it offers many universal lessons and recommendations on the importance
and use of evidence, which are applicable beyond the health sector to other sectors that
nonetheless have a direct or indirect influence on human health. The book thus speaks to
the reality of an increasingly globalised world where health challenges are transnational,
multidimensional and multi-sectoral.
In addition to its obvious value as a practical “A to Z” guide for decision-makers, the book
should be compulsory reading at the postgraduate level in the fields of public policy and
public administration, where future decision-makers need to be sensitized to the thoughts of
Goethe, who famously said “knowing is not enough, we must apply; willing is not enough, we
must act”.
I have no doubt that this landmark publication will go a long way in advancing the
cause of evidence-informed decision-making, which is the foundation for creating and
maintaining strong and sustainable health systems. Robust health systems can then achieve
their ultimate goal of improving the health status and lives of the people they serve in an
ethical, equitable and sustainable manner.
Preface
The idea for this book came to me when I was teaching a course on epidemiology to graduate
students in the Health and Health Policy (HHP) Programme at Princeton University’s
Woodrow Wilson School for Public and International Affairs. Many of my students were
completing a Master’s degree in Public Administration (MPA) or Public Policy (MPP). They
had already worked in government or for well-known international non-governmental
organisations (NGOs) and had been involved in making decisions that could affect the
health of hundreds of thousands of people. Yet for the most part they did not have any
formal education or training in health sciences upon which to base these decisions. With
undergraduate degrees in political science, management and economics, the process of
producing, appraising and using scientific evidence was a “black box” that was unveiled
during the course so that the students could be more critical readers of the research literature
(or even of reports of the literature published in the media, which is where most people read
about scientific evidence). Even health practitioners working on the frontlines – including
doctors, nurses, midwives, lay health workers and others – are not always well versed in
research methods and how research findings can be used to improve health. While evidence
is certainly not the only “ingredient” that goes into decision-making for health, making
decisions without evidence is like sailing the seas without a map and compass. Therefore, to
foster more evidence-informed decision-making, I thought it would be important to write a
book targeted towards practitioners and policy-makers that demystifies the process of
knowledge production and illustrates the complexity of decision-making so that knowledge
users are better able to incorporate the scientific evidence into decisions, to thereby influence
health outcomes in a more strategic and informed way. This is by no means an epidemiology
textbook, but rather a practical guide to evidence-informed decision-making with the goal of
improving health and reducing health inequities.
My main argument throughout this book is that the health of individuals and populations
is a product of the many decisions that we make on a daily basis. If our world has enormous
(and some might say highly unethical) health inequities whereby some people can expect to
die at age 40 whereas in other parts of the world people live on average to age 80, it is because
we make it so and we allow these disparities to continue. These are not laws of nature. There
are just people, like you and me, making a series of decisions that have consequences for
health – even when these decisions are being made outside of the health sector. The flip side
of this is that we also have the power to change the health landscape, or even our own health,
but this depends upon using the best available scientific evidence to inform decision-making,
and ensuring that decisions are not thwarted by vested interests or lack of political will.
Indeed, making evidence-informed decisions is not a straightforward process. I recall my
experiences as a researcher in a health technology assessment (HTA) agency. The role of this
organisation, at arm’s length from the Ministry of Health, was to provide government with
evidence-informed recommendations for improving health services, and ultimately for
improving health. My role was to develop a process for evidence-informed decision-making

