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Alderwick H, Hutchings A, Mays N. Solving poverty or tackling healthcare inequalities? Qualitative study exploring local interpretations of national policy on health inequalities under new NHS reforms in England. BMJ Open 2024; 14:e081954. [PMID: 38589267 PMCID: PMC11015303 DOI: 10.1136/bmjopen-2023-081954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/15/2024] [Indexed: 04/10/2024] Open
Abstract
OBJECTIVES Major reforms to the organisation of the National Health Service (NHS) in England established 42 integrated care systems (ICSs) to plan and coordinate local services. The changes are based on the idea that cross-sector collaboration is needed to improve health and reduce health inequalities-and similar policy changes are happening elsewhere in the UK and internationally. We explored local interpretations of national policy objectives on reducing health inequalities among senior leaders working in three ICSs. DESIGN We carried out qualitative research based on semistructured interviews with NHS, public health, social care and other leaders in three ICSs in England. SETTING AND PARTICIPANTS We selected three ICSs with varied characteristics all experiencing high levels of socioeconomic deprivation. We conducted 32 in-depth interviews with senior leaders of NHS, local government and other organisations involved in the ICS's work on health inequalities. Our interviewees comprised 17 leaders from NHS organisations and 15 leaders from other sectors. RESULTS Local interpretations of national policy objectives on health inequalities varied, and local leaders had contrasting-sometimes conflicting-perceptions of the boundaries of ICS action on reducing health inequalities. Translating national objectives into local priorities was often a challenge, and clarity from national policy-makers was frequently perceived as limited or lacking. Across the three ICSs, local leaders worried that objectives on tackling health inequalities were being crowded out by other short-term policy priorities, such as reducing pressures on NHS hospitals. The behaviour of national policy-makers appeared to undermine their stated priorities to reduce health inequalities. CONCLUSIONS Varied and vague interpretations of NHS policy on health inequalities are not new, but lack of clarity among local health leaders brings major risks-including interventions being poorly targeted or inadvertently widening inequalities. Greater conceptual clarity is likely needed to guide ICS action in future.
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Affiliation(s)
- Hugh Alderwick
- Health Foundation, London, UK
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Nicholas Mays
- London School of Hygiene and Tropical Medicine, London, UK
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Knowles R, Chandler C, O'Neill S, Sharland M, Mays N. A systematic review of national interventions and policies to optimize antibiotic use in healthcare settings in England. J Antimicrob Chemother 2024:dkae061. [PMID: 38507232 DOI: 10.1093/jac/dkae061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 02/19/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVES To identify and assess the effectiveness of national antibiotic optimization interventions in primary and secondary care in England (2013-2022). METHODS A systematic scoping review was conducted. Literature databases (Embase and Medline) were used to identify interventions and evaluations. Reports included the UK AMR Strategy (2013-2018), National Action Plan (2019-2024) and English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) reports (2014-2022). The design, focus and quality of evaluations and the interventions' effectiveness were extracted. FINDINGS Four hundred and seventy-seven peer-reviewed studies and 13 reports were screened. One hundred and three studies were included for review, identifying 109 interventions in eight categories: policy and commissioning (n = 9); classifications (n = 1); guidance and toolkits (n = 22); monitoring and feedback (n = 17); professional engagement and training (n = 19); prescriber tools (n = 12); public awareness (n = 17); workforce and governance (n = 12).Most interventions lack high-quality effectiveness evidence. Evaluations mainly focused on clinical, microbiological or antibiotic use outcomes, or intervention implementation, often assessing how interventions were perceived to affect behaviour. Only 16 interventions had studies that quantified effects on prescribing, of which six reported reductions. The largest reduction was reported with structural-level interventions and attributed to a policy and commissioning intervention (primary care financial incentives). Behavioural interventions (guidance and toolkits) reported the greatest impact in hospitals. CONCLUSIONS Many interventions have targeted antibiotic use, each pulling different levers across the health system simultaneously. On the basis of these studies, structural-level interventions may have the greatest impact. Collectively, the combination of interventions may explain England's decline in prescribing but direct evidence of causality is unavailable.
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Affiliation(s)
- Rebecca Knowles
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Clare Chandler
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Stephen O'Neill
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Mike Sharland
- Centre for Neonatal and Paediatric Infection, Institute for Infection and Immunity, St George's, University of London, London, UK
- Paediatric Infectious Diseases Department, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Nicholas Mays
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Boehm C, Boadu P, Exley J, Al-Haboubi M, Mays N. Public trust in the Government to control the spread of COVID-19 in England after the first wave-a longitudinal analysis. Eur J Public Health 2023; 33:1155-1162. [PMID: 37579239 PMCID: PMC10710334 DOI: 10.1093/eurpub/ckad148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND To control the spread of coronavirus disease 2019 (COVID-19), governments are increasingly relying on the public to voluntarily manage risk. Effectiveness is likely to rely in part on how much the public trusts the Government's response. We examined the English public's trust in the Conservative Government to control the spread of COVID-19 after the initial 'crisis' period. METHODS We analyzed eight rounds of a longitudinal survey of 1899 smartphone users aged 18-79 in England between October 2020 and December 2021. We fitted a random-effects logit model to identify personal characteristics and opinions associated with trust in the Conservative Government to control the spread of COVID-19. RESULTS Trust was lowest in January 2021 (28%) and highest in March 2021 (44%). Being older, having lower educational attainment and aligning with the Conservative Party were predictors of higher levels of trust. Conversely, being less deprived, reporting that Government communications were not clear and considering that the measures taken by the Government went too far or not far enough were predictors of being less likely to report a great deal or a fair amount of trust in the Government to control the pandemic. CONCLUSION Trust in the Government's response was found to be low throughout the study. Our findings suggest that there may be scope to avoid losing trust by aligning Government actions more closely with scientific advice and public opinion, and through clearer public health messaging. However, it remains unclear whether and how higher trust in the Government's response would increase compliance with Government advice.
