Getting England to be more physically active: are the Public Health Responsibility Deal's physical activity pledges the answer?

BACKGROUND

The Public Health Responsibility Deal (RD) in England is a public-private partnership involving voluntary pledges between government, industry, and other organisations to improve public health by addressing alcohol, food, health at work, and physical activity. This paper analyses the RD physical activity (PA) pledges in terms of the evidence of their potential effectiveness, and the likelihood that they have motivated actions among organisations that would not otherwise have taken place.

METHODS

We systematically reviewed evidence of the effectiveness of interventions proposed in four PA pledges of the RD, namely, those on physical activity in the community; physical activity guidelines; active travel; and physical activity in the workplace. We then analysed publically available data on RD signatory organisations' plans and progress towards achieving the physical activity pledges, and assessed the extent to which activities among organisations could be attributed to the RD.

RESULTS

Where combined with environmental approaches, interventions such as mass media campaigns to communicate the benefits of physical activity, active travel in children and adults, and workplace-related interventions could in principle be effective, if fully implemented. However, most activities proposed by each PA pledge involved providing information or enabling choice, which has limited effectiveness. Moreover, it was difficult to establish the extent of implementation of pledges within organisations, given that progress reports were mostly unavailable, and, where provided, it was difficult to ascertain their relevance to the RD pledges. Finally, 15 % of interventions listed in organisations' delivery plans were judged to be the result of participation in the RD, meaning that most actions taken by organisations were likely already under way, regardless of the RD.

CONCLUSIONS

Irrespective of the nature of a public health policy to encourage physical activity, targets need to be evidence-based, well-defined, measurable and encourage organisations to go beyond business as usual. RD physical activity targets do not adequately fulfill these criteria.

Taking knowledge users' knowledge needs into account in health: an evidence synthesis framework

The increased demand for evidence-based practice in health policy in recent years has provoked a parallel increase in diverse evidence-based outputs designed to translate knowledge from researchers to policy makers and practitioners. Such knowledge translation ideally creates user-friendly outputs, tailored to meet information needs in a particular context for a particular audience. Yet matching users’ knowledge needs to the most suitable output can be challenging. We have developed an evidence synthesis framework to help knowledge users, brokers, commissioners and producers decide which type of output offers the best ‘fit’ between ‘need’ and ‘response’. We conducted a four-strand literature search for characteristics and methods of evidence synthesis outputs using databases of peer reviewed literature, specific journals, grey literature and references in relevant documents. Eight experts in synthesis designed to get research into policy and practice were also consulted to hone issues for consideration and ascertain key studies. In all, 24 documents were included in the literature review. From these we identified essential characteristics to consider when planning an output—Readability, Relevance, Rigour and Resources—which we then used to develop a process for matching users’ knowledge needs with an appropriate evidence synthesis output. We also identified 10 distinct evidence synthesis outputs, classifying them in the evidence synthesis framework under four domains: key features, utility, technical characteristics and resources, and in relation to six primary audience groups—professionals, practitioners, researchers, academics, advocates and policy makers. Users’ knowledge needs vary and meeting them successfully requires collaborative planning. The Framework should facilitate a more systematic assessment of the balance of essential characteristics required to select the best output for the purpose.

Are the Public Health Responsibility Deal alcohol pledges likely to improve public health? An evidence synthesis

AIMS

The English Public Health Responsibility Deal (RD) is a public-private partnership involving voluntary pledges between industry, government and other actors in various areas including alcohol, and designed to improve public health. This paper reviews systematically the evidence underpinning four RD alcohol pledges.

METHODS

We conducted a systematic review of reviews of the evidence underpinning interventions proposed in four RD alcohol pledges, namely alcohol labelling, tackling underage alcohol sales, advertising and marketing alcohol, and alcohol unit reduction. In addition, we included relevant studies of interventions where these had not been covered by a recent review.

RESULTS

We synthesized the evidence from 14 reviews published between 2002 and 2013. Overall, alcohol labelling is likely to be of limited effect on consumption: alcohol unit content labels can help consumers assess the alcohol content of drinks; however, labels promoting drinking guidelines and pregnancy warning labels are unlikely to influence drinking behaviour. Responsible drinking messages are found to be ambiguous, and industry-funded alcohol prevention campaigns can promote drinking instead of dissuading consumption. Removing advertising near schools can contribute to reducing underage drinking; however, community mobilization and law enforcement are most effective. Finally, reducing alcohol consumption is more likely to occur if there are incentives such as making lower-strength alcohol products cheaper.