xi
xii Preface

with regard to genetic screening that also made explicit the underlying value judgements and
ethical considerations. However, there was a clash with the economist on the Board
of Directors who strongly believed that all considerations can be incorporated into a
cost-effectiveness analysis and who disagreed that cost issues are just one aspect – rather
than the central aspect – of decision-making. On another occasion, there was a clash with a
fellow researcher – a devout Catholic and anti-abortionist – who was developing recom-
mendations for prenatal screening that would affect the entire population. To what extent
should her own personal values be permitted to influence recommendations made in a multi-
cultural society where citizens do not share the same values? How can we ensure that value
judgements are made explicit rather than pretending that they do not exist? Even risk
tolerance varies from person to person. How to choose a threshold for an entire population
when some people would be comfortable with a risk of 1 in 100 of carrying an affected fetus,
and others would be unable to sleep at night if they had a risk of 1 in 1,000? This book
illustrates that decision-making for health is a highly complex and contentious area where
even experts can disagree on the best process for making these decisions – and quite often,
there isn’t a systematic or explicit process being used at all.
While there is no single, universally accepted approach to decision-making, this book
provides an algorithm that uses a series of questions for arriving at evidence-informed
decisions that take into consideration the multiple complexities and value judgements
involved. In many ways, the process (i.e. being participatory and involving stakeholders, as
well as being explicit in justifying why a certain decision is made) is just as important as the
product (i.e. the final decision made).
From my later experiences working as a public health consultant for another government
agency that provides technical assistance to local health regions, I witnessed first-hand how
decisions made by government can be very poorly received when certain stakeholders do not
understand how these decisions were made and feel that the decisions are unfair. Quite
literally there were fists thumping on tables and cries of injustice, followed by vehement
accusations that the government was simply trying to save money and ration services. This
was true decision-making in action. Not for the faint of heart. My role was to chaperone the
process of revisiting the decision, which was done in a systematic, evidence-informed and
participatory way. Everyone walked through the process together and various experts were
called in as needed to clarify certain issues. The key was that everyone was on the same page
and could appreciate the multiple complexities and considerations involved. While the local
stakeholders still wanted to lobby for their cause, they were much more understanding the
second time around when the government made the exact same decision – because this time
there was also a clear explanation and understanding of why this decision was made. Of
course, this does not mean that it was a straightforward case. Indeed, when the policy-maker
from the Ministry asked for my opinion prior to making their decision public, I had to admit
that it was a bit of a grey zone. On the one hand, offering this new preventive service to the
region could be justified on the basis that this region has a somewhat higher prevalence of the
health problem in question. On the other hand, this would be one of the first jurisdictions
worldwide to offer such a service outside of a research context, there are many known
technical and ethical ramifications involved in introducing this service, and the health
problem is also fairly common in other neighbouring jurisdictions (although not quite as
prevalent), which would lead to inequities in terms of access to services (also known as the
“postcode lottery”). Thus, there were reasons given that clearly explained why the govern-
ment chose not to go ahead with the introduction of this service – it was not simply a case of
 Preface xiii

rationing health care and saving money. Moreover, as the knowledge base and the context
evolve, this decision could certainly be revisited over time to see whether these reasons still
apply in future. The more I am involved in decision-making at a political level, the more
I empathise with the challenges involved in integrating so many diverse considerations and
viewpoints, and the more I believe in the value of a systematic approach that makes these
multiple factors explicit.
Reflecting these experiences, the scope of this book is very broad, from the personal
decisions that individual patients make about their own health to global policy decisions that
can impact the health of millions of people worldwide. As a graduate student at Oxford
University, the focus of my doctoral research was to better understand the expectations and
information needs of women presenting to primary care, and what factors could promote
evidence-informed patient choice. Later, as a family doctor, I experienced the daily chal-
lenges of helping my own patients make difficult decisions about their health: for instance,
whether to undergo surgery that can improve quality of life but entails a certain risk of dying
during the procedure or to forego surgery and live as long as possible with increasingly
impaired function. As a public health physician working to promote the health of an
Aboriginal population in the North of Canada (for public health physicians, the “patient”
is the population), I was involved in examining the Health Impact Assessments of economic
development projects and making recommendations on how to balance the needs of various
disadvantaged populations in the North in a way that is fair and maximises benefits while
minimising harm. As well, while working at the World Health Organization (WHO) in
Geneva, I advocated for universal access to primary health care worldwide as an important
method of social protection and lever for tackling health inequities. Currently, I combine
public health practice at the local and national level, clinical work in a university-affiliated
teaching hospital serving a diverse multi-cultural community, supervision and training of
medical students and residents, and global health research aimed at empowering frontline
health workers to tackle the social causes of poor health. I therefore write this book wearing
several “hats”: as a policy-maker, a researcher, an educator, a health practitioner and even as a
patient.
As one moves from patient choice to global policy, the level of complexity increases
significantly. Yet, all decisions fundamentally entail various trade-offs when considering the
different options and balancing the overall benefits and harms of choosing one option over
another. Through this book, I hope that I can help policy-makers and practitioners to make
more evidence-informed decisions for improving health. In particular, with the growing
emphasis on the upstream social determinants of health, I hope that this book will also reach
decision-makers outside of the health sector, as decisions made in areas such as education,
employment, housing, gender equality and so forth are fundamental to tackling the major
health inequities of our time. To make progress in reducing these inequities, we need
evidence-informed decisions that consider the health impact of all policies, not just those
involving the health care system. Better-informed decisions can lead to healthier and more
equitable societies. It is up to us to choose.
Endorsements
“To enable individuals to be in control of their lives, action is needed on the social circumstances in which
people are born, grow, live, work, and age. Evidence for Health: From Patient Choice to Global Policy is
an innovative and timely book that provides important insight on how to make more transparent and
informed decisions that will result in healthier individuals and more equitable societies.”
Professor Sir Michael Marmot, Director, UCL Institute of Health Equity, London, UK, and formerly
Chair, WHO Commission on the Social Determinants of Health