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Affiliation(s)
- Claudia Boehm
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, Policy Innovation and Evaluation Research Unit (PIRU), London, UK
| | - Paul Boadu
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, Policy Innovation and Evaluation Research Unit (PIRU), London, UK
| | - Josephine Exley
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, Policy Innovation and Evaluation Research Unit (PIRU), London, UK
| | - Mustafa Al-Haboubi
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, Policy Innovation and Evaluation Research Unit (PIRU), London, UK
| | - Nicholas Mays
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, Policy Innovation and Evaluation Research Unit (PIRU), London, UK
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Ellins J, Hocking L, Al-Haboubi M, Newbould J, Fenton SJ, Daniel K, Stockwell S, Leach B, Sidhu M, Bousfield J, McKenna G, Saunders C, O'Neill S, Mays N. Implementing mental health support teams in schools and colleges: the perspectives of programme implementers and service providers. J Ment Health 2023:1-7. [PMID: 37937764 DOI: 10.1080/09638237.2023.2278101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 08/25/2023] [Indexed: 11/09/2023]
Abstract
Background: Between 2018 and 2025, a national implementation programme is funding more than 500 new mental health support teams (MHSTs) in England, to work in education settings to deliver evidence-based interventions to children with mild to moderate mental health problems and support emotional wellbeing for all pupils. A new role, education mental health practitioner (EMHP), has been created for the programme.Aims: A national evaluation explored the development, implementation and early progress of 58 MHSTs in the programme's first 25 'Trailblazer' sites. This paper reports the views and experiences of people involved in MHST design, implementation and service delivery at a local, regional and national level.Methods: Data are reported from in-depth interviews with staff in five Trailblazer sites (n = 71), and the programme's regional (n = 52) and national leads (n = 21).Results: Interviewees universally welcomed the creation of MHSTs, but there was a lack of clarity about their purpose, concerns that the standardised CBT interventions being offered were not working well for some children, and challenges retaining EMHPs.Conclusions: This study raises questions about MHSTs' service scope, what role they should play in addressing remaining gaps in mental health provision, and how EMHPs can develop the skills to work effectively with diverse groups.
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Affiliation(s)
- Jo Ellins
- Health Services Management Centre, School of Social Policy, University of Birmingham, Birmingham, England
| | | | - Mustafa Al-Haboubi
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, England
| | | | - Sarah-Jane Fenton
- Institute for Mental Health, University of Birmingham, Birmingham, England
| | - Kelly Daniel
- Health Services Management Centre, School of Social Policy, University of Birmingham, Birmingham, England
| | | | | | - Manbinder Sidhu
- Health Services Management Centre, School of Social Policy, University of Birmingham, Birmingham, England
| | | | - Gemma McKenna
- Health Services Management Centre, School of Social Policy, University of Birmingham, Birmingham, England
| | - Catherine Saunders
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, England
| | - Stephen O'Neill
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, England
| | - Nicholas Mays
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, England
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Ellins J, Hocking L, Al-Haboubi M, Newbould J, Fenton SJ, Daniel K, Stockwell S, Leach B, Sidhu M, Bousfield J, McKenna G, Saunders K, O'Neill S, Mays N. Early evaluation of the Children and Young People's Mental Health Trailblazer programme: a rapid mixed-methods study. Health Soc Care Deliv Res 2023; 11:1-137. [PMID: 37470109 DOI: 10.3310/xqwu4117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
Background The Children and Young People's Mental Health Trailblazer programme is funding the creation of new mental health support teams to work in schools and further education colleges. Mental health support teams directly support children and young people with 'mild to moderate' mental health problems and work with school and college staff to promote well-being for all. A new workforce of education mental health practitioners is being trained for the teams. Objective(s) The National Institute for Health and Care Research Birmingham, RAND and Cambridge Evaluation Rapid Evaluation Centre and Policy Innovation and Evaluation Research Unit undertook an early evaluation of the Trailblazer programme to examine the development, implementation and early progress of mental health support teams in the programme's first 25 'Trailblazer' sites. Design A mixed-methods evaluation, comprising three work packages: 1. Establishing the baseline and understanding the development and early impacts of the Trailblazer sites, including two rounds of surveys with key informants and participating education settings in all 25 sites. 2. More detailed research in five purposively selected Trailblazer sites, including interviews with a range of stakeholders and focus groups with children and young people. 3. Scoping and developing options for a longer-term assessment of the programme's outcomes and impacts. Fieldwork was undertaken between November 2020 and February 2022. The University of Birmingham Institute for Mental Health Youth Advisory Group was involved throughout the study, including co-producing the focus groups with children and young people. Results Substantial progress had been made implementing the programme, in challenging circumstances, and there was optimism about what it had the potential to achieve. The education mental health practitioner role had proven popular, but sites reported challenges in retaining education mental health practitioners, and turnover left mental health support teams short-staffed and needing to re-recruit. Education settings welcomed additional mental health support and reported positive early outcomes, including staff feeling more confident and having faster access to advice about mental health issues. At the same time, there were concerns about children who had mental health problems that were more serious than 'mild to moderate' but not serious enough to be accepted for specialist help, and that the interventions offered were not working well for some young people. Mental health support teams were generally spending more time supporting children with mental health problems than working with education settings to develop 'whole school' approaches to mental health and well-being, and service models in some sites appeared to be more clinically oriented, with a strong focus on mental health support teams' therapeutic functions. Limitations Despite efforts to maximise participation, survey response rates were relatively low and some groups were less well represented than others. We were not able to gather sufficiently detailed data to develop a typology of Trailblazer sites, as was planned. Conclusions Key lessons for future programme implementation include: - Whether mental health support teams should expand support to children and young people with more complex and serious mental health problems. - How to keep the twin aims of prevention and early intervention in balance. - How to retain education mental health practitioners once trained. Future work The findings have important implications for the design of a longer-term impact evaluation of the programme, which is due to commence in summer 2023. Study registration Ethical approval from the University of Birmingham (ERN_19-1400 - RG_19-190) and London School of Hygiene and Tropical Medicine (Ref: 18040) and Health Research Authority approval (IRAS 270760). Funding The Birmingham, RAND and Cambridge Evaluation Rapid Evaluation Centre is funded by the National Institute for Health and Care Research Health Services and Delivery Research programme (HSDR 16/138/31). The Policy Innovation and Evaluation Research Unit is funded by the NIHR Policy Research Programme (PR-PRU-1217-20602).