CONCLUSIONS

The most effective evidence-based strategies to reduce alcohol-related harm are not reflected consistently in the RD alcohol pledges. The evidence is clear that an alcohol control strategy should support effective interventions to make alcohol less available and more expensive.

The Public Health Responsibility deal: has a public-private partnership brought about action on alcohol reduction?

BACKGROUND AND AIMS

The Public Health Responsibility Deal (RD) in England is a public-private partnership involving voluntary pledges between industry, government and other organizations, with the aim of improving public health. This paper aims to evaluate what action resulted from the RD alcohol pledges.

METHODS

We analysed publically available data on organizations' plans and progress towards achieving key alcohol pledges of the RD. We assessed the extent to which activities pledged by signatories could have been brought about by the RD, as opposed to having happened anyway (the counterfactual), using a validated coding scheme designed for the purpose.

RESULTS

Progress reports were submitted by 92% of signatories in 2013 and 75% of signatories in 2014, and provided mainly descriptive feedback rather than quantifiable performance metrics. Approximately 14% of 2014 progress reports were identical to those presented in 2013. Most organizations (65%) signed pledges that involved actions to which they appear to have been committed already, regardless of the RD. A small but influential group of alcohol producers and retailers reported taking measures to reduce alcohol units available for consumption in the market. However, where reported, these measures appear to involve launching and promoting new lower-alcohol products rather than removing units from existing products.

CONCLUSIONS

The RD is unlikely to have contributed significantly to reducing alcohol consumption, as most alcohol pledge signatories appear to have committed to actions that they would have undertaken anyway, regardless of the RD. Irrespective of this, there is considerable scope to improve the clarity of progress reports and reduce the variability of metrics provided by RD pledge signatories.

Can the Accountable Care Organization model facilitate integrated care in England?

Following the global economic recession, health care systems have experienced intense political pressure to contain costs without compromising quality. One response is to focus on improving the continuity and coordination of care, which is seen as beneficial for both patients and providers. However, cultural and structural barriers have proved difficult to overcome in the quest to provide integrated care for entire populations. By holding groups of providers responsible for the health outcomes of a designated population, in the United States, Accountable Care Organizations are regarded as having the potential to foster collaboration across the continuum of care. They could have a similar role in England's National Health Service. However, it is important to consider the difference in context before implementing a similar model, adapted to suit the system's strengths. Working together, general practice federations and the Academic Health Science Networks could form the basis of accountable care in England.

Patients' experiences of the choice of GP practice pilot, 2012/2013: a mixed methods evaluation

OBJECTIVES

To investigate patients' experiences of the choice of general practitioner (GP) practice pilot.

DESIGN

Mixed-method, cross-sectional study.

SETTING

Patients in the UK National Health Service (NHS) register with a general practice responsible for their primary medical care and practices set geographic boundaries. In 2012/2013, 43 volunteer general practices in four English NHS primary care trusts (PCTs) piloted a scheme allowing patients living outside practice boundaries to register as an out of area patient or be seen as a day patient.

PARTICIPANTS

Analysis of routine data for 1108 out of area registered patients and 250 day patients; postal survey of out of area registered (315/886, 36%) and day (64/188, 34%) patients over 18 years of age, with a UK mailing address; comparison with General Practice Patient Survey (GPPS); semistructured interviews with 24 pilot patients.

RESULTS

Pilot patients were younger and more likely to be working than non-pilot patients at the same practices and reported generally more or at least as positive experiences than patients registered at the same practices, practices in the same PCT and nationally, despite belonging to subgroups of the population who typically report poorer than average experiences. Out of area patients who joined a pilot practice did so: after moving house and not wanting to change practice (26.2%); for convenience (32.6%); as newcomers to an area who selected a practice although they lived outside its boundary (23.6%); because of dissatisfaction with their previous practice (13.9%). Day patients attended primarily on grounds of convenience (68.8%); 51.6% of the day patient visits were for acute infections, most commonly upper respiratory infections (20.4%). Sixty-six per cent of day patients received a prescription during their visit.