“Evidence for health seems self-evident, however, Andermann in her thought-provoking book, points not
only to the value of evidence, but also to the imperative to learn how to integrate it more systematically in
all decisions related to health from local to global. Progress on this front would certainly contribute to
better decisions and better health.”
Dr. Timothy Evans, Dean, BRAC School of Public Health, Dhaka, Bangladesh, and formerly Assistant
Director General of the World Health Organization, Geneva, Switzerland

“Public health has too often focused on making recommendations about what people ought to do rather
than considering what changes behaviours and policies. Drawing from multiple disciplines, Andermann
thoughtfully addresses this challenge, reviewing how we make decisions that affect health – from the
individual to the global level – and detailing how we can generate and best make use of evidence to reduce
health inequities and improve people’s health.”
Dr. Kumanan Rasanathan, Health Section, United Nations Children’s Fund (UNICEF), New York,
USA
“This book addresses key questions confronted by policymakers, health practitioners and the population at
large. Written in a very simple and user-friendly manner, Evidence for Health will be a highly valuable
tool for understanding and addressing health inequities in both developed and developing countries.”
Mr. Saeed Awan, Director, Centre for the Improvement of Working Conditions & Environment,
Department of Labour and Human Relations, Government of Punjab, Lahore, Pakistan

“A fresh, thoughtful, and panoramic look at the role of evidence in health. This book should be of interest to
any student of public health or public policy.”
Dr. Peter Singer, Professor of Medicine and Director, Sandra Rotman Centre, University Health
Network and University of Toronto

“Decision-making is a complex process, particularly in medicine and public health. It frequently implies
the simultaneous display of technical abilities, political appraisals, and moral judgements. Anne
Andermann’s book, Evidence for Health: From Patient Choice to Global Policy, makes this process
accessible to all. I have no doubt that it will become an invaluable tool for health professionals working in
clinical, management, and public health settings.”
Dr. Julio Frenk, Dean of the Faculty, Harvard School of Public Health, and former Minister of Health of
Mexico

xv
About the author
Chapter

NaN
Dr. Anne Andermann is a family physician, a public health specialist and a former Rhodes
Scholar. Her doctoral studies at Oxford University focused on the impact of new genetic and
genomic technologies in primary care, and she later worked for the Quebec Health
Technology Assessment Agency (formerly AETMIS) on developing guidance for population-
based genetic screening policy-making. Dr. Andermann has also worked at the World Health
Organization (WHO) in Geneva on research capacity strengthening in low- and middle-
income countries. During that time, she was a member of the WHO Research Ethics Review
Committee and a main contributing author to the World Health Report 2008 on increasing
universal access to primary health care. Dr. Andermann is currently an Associate Professor in
the Department of Family Medicine at McGill University, Regional Medical Officer for Health
Canada’s First Nations and Inuit Health Branch (FNIHB), Public health physician for the Cree
Board of Health and Social Services of James Bay Northern Quebec (CBHSSJB), Chair of the
public health theme for the new undergraduate medical curriculum at McGill’s Faculty of
Medicine, practising physician and Chair of the Community-Oriented Primary Care (COPC)
Committee at St Mary’s Hospital, and founder of an international research collaboration that
aims to provide guidance and support for frontline health workers so that they can play a
greater role in addressing the social causes of poor health and reducing health inequities. Her
main area of interest is promoting the health of vulnerable and marginalised populations,
including women and child health, Aboriginal health, global health and the health of families
with rare and orphan genetic diseases. In 2011, she received the Canadian Rising Stars in
Global Health Award from Grand Challenges Canada. This is her first book.

xvii
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 Plate XLIII.

PUNCHING AND SHEARING.