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Affiliation(s)
- Jo Ellins
- Health Services Management Centre, University of Birmingham, Edgbaston, Birmingham, UK
| | | | - Mustafa Al-Haboubi
- Policy Innovation and Evaluation Research Unit, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Sarah-Jane Fenton
- Department of Social Work and Social Care, University of Birmingham, Edgbaston, Birmingham, UK
| | - Kelly Daniel
- Health Services Management Centre, University of Birmingham, Edgbaston, Birmingham, UK
| | | | | | - Manbinder Sidhu
- Health Services Management Centre, University of Birmingham, Edgbaston, Birmingham, UK
| | | | - Gemma McKenna
- Health Services Management Centre, University of Birmingham, Edgbaston, Birmingham, UK
| | - Katie Saunders
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephen O'Neill
- Policy Innovation and Evaluation Research Unit, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Nicholas Mays
- Policy Innovation and Evaluation Research Unit, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Boadu P, McLaughlin L, Al-Haboubi M, Bostock J, Noyes J, O'Neill S, Mays N. A machine-learning approach to estimating public intentions to become a living kidney donor in England: Evidence from repeated cross-sectional survey data. Front Public Health 2023; 10:1052338. [PMID: 36684997 PMCID: PMC9846224 DOI: 10.3389/fpubh.2022.1052338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 11/30/2022] [Indexed: 01/05/2023] Open
Abstract
Background Living kidney organ donors offer a cost-effective alternative to deceased organ donation. They enable patients with life-threatening conditions to receive grafts that would otherwise not be available, thereby creating space for other patients waiting for organs and contributing to reducing overall waiting times for organs. There is an emerging consensus that an increase in living donation could contribute even more than deceased donation to reducing inequalities in organ donation between different population sub-groups in England. Increasing living donation is thus a priority for National Health Service Blood and Transplant (NHSBT) in the United Kingdom. Methods Using the random forest model, a machine learning (ML) approach, this study analyzed eight waves of repeated cross-sectional survey data collected from 2017 to 2021 (n = 14,278) as part of the organ donation attitudinal tracker survey commissioned by NHSBT in England to identify and help predict key factors that inform public intentions to become living donors. Results Overall, around 58.8% of the population would consider donating their kidney to a family member (50.5%), a friend (28%) or an unknown person (13.2%). The ML algorithm identified important factors that influence intentions to become a living kidney donor. They include, in reducing order of importance, support for organ donation, awareness of organ donation publicity campaigns, gender, age, occupation, religion, number of children in the household, and ethnic origin. Support for organ donation, awareness of public campaigns, and being younger were all positively associated with predicted propensity for living donation. The variable importance scores show that ethnic origin and religion were less important than the other variables in predicting living donor intention. Conclusion Factors influencing intentions to become a living donor are complex and highly individual in nature. Machine learning methods that allow for complex interactions between characteristics can be helpful in explaining these decisions. This work has identified important factors and subgroups that have higher propensity for living donation. Interventions should target both potential live donors and recipients. Research is needed to explore the extent to which these preferences are malleable to better understand what works and in which contexts to increase live organ donation.
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Affiliation(s)
- Paul Boadu
- Policy Innovation and Evaluation Research Unit, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Leah McLaughlin
- School of Medical and Health Sciences, Bangor University, Bangor, United Kingdom
| | - Mustafa Al-Haboubi
- Policy Innovation and Evaluation Research Unit, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jennifer Bostock
- Policy Innovation and Evaluation Research Unit, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jane Noyes
- School of Medical and Health Sciences, Bangor University, Bangor, United Kingdom
| | - Stephen O'Neill
- Policy Innovation and Evaluation Research Unit, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nicholas Mays
- Policy Innovation and Evaluation Research Unit, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Al-Haboubi M, Exley J, Allel K, Erens B, Mays N. One year of digital contact tracing: Who was more likely to install the NHS COVID-19 app? Results from a tracker survey in England and Wales. Digit Health 2023. [DOI: 10.1177/20552076231159449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
Objective To examine changes in the uptake of the National Health Service (NHS) COVID-19 proximity (contact) tracing application (‘app’) over one year, amongst smartphone users in England and Wales. Methods We conducted a longitudinal survey between October 2020 and September 2021, amongst an online panel representative of smartphone users aged 18–79 and a purposeful sample from six of the largest minority ethnic groups. We fitted pooled logistic regression models to examine factors associated with app installation and a longitudinal logistic regression model to estimate factors associated with installing/uninstalling the app over time. Results Around 50% of respondents had the app installed at each time point. The majority of installations took place soon after its launch. The key reason for installing at launch was ‘civic, public or social responsibility’. Amongst those who installed the app later, it was ‘needed to scan NHS QR code’. Uptake was higher amongst individuals who considered themselves vulnerable to COVID-19 or were concerned about the risk COVID-19 posed, were more highly educated, of White ethnicity, and who reported higher levels of trust in government information. Factors associated with installing the app over time included becoming more concerned about the risk COVID-19 poses to the country, or perceiving that the crisis in their local area had worsened. Conclusions Despite changes in pandemic response and case numbers, app installation in England and Wales remained relatively stable after launch. If governments wish to increase app installation and use rates in future pandemics, they need to highlight those app features that encourage engagement, and take related action to allay privacy concerns and improve trust in government information sharing.
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Affiliation(s)
- Mustafa Al-Haboubi
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Josephine Exley
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Kasim Allel
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Department of Disease Control, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Bob Erens
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Nicholas Mays
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Faherty G, Williams L, Noyes J, Mc Laughlin L, Bostock J, Mays N. Analysis of content and online public responses to media articles that raise awareness of the opt-out system of consent to organ donation in England. Front Public Health 2022; 10:1067635. [PMID: 36530724 PMCID: PMC9751921 DOI: 10.3389/fpubh.2022.1067635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 11/14/2022] [Indexed: 12/04/2022] Open
Abstract
Background Preceded by a national media campaign, in May 2020, England switched to a soft opt-out system of organ donation which rests on the assumption that individuals meeting specific criteria have consented to organ donation unless they have expressed otherwise. We aimed to learn more about how the changes were communicated, how people responded and any discrepancies between key messages and how they were interpreted by the public. Methods Summative content analysis of 286 stories and related reader-generated comments in leading UK online news sources (April 2019 to May 2021). Further detailed thematic analysis of 21 articles with reader-generated content, complemented by thematic content analysis coding of all 286 stories. Results Most media coverage on both organ donation and the law change was positive, with little variation over time or between publications. The importance of organ donation, benefits of the law change, and emotive stories (often involving children) of those who had donated an organ described as "superheroes" or those who had received organs as benefiting from a "miracle" were frequently cited. In contrast, reader-generated comments were markedly more negative, for example, focusing on loss of individual freedom and lack of trust in the organ donation system. Commentators wished to be able to choose who their organs were donated to, were dismissive and blaming towards minority ethnic groups, including undermining legitimate worries about the compatibility of organ donation with religious beliefs and end of life cultural norms, understanding and acceptance of brain-stem death and systemic racism. Misinformation including use of inflammatory language was common. Conclusion The portrayal of donors and recipients as extraordinary is unlikely to help to normalise organ donation. Undermining legitimate concerns, in particular those from ethnic minorities, can alienate and encourage harmful misinformation in underrepresented groups. The discrepancies between the tone of the articles and the readers comments suggests a lack of trust across the public, health, policy and media outlets. Easily accessible, ongoing and tailored sources are needed to mitigate misinformation and disinformation and ensure key messages are better understood and accepted in order to realise the ambitions of soft opt-out organ donation policies.