CONCLUSIONS

Though the 12-month pilot was too brief to identify all costs and benefits, the scheme provided a positive experience for participating patients and practices.

Comparing end-of-life practices in different policy contexts: a scoping review

Objectives

End-of-life policy reforms are being debated in many countries. Research evidence is used to support different assumptions about the effects of public policies on end-of-life practices. It is however unclear whether reliable international practice comparisons can be conducted between different policy contexts. Our aim was to assess the feasibility of comparing similar end-of-life practices in different policy contexts.

Methods

This is a scoping review of empirical studies on medical end-of-life practices. We developed a descriptive classification of end-of-life practices that distinguishes practices according to their legal status. We focused on the intentional use of lethal drugs by physicians because of international variations in the legal status of this practice. Bibliographic database searches were supplemented by expert consultation and hand searching of reference lists. The sensitivity of the search strategy was tested using a set of 77 articles meeting our inclusion criteria. Two researchers extracted end-of-life practice definitions, study methods and available comparisons across policy contexts. Canadian decision-makers were involved to increase the policy relevance of the review.

Results

In sum, 329 empirical studies on the intentional use of lethal drugs by doctors were identified, including studies from 19 countries. The bibliographic search captured 98.7% of studies initially identified as meeting the inclusion criteria. Studies on the intentional use of lethal drugs were conducted in jurisdictions with permissive (62%) and restrictive policies (43%). The most common study objectives related to the frequency of end-of-life practices, determinants of practices, and doctors’ adherence to regulatory standards. Large variations in definitions and research methods were noted across studies. The use of a descriptive classification was useful to translate end-of-life practice definitions across countries. A few studies compared end-of-life practice in countries with different policies, using consistent research methods. We identified no comprehensive review of end-of-life practices across different policy contexts.

Conclusions

It is feasible to compare end-of-life practices in different policy contexts. A systematic review of international evidence is needed to inform public deliberations on end-of-life policies and practice.

Evaluating the Labour Government's English NHS health system reforms: the 2008 Darzi reforms

Starting in 2002, the UK Labour Government of 1997-2010 introduced a series of changes to the National Health Service (NHS) in England designed to increase patients' choices of the place of elective hospital care and encourage competition among public and private providers of elective hospital services for NHS-funded patients. In 2006, the Department of Health initiated the Health Reform Evaluation Programme (HREP) to assess the impact of the changes. In June 2008, the White Paper, High quality care for all, was published. It represented the government's desire to focus the next phase of health care system reform in England as much on the quality of care as on improving its responsiveness and efficiency. The 2008 White Paper led to the commissioning of a further wave of evaluative research under the auspices of HREP, as follows: an evaluation of the implementation and outcomes of care planning for people with long-term conditions; an evaluation of the personal health budget pilots; an evaluation of the implementation and outcomes of the Commissioning for Quality and Innovation (CQUIN) framework; and an evaluation of cultural and behavioural change in the NHS focused on ensuring high quality care for all. This Supplement includes papers from each project. The evaluations present a mixed picture of the impact and success of the 2008 reforms. All the studies identify some limitations of the policies in the White Paper. The introduction of personal health budgets appears to have been the least problematic and, depending on assumptions, likely to be cost-effective for the sorts of patients involved in the pilot. For the rest of the changes, impacts ranged from little or none (CQUIN and care planning for people with chronic conditions) to patchy and highly variable (instilling a culture of quality in acute hospitals) in the three years following the publication of the White Paper. On the other hand, each of the studies identifies important insights relevant to modifying and improving the policies. These findings have continuing relevance since both the 2008 White Paper's policies, and the issues they were focused on remedying, remain central to the current Coalition Government's reform agenda.

Impact of initiatives to improve access to, and choice of, primary and urgent care in the England: a systematic review

BACKGROUND

There were ten initiatives in the primary and urgent care system in the English NHS during the New Labour government, 1997-2010, aimed at delivering higher quality, more accessible and responsive care by expanding access, increasing convenience and introducing greater patient choice of provider. We examine their impact on demand, equity, patient satisfaction, referrals, and costs.