Larger image

The modern practice of joggling and of scarfing the laps and

edges of plates is applied in many instances, and special hydraulic
tools are provided to carry out this work. The firm were also early in
adopting the practice of joggling frames, deck beams, etc. The
frames and beams are joggled when cold, to suit each alternate
inner strake of plating, in a special design of hydraulic press, of
which there are several in the works. This tool, illustrated on Plate
XLI., adjoining page 95, carries dies on the ram-head and on the
anvil, to form between them the obverse and reverse sides of the
dent or joggle desired. Movable centre-pieces on the ram-head and
anvil are traversed in all directions by screw thread to suit the
position and width of the joggled part, and a gauge shows variations
of 0.1 in. in the position of the joggled part of the frame. A 2 ft.
length of angle can be joggled at each stroke. The machines are by
Messrs. Hugh Smith and Co., Limited, Glasgow.
The same machine joggles the lap or edge of a shell, inner
bottom, or deckplate in a similar way. The whole length of the frame
or plate can thus be worked in a very short time. A powerful jib
crane, of 16 ft. radius, assists materially in the rapidity of the work
turned out by these tools. The only slips required are at the ends of
the vessel, where the bevel of the frames precludes the use of
joggling. A special electrically-driven hammer is used for forming
these taper slips.
The angles, etc., to form the frames are assembled at the head
of the building-berth, and when lying on skids are riveted to form
the double bottom, frames and margin plates. Hydraulic riveters are
used wherever possible. There are about a score of these at work in
the shipbuilding yard, with cylinders from 8 in. to 10-1/2 in. in
diameter, a stroke of 7-1/2 in., and a gap of 55 in., so that heavy
work can be done. Some of them are specially designed for keel
work, for closing rivets in beams, and for difficult parts.
The frames thus riveted are conveyed down the berth by a
simple and ingenious cableway, known in the Works as the
"switchback," from its resemblance to the well-known amusement
railway. A derrick-post stands at the head of the berth adjacent to
the skids on which the frames are riveted. The cable stretches from
a small derrick at the foot of the shipbuilding berth over a pulley at
the top of the large derrick-post, and thence, through a similar block
at its base, to an electric winch. The frame or unit of the ship's
structure is suspended on a running block on the cable, which is
then made taut, partly by the working of the winch and partly by the
large derrick post being inclined backwards. The running block with
its load travels down the taut cable by gravity, under the guidance of
the squad of fitters. The gradient of the cableway is only sufficient to
enable the load to move slowly to its position in the shipbuilding
berth.
The double-bottom frames and margin plates are united with the
keel-plate, and subsequently there are successively worked into the
structure the tank top plates, side frames, the skin plates, beams,
bulk-heads, and other units, portable hydraulic punches and riveters
being largely used. Pneumatic tools are also extensively employed
for boring, drilling, riveting, chipping, caulking, etc. There are from
130 to 140 of these tools in use on vessels in course of construction.
There are ten building berths ranging in length up to 700 ft.; but
slight alterations would enable the firm to build vessels of still
greater size. Several of these are shown on the engraving on Plate
XXXVII., facing page 88. The launching ground is probably the finest
in the river, the channel being here of great depth and very wide, as
is shown on the engraving opposite. Indeed, ordinary merchant
vessels with full lines are launched without any check chains; the
fine-ended ships—mail steamers and cruisers—are, as a
precautionary measure, checked by drags in the usual way. The
engraving on Plate XXXVIII., facing page 90, shows the launch of
H.M.S. Argyll.
 Plate XLIV.

THE FITTING-OUT DOCK.

Larger image
 Plate XLV.

THE GRAVING DOCK.

Larger image

The ships launched are completed in the fitting-out dock,

constructed about two years ago, and illustrated on Plate XLIV. The
engraving shows H.M.S. Argyll under the big jib-crane. This dock has
a length of 560 ft. and a width of 172 ft., and opens directly into the
channel of the Clyde. The depth of water is never less than 28 ft., so
that warships are afloat at all states of the tide. A prominent feature
in the view is the crane, which was supplied by Messrs. George
Russell and Co., Limited, of Motherwell, and lifts 120 tons at a radius
of 70 ft. It is carried on concrete foundations and piers, which rise
20 ft. above the level of the quay. In addition to the pier for carrying
the mast of the crane, there are similar supports for each of the
back legs through which the crane is anchored.
One advantage of the derrick type is that the crane may be
placed close to the edge of the quay; in this case the centre is only 7
ft. from the front of the wharf, so that the full load of 120 tons can
be dealt with at an effective outreach of 63 ft. from the quay. The
maximum radius of the heavy purchase with a load of over 60 tons
is 90 ft., and of the light purchase gear, with a load of 10 tons, 98 ft.
The minimum radius of the crane is 25 ft. There are four sets of
gear: for lifting heavy loads, for raising light weights, for derricking
the jib, and for slewing; a separate controller of the enclosed
tramway type is provided for each. The main hoisting and derricking
motors are of 50 horse-power, and the others of 35 horse-power.
The speed of hoisting 120 tons is 5 ft. per minute, while a 10-ton
load is raised at the rate of 40 ft. per minute. Automatic brakes are
fitted for the slewing motion, and powerful hand-brakes for the
hoisting and derricking gears. All motions are controlled by one man
in the steelhouse fixed to the mast of the crane 56 ft. above the
quay level.
There is on the opposite wharf of the dock a 20-ton travelling
electric crane, and throughout the Works there are many portable
and hydraulic cranes, in addition to the hydraulic and other cranes
commanding the machine tools.
Reference may here be made to the Company's graving dock,
illustrated on Plate XLV., adjoining page 101. The length is 360 ft.,
and it is largely used for docking ships for repair, as well as for
cleaning ships preparatory to trial. Our view shows a torpedo-boat
destroyer in the dock. The pumps for the emptying of the dock are
electrically driven.
We may return now to our narrative of the construction of a ship,
and deal with the supplementary departments, including those of
joiners, smiths, plumbers, sheet-iron, and other workers.
Wood-work forms a large and important item in most of Scotts'
ships, as many of them are for passenger service. We illustrate on
Plate XLVI. one of the saw-mills. It is self-contained, having its own
power plant, including a compound engine, having cylinders 15-1/4
in. and 27-1/2 in. in diameter by 44-in. stroke. There are four
vertical saw frames, the largest having a 36-in. frame, six rollers,
and two bogies to take in the heaviest logs. In addition, there are
circular saws, ranging up to 6 ft. in diameter, a swing cross-cut saw,
special planing, moulding, and turning machines to do heavy work,
and saw-sharpeners, grindstones, punching machines and anvils to
carry out all repairs and fettling of the blades, etc. There are also
large steam-heated drying stoves, and a timber-drying yard of about
three acres in extent. The overhead travelling cranes range up to 5
tons capacity, and the rails on which they run are extended on
columns across the yard. The saw-mill is the largest and best-
equipped in the district, and does the sawing and planing of timber
for three of the largest shipbuilding yards, as well as the general
work for two other firms.
 Plate XLVI.