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Affiliation(s)
- Georgia Faherty
- Policy Innovation and Evaluation Research Unit (PIRU), Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Lorraine Williams
- Policy Innovation and Evaluation Research Unit (PIRU), Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jane Noyes
- School of Medical and Health Sciences, Bangor University, Bangor, United Kingdom
| | - Leah Mc Laughlin
- School of Medical and Health Sciences, Bangor University, Bangor, United Kingdom
| | - Jennifer Bostock
- Policy Innovation and Evaluation Research Unit (PIRU), Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nicholas Mays
- Policy Innovation and Evaluation Research Unit (PIRU), Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom,*Correspondence: Nicholas Mays
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Dixon J, Exley J, Wistow G, Wittenberg R, Knapp M, Mays N. The sociocultural framing of public attitudes to sharing the costs of social care for older people in England. Health Soc Care Community 2022; 30:e5270-e5280. [PMID: 35929403 PMCID: PMC10087265 DOI: 10.1111/hsc.13946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 06/09/2022] [Accepted: 07/08/2022] [Indexed: 06/15/2023]
Abstract
Twelve synchronous online focus groups were conducted, each involving four to six members of the general public who had expressed in-principle support for sharing the costs of social care for older people between service users and government. These explored participants' reasons for preferring a shared approach and their views on how costs should be shared, with particular attention given to the sociocultural frames employed. Four main sociocultural frames were identified, reflecting dominant discourses concerning (i) the financial burden of meeting social care need ('scarcity' frame) (ii) the core purpose of social care ('medicalised conception of care' frame) (iii) the role and perceived limitations of the private market ('consumer' frame), and (iv) fundamental concerns about safety, security and belonging ('loss and abandonment' frame). Of these four frames, the 'scarcity' frame was dominant, with views about how costs should be shared overwhelmingly formulated upon assumptions of insufficient resources. This was reflected in concerns about affordability and the consequent need for the financial burden to be shared between individuals and government, and resulted in a residual vision for care and anxieties about care quality, cliff-edge costs and abandonment. The concept of shared funding was also employed rhetorically to suggest an equitable approach to managing financial burden, reflected in phrases such as 'splitting the difference'. Whilst out-of-pocket payments were sometimes seen as useful or necessary in the context of scarce public resources, the idea of shared funding was sometimes interpreted more flexibly to include individual contributions made in a range of ways, including tax, social insurance payments and wider social and economic contributions to society. Despite the dominance of the 'scarcity' frame, participants favoured greater government contribution than currently. These four frames and their associated discourses provide insight into how the public 'hear' and make sense of the debate about social care funding and, specifically, how apparent support for shared public-private funding is structured. Government and those hoping to influence the future of social care funding need to promote a vision of funding reform and win support for it by actively engaging with the sociocultural frames that the public recognise and engage with, with all of their apparent inconsistencies and contradictions.
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Affiliation(s)
- Josie Dixon
- Care Policy and Evaluation Centre (CPEC), Department of Health PolicyLondon School of Economics and Political ScienceLondonUK
| | - Josephine Exley
- Policy Innovation and Evaluation Research Unit (PIRU), Department of Health Services Research and PolicyLondon School of Hygiene & Tropical MedicineLondonUK
| | - Gerald Wistow
- Care Policy and Evaluation Centre (CPEC), Department of Health PolicyLondon School of Economics and Political ScienceLondonUK
| | - Raphael Wittenberg
- Care Policy and Evaluation Centre (CPEC), Department of Health PolicyLondon School of Economics and Political ScienceLondonUK
| | - Martin Knapp
- Care Policy and Evaluation Centre (CPEC), Department of Health PolicyLondon School of Economics and Political ScienceLondonUK
| | - Nicholas Mays
- Policy Innovation and Evaluation Research Unit (PIRU), Department of Health Services Research and PolicyLondon School of Hygiene & Tropical MedicineLondonUK
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Exley J, Glover R, McCarey M, Reed S, Ahmed A, Vrijhoef H, Manacorda T, Stewart E, Mays N, Nolte E. Meeting the governance challenges of integrated health and social care. Eur J Public Health 2022. [DOI: 10.1093/eurpub/ckac129.471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Many countries are experimenting with novel ways of organising and delivering more integrated health and social care. Governance is relatively neglected as a focus of attention in this context but addressing governance challenges is key for successful collaboration.
Methods
Cross-country case analysis involving document review and semi-structured interviews with 27 local, regional and national level stakeholders in Italy, the Netherlands and Scotland. We used the Transparency, Accountability, Participation, Integrity and Capability (TAPIC) framework to structure our analytical enquiry to explore factors that influence the governance arrangements in each system.
Results
Governance arrangements ranged from informal agreements in the Netherlands to mandated integration in Scotland. Novel service models were generally participative involving a wide range of stakeholders, including the public, although integration was seen to be driven, largely, from a health perspective. In Italy and Scotland some reversion to ‘command & control’ was reported in response to the imperatives of the Covid-19 pandemic. Policies, budgets, auditing and reporting systems that are clearly aligned at all levels were seen to help with implementing innovations in service organisation. Where alignment was lacking, cooperation and integration was suboptimal, regardless of whether governance arrangements were statutory or not. There was wide recognition of the importance of buy-in. Enablers of greater engagement included visible leadership, time and long-standing working relationships. Lack of suitable indicators and openness to data sharing to measure integration hindered working relationships and thus the successful delivery of integrated services.
Conclusions
Our study provides important insights into how to more effectively and efficiently govern service delivery structures within care systems. We will discuss approaches to governance that help support more resilient integrated care systems.
Key messages
• Different governance arrangements face common challenges to greater integration of care. Enablers include strong leadership, inclusivity and openness to work across traditional boundaries.
• Meeting the governance challenges of integrated health and social care requires clear lines of accountability, aligned policies, budgets and reporting systems.