METHODS

Studies were systematically identified through electronic databases and reference lists of publications. Studies of all designs were included if published between 1997 and 2013, and with empirical data on the impacts above.

RESULTS

Nineteen studies of ten initiatives were included. Innovations often overlapped, complicating care. There was some demand for new provision on grounds of convenience, but little evidence of substitution between services. Patient satisfaction varied across schemes. There was little evidence on the costs and benefits of new versus existing provision.

CONCLUSION

New services generated a more complex system where new and existing providers delivered overlapping services. The new provision did not induce substitution and was likely to have increased overall demand. Initiatives to improve access to existing provision may have greater potential to improve access and convenience at lower marginal costs than developing new forms of provision.

Why public trust in health care systems matters and deserves greater research attention

Considering the underlying importance of trust, there is too little research into the understanding, protection and recovery of trust in health care systems, not only for the effective functioning of health care systems but also for society in general. Several researchers have pointed towards a contemporary crisis of trust in health care systems and there have been many examples that show the severe effects of mistrust. More research into public trust in health care systems could contribute to improving efficiency while protecting the health of the public.

Effect of a telephonic alert system (Healthy outlook) for patients with chronic obstructive pulmonary disease: a cohort study with matched controls

BACKGROUND

Healthy Outlook was a telephonic alert system for patients with chronic obstructive pulmonary disease (COPD) in the UK. It used routine meteorological and communicable disease reports to identify times of increased risk to health. We tested its effect on hospital use and mortality.

METHODS

Enrolees with a history of hospital admissions were linked to hospital administrative data. They were compared with control patients from local general practices, matched for demographic characteristics, health conditions, previous hospital use and predictive risk scores. We compared unplanned hospital admissions, admissions for COPD, outpatient attendances, planned admissions and mortality, over 12 months following enrolment.

RESULTS

Intervention and matched control groups appeared similar at baseline (n = 1413 in each group). Over the 12 months following enrolment, Healthy Outlook enrolees experienced more COPD admissions than matched controls (adjusted rate ratio 1.26, 95% confidence interval (CI), 1.05-1.52) and more outpatient attendances (adjusted rate ratio 1.08, 95% CI, 1.03-1.12). Enrolees also had lower mortality rates over 12 months (adjusted odds ratio 0.61, 95% CI, 0.45-0.84).

CONCLUSION

Healthy Outlook did not reduce admission rates, though mortality rates were lower. Findings for hospital utilization were unlikely to have been affected by confounding.

Success factors for reducing maternal and child mortality

Reducing maternal and child mortality is a priority in the Millennium Development Goals (MDGs), and will likely remain so after 2015. Evidence exists on the investments, interventions and enabling policies required. Less is understood about why some countries achieve faster progress than other comparable countries. The Success Factors for Women's and Children's Health studies sought to address this knowledge gap using statistical and econometric analyses of data from 144 low- and middle-income countries (LMICs) over 20 years; Boolean, qualitative comparative analysis; a literature review; and country-specific reviews in 10 fast-track countries for MDGs 4 and 5a. There is no standard formula--fast-track countries deploy tailored strategies and adapt quickly to change. However, fast-track countries share some effective approaches in addressing three main areas to reduce maternal and child mortality. First, these countries engage multiple sectors to address crucial health determinants. Around half the reduction in child mortality in LMICs since 1990 is the result of health sector investments, the other half is attributed to investments made in sectors outside health. Second, these countries use strategies to mobilize partners across society, using timely, robust evidence for decision-making and accountability and a triple planning approach to consider immediate needs, long-term vision and adaptation to change. Third, the countries establish guiding principles that orient progress, align stakeholder action and achieve results over time. This evidence synthesis contributes to global learning on accelerating improvements in women's and children's health towards 2015 and beyond.

The work of commissioning: a multisite case study of healthcare commissioning in England's NHS

OBJECTIVE

To examine the work of commissioning care for people with long-term conditions and the factors inhibiting or facilitating commissioners making service change.

DESIGN

Multisite mixed methods case study research, combining qualitative analysis of interviews, documents and observation of meetings.

PARTICIPANTS

Primary care trust managers and clinicians, general practice-based commissioners, National Health Service trust and foundation trust senior managers and clinicians, voluntary sector and local government representatives.