THE SAW MILL.

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Plate XLVII.

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 Larger image

TWO VIEWS IN THE JOINER SHOPS.

The joiners' and cabinet-makers' shop, as we have already

indicated, occupies two floors of a building 240 ft. long and 52 ft.
wide; while the fourth floor is utilised for the French polishing work,
as well as for storing the completed wood-work until the vessel is
ready to receive it. Provision is also made in the same building for
the model-making department, in which replicas of nearly all ships
are produced, and, being works of art, because of their
completeness, accuracy, and beauty, have earned high awards at
many Exhibitions.
In the joiners' shops, illustrated by two engravings on Plate
XLVII., adjoining this page, there is a complete equipment of wood-
working machines for sawing, turning, planing, moulding, sand-
papering, mortising, boring, tenoning, dovetailing, dowelling and
joining. These are electrically driven, and are grouped at three
places in the length of the shop on each floor, with benches around
them, so that the joiners do not require to carry their jobs any
distance in order to have them machined. There is also in use in
connection with the department a portable electric circular saw,
which is specially useful for carpenters and joiners, etc., on board
the ship in the dock. An electric deck-planer, of the lawnmower form,
has proved serviceable in reducing enormously the most laborious
task experienced by carpenters and joiners.
There are two large smithies convenient to the shipbuilding
berths, and in both cases the finishing department adjoins. In one
case there are fifty-four fires and eight hammers; in the other, forty
fires, with five hammers, ranging up to 15 cwt. The fires are
operated by mechanical blowers, and the smoke and waste gases
are carried off by overhead ventilating pipes. Extensive work is
carried out by the smiths. Die-stamping is largely adopted in
connection with the making of eye-plates, cleats, stanchions, clips,
etc. In each finishing shop there are band saws, radial and other
drills, screwing machines, and grindstones. Smiths' stores are
arranged above the finishing shops.
The plumbers' shop is fitted with a special machine for bending
pipes when cold, as well as screwing and tapping machines, drills,
saws, grinders, and fires.
The sheet-iron department is equally well equipped, having
straightening rolls, shearing, punching, chipping, drilling, and other
tools, with various hammers; and here work is done in connection
with ventilating and other light ironwork.
In view of the warship contracts undertaken, the mechanics'
shop, for work peculiar to the ship as distinct from the propeller
machinery, etc., is extensive. The four lathes here range up to 27 ft.
in length over all, with a 14-in. headstock and a 22-ft. bed. There is
a useful shaping machine, a fair-sized planer, and several drills, all
adequate for the work required, which is remarkable more, perhaps,
for its great variety than for size.
All the machinery in the yard, and in several departments in the
engine and boiler works, is run from one central station, of which
two views are given on Plate XLVIII., opposite. The electric
generators occupy one side of the power station, and the air
compressors and hydraulic pumps the other. Steam at 200 lb.
pressure is supplied by one marine cylindrical, and four Babcock and
Wilcox water-tube, boilers, with superheater, coal conveyors, and
mechanical stokers.
 Plate XLVIII.

ELECTRIC GENERATORS IN THE POWER STATION.

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 HYDRAULIC PUMPS AND AIR COMPRESSORS IN THE
POWER STATION.
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There are three electric generating sets, with a total capacity of