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Affiliation(s)
- J Exley
- Health Service Research and Policy, LSHTM , London, UK
| | - R Glover
- Health Service Research and Policy, LSHTM , London, UK
| | | | - S Reed
- The Nuffiled Trust , London, UK
| | - A Ahmed
- Panaxea , Amsterdam, Netherlands
| | | | - T Manacorda
- Health Service Research and Policy, LSHTM , London, UK
| | - E Stewart
- School of Social Work and Social Policy, University of Strathclyde , Glasgow, UK
| | - N Mays
- School of Social Work and Social Policy, University of Strathclyde , Glasgow, UK
| | - E Nolte
- Health Service Research and Policy, LSHTM , London, UK
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11
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Alderwick H, Hutchings A, Mays N. A cure for everything and nothing? Local partnerships for improving health in England. BMJ 2022; 378:e070910. [PMID: 35788447 PMCID: PMC9273030 DOI: 10.1136/bmj-2022-070910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Collaboration between local agencies is no replacement for national policy and investment, argue Hugh Alderwick, Andrew Hutchings, and Nicholas Mays
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Affiliation(s)
| | | | - Nicholas Mays
- London School of Hygiene and Tropical Medicine, London, UK
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12
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Mays N, Harris-Roxas B. Co-production: aspirations, challenges, and the way ahead for public health and health services research. Public Health Res Pract 2022; 32:3222208. [PMID: 35702741 DOI: 10.17061/phrp3222208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Nicholas Mays
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, UK;
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13
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Douglas N, Mays N, Al-Haboubi M, Manacorda T, Thana L, Wistow G, Durand MA. Observations of community-based multidisciplinary team meetings in health and social care for older people with long term conditions in England. BMC Health Serv Res 2022; 22:758. [PMID: 35676685 PMCID: PMC9175164 DOI: 10.1186/s12913-022-07971-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 04/05/2022] [Indexed: 11/20/2022] Open
Abstract
Background Community-based multi-disciplinary teams (MDTs) are the most common means to encourage health and social care service integration in England yet are rarely studied or directly observed. This paper reports on two rounds of non-participant observations of community-based multi-disciplinary team (MDT) meetings in two localities, as part of an evaluation of the Integrated Care and Support Pioneers Programme. We sought to understand how MDT meetings coordinate care and identify their ‘added value’ over bilateral discussions. Methods Two rounds of structured non-participant observations of 11 MDTs (28 meetings) in an inner city and mixed urban–rural area in England (June 2019-February 2020), using a group analysis approach. Results Despite diverse settings, attendance and caseloads, MDTs adopted similar processes of case management: presentation; information seeking/sharing; narrative construction; solution seeking; decision-making and task allocation. Patient-centredness was evident but scope to strengthen ‘patient-voice’ exists. MDTs were hampered by information governance rules and lack of interoperability between patient databases. Meetings were characterised by mutual respect and collegiality with little challenge. Decision-making appeared non-hierarchical, often involving dyads or triads of professionals. ‘Added value’ lay in: rapid patient information sharing; better understanding of contributing agencies’ services; planning strategies for patients that providers had struggled to find the right way to engage satisfactorily; and managing risk and providing mutual support in stressful cases. Conclusions More attention needs to be given to removing barriers to information sharing, creating scope for constructive challenge between staff and deciding when to remove cases from the caseload.
Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07971-x.
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Affiliation(s)
- Nick Douglas
- Policy Innovation and Evaluation Research Unit (PIRU), Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK. .,Now School of Psychology, University of Sussex, Brighton, East Sussex, UK.
| | - Nicholas Mays
- Policy Innovation and Evaluation Research Unit (PIRU), Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Mustafa Al-Haboubi
- Policy Innovation and Evaluation Research Unit (PIRU), Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Tommaso Manacorda
- Policy Innovation and Evaluation Research Unit (PIRU), Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK.,Now Public Health, Advocacy and Welfare, Italian Multiple Sclerosis Society, Genoa, Italy
| | - Lavanya Thana
- Policy Innovation and Evaluation Research Unit (PIRU), Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Gerald Wistow
- Policy Innovation and Evaluation Research Unit (PIRU), Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK.,Care Policy & Evaluation Centre, London School of Economics & Political Science, London, UK
| | - Mary Alison Durand
- Policy Innovation and Evaluation Research Unit (PIRU), Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
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14
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Blake LJ, Häsler B, Bennani H, Mateus ALP, Eastmure E, Mays N, Stärk KDC. The UK Antimicrobial Resistance Strategy 2013–18: A Qualitative Study of International and Domestic Policy and Action Related to Livestock and the Food Chain. Front Sustain Food Syst 2022. [DOI: 10.3389/fsufs.2022.819158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Antimicrobial resistance (AMR) is an increasingly important challenge within global health, and growing action is being taken by countries across the world. The UK Government established a national AMR Strategy in 2013, encompassing human and animal health. An evaluation of the implementation of the Strategy was commissioned, to feed into a refresh of the Strategy in 2018. This article addresses the implementation of the parts of the Strategy related to food sourced from animals. It is based on 15 semi-structured interviews with policy officials and professionals from UK and international agencies. Four themes comprise the findings from thematic analysis. (1) The UK's advocacy and leadership at the global level to encourage international action, which was praised. However, the UK's actions were limited in permeating complex international food supply chains. (2) Integrating a One Health approach, adopted in the Strategy, which had successfully facilitated bringing together human and animal health sectors, but still lacked input from environmental agencies and integration of the role of environmental factors in understanding and tackling AMR. (3) Changes in antimicrobial use and attempts to reduce AMR brought about by the Strategy, including the disparity in variations of actions and progress between livestock sectors, the pros and cons of antimicrobial usage reduction targets—felt to be best when adapted for each livestock species sector, the preference for voluntary sector-led approaches to reduction in antimicrobial use, and the need for changes in production systems and animal husbandry. (4) The challenges relating to costs, drivers and incentives identified to reduce antimicrobial use, and how research, data and surveillance systems support continued action. In particular, the need for adequate investment and financial incentives to enable changes in production and husbandry to take a more preventative approach, the importance of working with different actors throughout the food chain in each livestock sector, and the need for adequate and consistent surveillance data to measure antimicrobial use and continued research to understand AMR. The findings have implications for how to implement further changes at both farm and policy level, how to implement harmonized surveillance whilst maintaining sectoral autonomy, the need for a whole food chain approach, and greater integration of research, actions and actors working on environmental factors of AMR.