SETTING

Three 'commissioning communities' (areas covered by a primary care trust) in England, 2010-2012.

RESULTS

Commissioning services for people with long-term conditions was a long drawn-out process involving a range of activities and partners. Only some of the activities undertaken by commissioners, such as assessment of local health needs, coordination of healthcare planning and service specification, appeared in the official 'commissioning cycle' promoted by the Department of Health. Commissioners undertook a significant range of additional activities focused on reviewing and redesigning services and providing support for implementation of new services. These activities often involved partnership working with providers and other stakeholders and appeared to be largely divorced from contracting and financial negotiations. At least for long-term condition services, the time and effort involved in such work appeared to be disproportionate to the anticipated or likely service gains. Commissioners adopting an incremental approach to service change in defined and manageable areas of work appeared to be more successful in terms of delivering planned changes in service delivery than those attempting to bring about wide-scale change across complex systems.

CONCLUSIONS

Commissioning for long-term condition services challenges the conventional distinction between commissioners and providers with a significant amount of work focused on redesigning services in partnership with providers. Such work is labour-intensive and potentially unsustainable at a time of reduced finances. New clinical commissioning groups will need to determine how best to balance the relational and transactional elements of commissioning.

Divergence of NHS choice policy in the UK: what difference has patient choice policy in England made?

OBJECTIVES

To examine the types of choices available to patients in the English NHS when being referred for acute hospital care in the light of the divergence of patient choice policy in the four countries of the UK.

METHODS

Case studies of eight local health economies in England, Scotland, Northern Ireland and Wales (two in each country); 125 semi-structured interviews with staff in acute services providers, purchasers and general practitioners (GPs).

RESULTS

GPs and providers in England both had a clear understanding of the choice of provider policy and the right of patients to choose a provider. Other referral choices potentially available to patients in all four countries were date and time of appointment, site and specialist. In practice, the availability of these choices differed between and within countries and was shaped by factors beyond choice policy, such as the number of providers in an area. There were similarities between the four countries in the way choices were offered to patients, namely lack of clarity about the options available, limited discussion of choices between referrers and patients, and tension between offering choice and managing waiting lists.

CONCLUSIONS

There are challenges in implementing pro-choice policy in health care systems where it has not traditionally existed. Differences between England and the other countries of the UK were limited in the way choice was offered to patients. A cultural shift is needed to ensure that patients are fully informed by GPs of the choices available to them.

Commissioning healthcare for people with long term conditions: the persistence of relational contracting in England's NHS quasi-market

Background

Since 1991, there has been a series of reforms of the English National Health Service (NHS) entailing an increasing separation between the commissioners of services and a widening range of public and independent sector providers able to compete for contracts to provide services to NHS patients. We examine the extent to which local commissioners had adopted a market-oriented (transactional) model of commissioning of care for people with long term conditions several years into the latest period of market-oriented reform. The paper also considers the factors that may have inhibited or supported market-oriented behaviour, including the presence of conditions conducive to a health care quasi-market.

Methods

We studied the commissioning of services for people with three long term conditions - diabetes, stroke and dementia - in three English primary care trust (PCT) areas over two years (2010-12). We took a broadly ethnographic approach to understanding the day-to-day practice of commissioning. Data were collected through interviews, observation of meetings and from documents.

Results

In contrast to a transactional, market-related approach organised around commissioner choice of provider and associated contracting, commissioning was largely relational, based on trust and collaboration with incumbent providers. There was limited sign of commissioners significantly challenging providers, changing providers, or decommissioning services.

In none of the service areas were all the conditions for a well functioning quasi-market in health care in place. Choice of provider was generally absent or limited; information on demand and resource requirements was highly imperfect; motivations were complex; and transaction costs uncertain, but likely to be high. It was difficult to divide care into neat units for contracting purposes. As a result, it is scarcely surprising that commissioning practice in relation to all six commissioning developments was dominated by a relational approach.

Conclusions

Our findings challenge the notion of a strict separation of commissioners and providers, and instead demonstrate the adaptive persistence of relational commissioning based on continuity of provision, trust and interdependence between commissioners and providers, at least for services for people with long-term conditions.