1200 kilowatts, the voltage being 240. They are illustrated on Plate
XLVIII., facing this page. The engines are of the high-speed,
enclosed, forced lubrication, condensing type. The current is
distributed from a switchboard in the power station by overhead
mains, with three-way distributing panels in the various
departments. The motors, of which there are about 130 in the
shipbuilding department alone, are of the two- and four-pole type,
partly or entirely enclosed, and mostly of 10 to 20 electric horse-
power. Arc lamps are used for lighting, but the shops and offices are
also illumined by 16 and 32 candle-power incandescent lamps. Plugs
are arranged at various points throughout the yard for portable
lights, and for connecting mains for lighting the various ships while
being completed in the docks.
Hydraulic power at 800 lb. pressure is generated by two high-
pressure pumps, with steam cylinders 15 in. in diameter, and rams 4
in. in diameter. There are separate accumulators for each. The
pressure pipes are led underground throughout the Works to the
various hydraulic tools already referred to.
There are two air compressors for supplying power for the
pneumatic tools. The combined capacity is 1800 cubic feet of free air
per minute. Each has two steam cylinders 6 in. in diameter, working
respectively high- and low-pressure air cylinders 15-1/4 in. and 21-
1/4 in. in diameter, the stroke being 18 in. The hydraulic pumps and
the air compressors are illustrated on Plate XLVIII., facing page 104.
As we have already stated, part of the power generated in this
station is utilised at the engine works, to which we may now turn
our attention.
 The Engine and Boiler Works.

APIDITY of construction has been characteristic of the

engine and boiler works of the Scotts to at least as
great an extent as in the shipbuilding yard. Several
instances might be noted, beginning with six blockade-
runners, built in a very short period, in 1864, and fitted
with engines to give a speed of 12 knots at sea and 13-1/2 knots on
trial. A recent and striking instance is the construction of boilers and
engines for twenty of the passenger steamers built for traffic on the
Thames, to the order of the London County Council, and described
on pages 83 and 84, ante. The contract for this work was signed
towards the end of November, 1904, and work was commenced
about the beginning of December. The various parts of the engines
were being machined and finished during the month of January and
the beginning of February, 1905; and all of the twenty sets of
engines and boilers were completed by the end of May. Another
noteworthy case is the construction of the machinery for the
steamship Fengtien, described on page 80, ante. Work was
commenced on the machinery in the middle of January, and finished
about the end of April. The machinery was fitted in the ship and
ready for the trials on the 29th May. The total time taken from the
beginning of work was well under five months.[69]
 Plate XLIX.

VIEW IN MAIN MACHINE SHOP.

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The pattern shop, where all work originates, is fitted with the
usual pattern-making machinery, including a core-making machine.
The iron foundry, which was begun in 1790,[70] and around
which the large engineering establishment has since been raised
step by step, continues to do sound work. There are four cupolas, of
a combined capacity of about 20 tons, and cylinders up to 120 in. in
diameter are cast. These facts suggest the satisfactory character of
the equipment.
The brass foundry is an equally important department, where
first-class work is done. There are fifty-two crucible pots in use,
varying in size up to 150 lb., and of a collective capacity of about 2
tons; also an air furnace capable of producing at one heat 12 tons of
metal, for such heavy castings as are required for preparing shaft
liners, large sea chests for naval ships, etc. The strength of
Admiralty gun metal made in this foundry is up to 18 tons per
square inch, with 30 per cent. of elongation in a 2-in. length. The
foundry is served by an electrically-operated jib crane.
In the forge and smiths' shops a large amount of detail work is
done, in units ranging up to 3 tons in weight. The hammers vary up
to 15 cwt. power. A considerable amount of die-stamping is done in
connection with auxiliary engine forgings, etc. All paddle-wheels are
made in this department. The blast for the fires is got from an
electrically-driven fan.
The machine shop, which was one of the first constructed with a
completely glazed roof, occupies a site on a steep slope, one side
being formed by a heavy retaining wall, as shown in the engraving
on Plate XLIX., facing page 106. At the level of the top of the wall,
which is 25 ft. high, there is the light machine shop, while at the end
of the bay and over the annexe situated to the left of the engraving,
is the brass-finishing shop. There is a 2-ton hoist between the
erecting-shop floor and the galleries, so that no inconvenience, so
far as transport is concerned, is involved by this arrangement.
Originally a stream ran down the hill and over the site on which
the Works are located, and its waters have for many years been
utilised as a source of power. A special 24-in. inward-flow turbine
works in the conduit which conveys the water across the site, and
this turbine develops continuously 80 horse-power. This serves to
drive some of the machines in the boiler works. The turbine runs in
parallel with a compound vertical engine, which drives the shafts
actuating the groups of small machines in the engine shop. Many of
the larger tools, however, are electrically-driven by separate motors,
the current being transmitted from the central station already
described.
The engravings on Plates XXXIX. and XLIX., facing pages 92 and
106 respectively, illustrate the main machine shop, which has a
width of 60 ft., and, with the adjoining bay, accommodates some of
the finest marine engineering tools made. Perhaps the best
indication of their efficiency is the fact that three weeks suffice for
the machining of the parts of a complete set of engines to develop
2000 horse-power. The shops are traversed by five overhead electric
cranes, ranging up to 40 tons lifting capacity.
 Plate L.

VERTICAL PLANING MACHINE.

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MULTIPLE SPINDLE DRILLING MACHINE.
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 Plate LI.