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15
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Gille F, Smith S, Mays N. Evidence-based guiding principles to build public trust in personal data use in health systems. Digit Health 2022; 8:20552076221111947. [PMID: 35874863 PMCID: PMC9297454 DOI: 10.1177/20552076221111947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 06/19/2022] [Indexed: 11/24/2022] Open
Abstract
Objective Public trust in health systems is pivotal for their effective and efficient functioning. In particular, public trust is essential for personal data use, as demonstrated in debates in many countries, for example, about whether data from COVID-19 contact tracing apps should be pooled or remain on individuals’ smartphones. Low levels of public trust pose a risk not only to health system legitimacy but can also harm population health. Methods Synthesising our previous qualitative and theoretical research in the English National Health Service which enabled us to conceptualise the nature of public trust in health systems, we present guiding principles designed to rebuild public trust, if lost, and to maintain high levels of public trust in personal data use within the health system, if not. Results To build public trust, health system actors need to not rush trust building; engage with the public; keep the public safe; offer autonomy to the public; plan for diverse trust relationships; recognise that trust is shaped by both emotion and rational thought; represent the public interest; and work towards realising a net benefit for the health system and the public. Conclusions Beyond policymakers and government officials, the guiding principles address a wide range of actors within health systems so that they can work collectively to build public trust. The guiding principles can be used to inform policymaking in health and health care and to analyse the performance of different governments to see if those governments that operate in greater conformity with the guiding principles perform better.
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Affiliation(s)
- Felix Gille
- University of Zurich, Digital Society Initiative (DSI), Zürich, CH, Switzerland
- University of Zurich, Institute for Implementation Science in Health Care (IfIS), Zürich, CH, Switzerland
| | - Sarah Smith
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Nicholas Mays
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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16
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Erens B, Williams L, Exley J, Ettelt S, Manacorda T, Hajat S, Mays N. Public attitudes to, and behaviours taken during, hot weather by vulnerable groups: results from a national survey in England. BMC Public Health 2021; 21:1631. [PMID: 34488695 PMCID: PMC8422617 DOI: 10.1186/s12889-021-11668-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 08/26/2021] [Indexed: 11/23/2022] Open
Abstract
Background Hot weather leads to increased illness and deaths. The Heatwave Plan for England (HWP) aims to protect the population by raising awareness of the dangers of hot weather, especially for those most vulnerable. Individuals at increased risk to the effects of heat include older adults, particularly 75+, and those with specific chronic conditions, such as diabetes, respiratory and heart conditions. The HWP recommends specific protective actions which relate to five heat-health alert levels (levels 0–4). This study examines the attitudes to hot weather of adults in England, and the protective measures taken during a heatwave. Methods As part of a wider evaluation of the implementation and effects of the HWP, a survey (n = 3153) and focus groups, a form of group interview facilitated by a researcher, were carried out after the June 2017 level 3 heat-health alert. Survey respondents were categorised into three groups based on their age and health status: ‘vulnerable’ (aged 75+), ‘potentially vulnerable’ (aged 18–74 in poor health) and ‘not vulnerable’ (rest of the adult population) to hot weather. Multivariable logistic regression models identified factors associated with these groups taking protective measures. In-person group discussion, focused on heat-health, were carried out with 25 people, mostly aged 75 + . Results Most vulnerable and potentially vulnerable adults do not consider themselves at risk of hot weather and are unaware of the effectiveness of important protective behaviours. Only one-quarter of (potentially) vulnerable adults reported changing their behaviour as a result of hearing hot weather-related health advice during the level 3 alert period. Focus group findings showed many vulnerable adults were more concerned about the effects of the sun’s ultra-violet radiation on the skin than on the effects of hot temperatures on health. Conclusions Current public health messages appear to be insufficient, given the low level of (potentially) vulnerable adults changing their behaviour during hot weather. In the context of increasingly warmer summers in England due to climate change, public health messaging needs to convince (potentially) vulnerable adults of all the risks of hot weather (not just effects of sunlight on the skin) and of the importance of heat protective measures. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-11668-x.
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Affiliation(s)
- Bob Erens
- Policy Innovation & Evaluation Research Unit, Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK.
| | - Lorraine Williams
- Policy Innovation & Evaluation Research Unit, Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
| | - Josephine Exley
- Policy Innovation & Evaluation Research Unit, Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
| | - Stefanie Ettelt
- Policy Innovation & Evaluation Research Unit, Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
| | - Tommaso Manacorda
- Policy Innovation & Evaluation Research Unit, Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
| | - Shakoor Hajat
- Department of Public Health, Environments & Society, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
| | - Nicholas Mays
- Policy Innovation & Evaluation Research Unit, Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
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17
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Abstract
The health secretary gains sweeping new powers, with unclear consequences for patients
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18
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Morciano M, Checkland K, Durand MA, Sutton M, Mays N. Comparison of the impact of two national health and social care integration programmes on emergency hospital admissions. BMC Health Serv Res 2021; 21:687. [PMID: 34247592 PMCID: PMC8274044 DOI: 10.1186/s12913-021-06692-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 06/23/2021] [Indexed: 12/26/2022] Open
Abstract
Background Policy-makers expect that integration of health and social care will improve user and carer experience and reduce avoidable hospital use. [We] evaluate the impact on emergency hospital admissions of two large nationally-initiated service integration programmes in England: the Pioneer (November 2013 to March 2018) and Vanguard (January 2015 to March 2018) programmes. The latter had far greater financial and expert support from central agencies. Methods Of the 206 Clinical Commissioning Groups (CCGs) in England, 51(25%) were involved in the Pioneer programme only, 22(11%) were involved in the Vanguard programme only and 13(6%) were involved in both programmes. We used quasi-experimental methods to compare monthly counts of emergency admissions between four groups of CCGs, before and after the introduction of the two programmes. Results CCGs involved in the programmes had higher monthly hospital emergency admission rates than non-participants prior to their introduction [7.9 (95% CI:7.8–8.1) versus 7.5 (CI: 7.4–7.6) per 1000 population]. From 2013 to 2018, there was a 12% (95% CI:9.5–13.6%) increase in emergency admissions in CCGs not involved in either programme while emergency admissions in CCGs in the Pioneer and Vanguard programmes increased by 6.4% (95% CI: 3.8–9.0%) and 8.8% (95% CI:4.5–13.1%), respectively. CCGs involved in both initiatives experienced a smaller increase of 3.5% (95% CI:-0.3–7.2%). The slowdown largely occurred in the final year of both programmes. Conclusions Health and social care integration programmes can mitigate but not prevent rises in emergency admissions over the longer-term. Greater financial and expert support from national agencies and involvement in multiple integration initiatives can have cumulative effects. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06692-x.
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Affiliation(s)
- Marcello Morciano
- Health Organisation, Policy and Economics (HOPE) Research Group, University of Manchester, Manchester, M13 9PL, UK.
| | - Katherine Checkland
- Health Organisation, Policy and Economics (HOPE) Research Group, University of Manchester, Manchester, M13 9PL, UK
| | - Mary Alison Durand
- Department of Health Services Research and Policy, Policy Innovation and Evaluation Research Unit, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
| | - Matt Sutton
- Health Organisation, Policy and Economics (HOPE) Research Group, University of Manchester, Manchester, M13 9PL, UK
| | - Nicholas Mays
- Department of Health Services Research and Policy, Policy Innovation and Evaluation Research Unit, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
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19
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Gosling J, Mays N, Erens B, Reid D, Exley J. Quality improvement in general practice: what do GPs and practice managers think? Results from a nationally representative survey of UK GPs and practice managers. BMJ Open Qual 2021; 10:bmjoq-2020-001309. [PMID: 34049868 PMCID: PMC8166611 DOI: 10.1136/bmjoq-2020-001309] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 05/11/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND This paper presents the results of the first UK-wide survey of National Health Service (NHS) general practitioners (GPs) and practice managers (PMs) designed to explore the service improvement activities being undertaken in practices, and the factors that facilitated or obstructed that work. The research was prompted by growing policy and professional interest in the quality of general practice and its improvement. The analysis compares GP and PM involvement in, and experience of, quality improvement activities. METHODS This was a mixed-method study comprising 26 semistructured interviews, a focus group and two surveys. The qualitative data supported the design of the surveys, which were sent to all 46 238 GPs on the Royal College of General Practitioners (RCGP) database and the PM at every practice across the UK (n=9153) in July 2017. RESULTS Responses from 2377 GPs and 1424 PMs were received and were broadly representative of each group. Ninety-nine per cent reported having planned or undertaken improvement activities in the previous 12 months. The most frequent related to prescribing and access. Key facilitators of improvement included 'good clinical leadership'. The two main barriers were 'too many demands from external stakeholders' and a lack of protected time. Audit and significant event audit were the most common improvement tools used, but respondents were interested in training on other quality improvement tools. CONCLUSION GPs and PMs are interested in improving service quality. As such, the new quality improvement domain in the Quality and Outcomes Framework used in the payment of practices is likely to be relatively easily accepted by GPs in England. However, if improving quality is to become routine work for practices, it will be important for the NHS in the four UK countries to work with practices to mitigate some of the barriers that they face, in particular the lack of protected time.
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Affiliation(s)
- Jennifer Gosling
- Health Services Research & Policy, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
| | - Nicholas Mays
- Health Services Research & Policy, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
| | - Bob Erens
- Health Services Research & Policy, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
| | - David Reid
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Josephine Exley
- Health Services Research & Policy, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
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20
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Alderwick H, Hutchings A, Briggs A, Mays N. The impacts of collaboration between local health care and non-health care organizations and factors shaping how they work: a systematic review of reviews. BMC Public Health 2021; 21:753. [PMID: 33874927 PMCID: PMC8054696 DOI: 10.1186/s12889-021-10630-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/11/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Policymakers in many countries promote collaboration between health care organizations and other sectors as a route to improving population health. Local collaborations have been developed for decades. Yet little is known about the impact of cross-sector collaboration on health and health equity. METHODS We carried out a systematic review of reviews to synthesize evidence on the health impacts of collaboration between local health care and non-health care organizations, and to understand the factors affecting how these partnerships functioned. We searched four databases and included 36 studies (reviews) in our review. We extracted data from these studies and used Nvivo 12 to help categorize the data. We assessed risk of bias in the studies using standardized tools. We used a narrative approach to synthesizing and reporting the data. RESULTS The 36 studies we reviewed included evidence on varying forms of collaboration in diverse contexts. Some studies included data on collaborations with broad population health goals, such as preventing disease and reducing health inequalities. Others focused on collaborations with a narrower focus, such as better integration between health care and social services. Overall, there is little convincing evidence to suggest that collaboration between local health care and non-health care organizations improves health outcomes. Evidence of impact on health services is mixed. And evidence of impact on resource use and spending are limited and mixed. Despite this, many studies report on factors associated with better or worse collaboration. We grouped these into five domains: motivation and purpose, relationships and cultures, resources and capabilities, governance and leadership, and external factors. But data linking factors in these domains to collaboration outcomes is sparse. CONCLUSIONS In theory, collaboration between local health care and non-health care organizations might contribute to better population health. But we know little about which kinds of collaborations work, for whom, and in what contexts. The benefits of collaboration may be hard to deliver, hard to measure, and overestimated by policymakers. Ultimately, local collaborations should be understood within their macro-level political and economic context, and as one component within a wider system of factors and interventions interacting to shape population health.
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Affiliation(s)
- Hugh Alderwick
- Health Foundation, 8 Salisbury Square, London, EC4Y 8AP UK
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Andrew Hutchings
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Adam Briggs
- Health Foundation, 8 Salisbury Square, London, EC4Y 8AP UK
- University of Warwick, Coventry, CV4 7AL UK
| | - Nicholas Mays
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
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21
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Read S, Erens B, Wittenberg R, Wistow G, Dickinson F, Knapp M, Cyhlarova E, Mays N. Public preferences for paying for social care in later life in England: A latent class analysis. Soc Sci Med 2021; 274:113803. [PMID: 33684699 DOI: 10.1016/j.socscimed.2021.113803] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/18/2021] [Accepted: 02/22/2021] [Indexed: 11/24/2022]
Abstract
There is ongoing debate about how the funding system for social care of older people in England should best be reformed. We investigated how public attitudes to individual and state responsibility for paying for social care in later life vary with demographic and socio-economic characteristics. Four vignettes of individuals in need of home care or residential care with varying levels of savings, income and housing wealth were presented to a sample of people aged 18-75 years (n = 3000) in December 2018. Respondents were asked if care costs should be paid by the user, the state or shared. They were also asked about the best way to pay for social care in old age. Latent class analysis was used to identify sub-groups with similar preferences for paying for care, and to explore their socio-demographic characteristics. We identified five classes. The majority (Class 1, 58%) preferred that the state and the user should share social care costs. Class 2 (18%) thought that the state should pay all costs regardless of users' savings, income or housing wealth. Class 3 (15%) preferred users to pay all costs at all levels of savings, income and housing wealth, with the exception of those unable to afford the costs. Classes 4 and 5 (5% each) were characterised by different patterns of 'don't know' answers. Socio-economic status was higher among those proposing higher user contributions (Class 3) and lower among those with several 'don't' know' responses (Classes 4 and 5). Concerns about care costs in old age were high among those proposing that the state pays all costs (Class 2) and those preferring that users pay all costs (Class 3). This study shows that public views on social care funding vary with respondents' characteristics and that proposals to reform the system need to be carefully calibrated.