SURFACE AND BORING LATHE.

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The leading dimensions and the principal work done by the more
important tools afford an idea of the extent of the equipment. There
are several planing and slotting machines, one of which is shown in
the engraving on Plate L., facing this page. There are two combined
machines, to plane 21 ft. and to slot 18 ft., used in connection with
the condensers, cylinders, large bearing frames and sole-plates of
engines, while two other smaller tools are devoted to finishing the
castings for bed-plates and columns. For machining eccentric-rod
ends, etc., there is a 24-in. slotter with a circular table. There are
two high-speed planers with two tool-boxes on the cross-slide, which
take in pieces 10 ft. by 5 ft. by 5 ft., and one to take work 12 ft. by 3
ft. by 3 ft.
In the driving of some of the heavier tools very good results have
been attained by the application of a reversible motor, which in one
case has dispensed with four belts, a pair of bevel wheels, and two
countershafts, reducing enormously the frictional waste, and
enabling higher speeds and quicker return strokes to be attained.[71]
 For drilling work there are several large tools. Recently there has
just been fitted a multiple machine which, while primarily intended
for drilling the tube-holes in drums and water-pockets of Yarrow
water-tube boilers, is also utilised in connection with ordinary
machine work. This tool, of which an engraving is given on Plate L.,
facing page 108, was manufactured by Messrs. Campbells and
Hunter, Limited, Leeds. It has a massive cross-slide carrying four
saddles, movable by a powerful screw, driven by spur-gearing and
friction-clutch, controlled from one of the saddles. The steel spindles
are balanced, and have a special self-acting, variable, rack-feed
motion, as well as a quick vertical motion by hand for rapidly
adjusting the drill through the jig. Each spindle can be operated
independently. The table has a sliding motion, directed by two
straight screws coupled to the cross shaft and vertical shaft, and is
carried by a straight bed with three bearing surfaces. This machine,
which weighs 20 tons, is driven by a 30 brake-horse-power electric
motor.
There are two vertical boring mills used for cylinder work, one
being capable of boring up to 120 in. in diameter, and the other to
94 in. in diameter. A combined boring and facing machine, with a
table 4 ft. square, is usefully employed on propeller bosses, valve-
chests, small cylinders, and built-up bed-plates, machine bearings,
etc.
The installation of high-speed lathes is specially noteworthy. In
one, the face-plate can take in 12 ft. in diameter, and, as the length
of bed is 30 ft., it is useful for large surfacing work, as well as for
turning crankshafts of the larger sizes. There are two 12-in. double-
geared lathes for surfacing and screw cutting. These are self-acting,
and the lengths of bed are 19 ft. and 12 ft. respectively. For turning
piston and connecting rods, two screw-cutting lathes of 16-1/4-in.
centres are in use, the length of the bed being 22-1/2 ft. These have
each a triple-gear headstock, and a chuck 48 in. in diameter; with
rack motion and slide-rest feeds. A 20-in. centre lathe, with a bed 28
ft. 6 in. long, is fitted with two saddles and four slide-rests for shaft
liners, etc. Amongst others, there is a 27-in. centre lathe for
shafting, the bed being 36 ft. long.
One of the lathes is illustrated on Plate LI., adjoining page 109.
This is a 48-in. surfacing and boring lathe, by Messrs. John Lang and
Sons, Limited, Johnstone. The two new features introduced are the
variable speed drive and automatic speed-changing mechanism. The
headstocks can be used for single or triple gear, and are so arranged
that, even when running at the greatest speed, there is a reduction
by gearing. With this arrangement the lathes have greater power
when turning small diameters than when the belt is used driving
direct to the main spindle. The spindles, which are hollow, with
hexagonal turrets, are of crucible cast steel, and run in gun-metal
bearings. By means of the speed-changing mechanism, the cutting
speed of the tool is kept practically constant when surfacing. This
means that any surface can be finished off in about one-half of the
time taken by a lathe having the ordinary step-cone drive, where the
workman will not change the position of the belt while surfacing.
The self-acting feed-motions are positive.
 Plate LII.

BRASS FINISHING SHOP.

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Milling is adopted in many instances in preference to planing or

slotting, and this is especially so in connection with valve quadrants,
columns, faces, etc. For the first-named there is a large vertical
miller, and for the latter a horizontal tool with a vertical milling
apparatus. For grinding bolts, etc., a machine having a separate
head for grinding taps is used, the emery wheel being 18 in. in
diameter and 1-1/2 in. broad.
A shop, now in course of construction, is to be specially laid out
for the manufacture of turbine machinery of the greatest power. It is
to be 285 ft. long, with a span of 60 ft. Heavy lifts will be taken by a
100-ton overhead crane, and ordinary work will be handled by a 40-
ton electric crane. The heavy machine tools, while specially chosen
for turbine work, are also adaptable for use in the manufacture of
the heaviest reciprocating machinery. The principal tools are large
lathes suitable for turbine rotors and crank-shafts; vertical boring
machines which may be utilised for work on cylinders as well as on
turbine casings; and a heavy planer, 10 ft. by 10 ft. by 25 ft. stroke.
The necessary small machine tools for turbine work will be put down
in this department, whence also some of the large tools will be
removed from the existing shops, so that it will be fully equipped for
the purpose intended.
The brass-finishing shop, which is illustrated on Plate LII., facing
page 110, serves both for ship and engine work. It has only recently
been laid out anew. The machines, according to the latest practice,
are arranged down each side of the shop, and the benches occupy
the centre. Each alternate bench is utilised for the material to be
operated upon, so that the working bench is not littered in a
confused way, as is too often the case. There are representative
types of the best makes of automatic tools, turret lathes, brass-
finishers' lathes, and grinding machines with specially large discs.
A considerable amount of work is done to limit gauge in all the
shops which we have described. This practice has been considerably
developed recently, and a specially equipped department has been
organised, where gauges, templates, and cutting tools are made.
This department is illustrated on Plate LIII., facing this page. A word
may first be said as to the significance of this new department.
Where three or four ships have engines of the same type, a set of
jigs and templates for the most important parts are at once made,
so that a unit from an engine in one ship may be fitted to an engine
in another. This simplifies the ordering of new parts, and greatly
reduces the number of spare items which have to be kept in store by
the owners, in order that repairs or refits may be effected at short
notice.
For some time the Scotts have adopted this system, so that it
was a simple matter to enforce it in connection with the machinery
of the twenty Thames Steamers, and in recent naval work, where
the practice is being applied in an extended form. In the recent
Admiralty work every part of an engine is made interchangeable and
identical with the corresponding parts of other engines for the same
type of ship, although built in different parts of the country; and this
fact alone will indicate the extent and intricacy as well as the care
and degree of accuracy necessary. This standardisation to ensure
interchangeability has reached its highest exemplification in the case
of the machinery for the armoured cruiser Defence, of 27,000
indicated horse-power, to be completed in twenty-one months from
the placing of the order by the Admiralty.
 Plate LIII.

TOOL, GAUGE, TEMPLATE, AND JIG DEPARTMENT.

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Then, as regards the tool-making and fettling—the other branch

of work carried out in the tool room—it has been recognised that, to
make the cutting tools efficient, it is necessary to utilise the most
suitable steel for the tools working on various metals and alloys; and
the selection of the tool steel for each metal has been systematised
by the careful collation of data of actual work. In the manufacture of
the tools special appliances are used and will be referred to
presently. The workmen are encouraged to use only tools in sound
condition. Each machine-man in the shops has ten checks, and may
borrow from the store a corresponding number of tools, but these
must be returned as soon as possible for overhaul and re-grinding.
The bonus system further induces the men to ensure that their tools
are in good condition.
The tool department is separate from the main structure, and in
it all jigs, templates, and gauges, as well as tools, are constructed.
Standard gauges, as well as limit gauges, are used, and both are
marked in metrical and English dimensions. The tool room is not
only carefully maintained at a regular temperature, in order to
prevent the templates and jigs from varying in the course of their
manufacture, but the appliances adopted have been selected so as
to get the most precise results. In connection with the manufacture
of large boiler taps, drill gauges, milling cutters, etc., a specially
designed gas furnace has been built, with a number of
compartments which can be used separately or collectively,
according to the size of the tool being made. The toolsmith's forge is
on the down-draught principle, so that, in addition to carrying off all
smoke and dust, it tends to keep the atmosphere pure.
Amongst the principal machines used in this tool-manufacturing
department is an 8-in. Whitworth self-acting, sliding-surfacing, and
screw-cutting lathe, with a backing-off and taper-turning
attachment. The milling, drilling, and grinding machines are all by
the best makers. A 10-ft. machine is used for making the
comparative measurements from existing standards. This machine,
also of Whitworth make, has a measuring screw in a fast headstock
with a large dividing wheel, one division of the latter representing
0.0001-in. in the end movement of the spindle. All transverse and
tensile testing of bars is done in this department.
A check system is used in connection with the distribution of
templates, tools, drawings, etc., and a separate store in the centre of
the works is arranged for this purpose.
 HYDRAULIC PLATE-BENDING MACHINE.
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As to the boiler works, the fact that in 1905 the production was
practically one boiler per week is, of itself, testimony to the nature of
the plant adopted. The main boiler shop, together with its yard, has
an area of 7000 square yards, and a height of 45 ft. to the crane
rail, and is served by five overhead electric cranes, ranging in lifting
power up to 100 tons, with numerous jib and other cranes
associated with the various machine tools.
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