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Affiliation(s)
- Sanna Read
- Care Policy and Evaluation Centre (CPEC), London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK.
| | - Bob Erens
- Policy Innovation and Evaluation Research Unit (PIRU), Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | - Raphael Wittenberg
- Policy Innovation and Evaluation Research Unit (PIRU), Care Policy and Evaluation Centre (CPEC), London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK.
| | - Gerald Wistow
- Care Policy and Evaluation Centre (CPEC), London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK.
| | - Francis Dickinson
- Care Policy and Evaluation Centre (CPEC), London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK.
| | - Martin Knapp
- Policy Innovation and Evaluation Research Unit (PIRU), Care Policy and Evaluation Centre (CPEC), London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK.
| | - Eva Cyhlarova
- Care Policy and Evaluation Centre (CPEC), London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK.
| | - Nicholas Mays
- Policy Innovation and Evaluation Research Unit (PIRU), Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
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Affiliation(s)
| | | | | | - Nicholas Mays
- London School of Hygiene and Tropical Medicine, London, UK
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23
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Knai C, Petticrew M, Capewell S, Cassidy R, Collin J, Cummins S, Eastmure E, Fafard P, Fitzgerald N, Gilmore AB, Hawkins B, Jensen JD, Katikireddi SV, Maani N, Mays N, Mwatsama M, Nakkash R, Orford JF, Rutter H, Savona N, van Schalkwyk MCI, Weishaar H. The case for developing a cohesive systems approach to research across unhealthy commodity industries. BMJ Glob Health 2021; 6:e003543. [PMID: 33593757 PMCID: PMC7888371 DOI: 10.1136/bmjgh-2020-003543] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 10/22/2020] [Accepted: 11/11/2020] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Most non-communicable diseases are preventable and largely driven by the consumption of harmful products, such as tobacco, alcohol, gambling and ultra-processed food and drink products, collectively termed unhealthy commodities. This paper explores the links between unhealthy commodity industries (UCIs), analyses the extent of alignment across their corporate political strategies, and proposes a cohesive systems approach to research across UCIs. METHODS We held an expert consultation on analysing the involvement of UCIs in public health policy, conducted an analysis of business links across UCIs, and employed taxonomies of corporate political activity to collate, compare and illustrate strategies employed by the alcohol, ultra-processed food and drink products, tobacco and gambling industries. RESULTS There are clear commonalities across UCIs' strategies in shaping evidence, employing narratives and framing techniques, constituency building and policy substitution. There is also consistent evidence of business links between UCIs, as well as complex relationships with government agencies, often allowing UCIs to engage in policy-making forums. This knowledge indicates that the role of all UCIs in public health policy would benefit from a common approach to analysis. This enables the development of a theoretical framework for understanding how UCIs influence the policy process. It highlights the need for a deeper and broader understanding of conflicts of interests and how to avoid them; and a broader conception of what constitutes strong evidence generated by a wider range of research types. CONCLUSION UCIs employ shared strategies to shape public health policy, protecting business interests, and thereby contributing to the perpetuation of non-communicable diseases. A cohesive systems approach to research across UCIs is required to deepen shared understanding of this complex and interconnected area and also to inform a more effective and coherent response.
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Affiliation(s)
- Cécile Knai
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
- SPECTRUM Consortium, UK
| | - Mark Petticrew
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
- SPECTRUM Consortium, UK
| | - Simon Capewell
- Department of Public Health, Policy & Systems, University of Liverpool, Liverpool, UK
| | - Rebecca Cassidy
- Department of Anthropology, Goldsmiths University of London, London, UK
| | - Jeff Collin
- SPECTRUM Consortium, UK
- Global Public Health Unit, University of Edinburgh, Edinburgh, UK
| | - Steven Cummins
- Population Health Innovation Lab, Department of Public Health, Environments & Society, London School of Hygiene & Tropical Medicine, London, UK
| | - Elizabeth Eastmure
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Patrick Fafard
- Faculty of Social Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Niamh Fitzgerald
- SPECTRUM Consortium, UK
- Institute for Social Marketing and Health, University of Stirling, Stirling, UK
| | - Anna B Gilmore
- SPECTRUM Consortium, UK
- Tobacco Control Research Group, Department for Health, University of Bath, Bath, UK
| | - Ben Hawkins
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Jørgen Dejgård Jensen
- Institute of Food and Resource Economics, University of Copenhagen, Frederiksberg, Denmark
| | | | - Nason Maani
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
- SPECTRUM Consortium, UK
- School of Public Health, Boston University, Boston, Massachusetts, USA
| | - Nicholas Mays
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Rima Nakkash
- Health Promotion and Community Health, American University of Beirut, Beirut, Lebanon
| | - Jim F Orford
- School of Psychology, University of Birmingham, Birmingham, UK
- King's College London, London, UK
| | - Harry Rutter
- Department of Social and Policy Sciences, University of Bath, Bath, Bath and North East Somer, UK
| | - Natalie Savona
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - May C I van Schalkwyk
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Heide Weishaar
- Center for International Health Protection, Robert Koch Institute, Berlin, Germany
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Affiliation(s)
- Luisa M Pettigrew
- London School of Hygiene and Tropical Medicine, Department of Health Services Research and Policy, London, UK
| | | | - Nicholas Mays
- London School of Hygiene and Tropical Medicine, Department of Health Services Research and Policy, London, UK
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Al-Haboubi M, Trathen A, Black N, Eastmure E, Mays N. Views of health care professionals and policy-makers on the use of surveillance data to combat antimicrobial resistance. BMC Public Health 2020; 20:279. [PMID: 32122326 PMCID: PMC7053143 DOI: 10.1186/s12889-020-8383-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 02/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Providing healthcare professionals with health surveillance data aims to support professional and organisational behaviour change. The UK Five Year Antimicrobial Resistance (AMR) Strategy 2013 to 2018 identified better access to and use of surveillance data as a key component. Our aim was to determine the extent to which data on antimicrobial use and resistance met the perceived needs of health care professionals and policy-makers at national, regional and local levels, and how provision could be improved. METHODS We conducted 41 semi-structured interviews with national policy makers in the four Devolved Administrations and 71 interviews with health care professionals in six locations across the United Kingdom selected to achieve maximum variation in terms of population and health system characteristics. Transcripts were analysed thematically using a mix of a priori reasoning guided by the main topics in the interview guide together with themes emerging inductively from the data. Views were considered at three levels - primary care, secondary care and national - and in terms of availability of data, current uses, benefits, gaps and potential improvements. RESULTS Respondents described a range of uses for prescribing and resistance data. The principal gaps identified were prescribing in private practice, internet prescribing and secondary care (where some hospitals did not have electronic prescribing systems). Some respondents under-estimated the range of data available. There was a perception that the responsibility for collecting and analysing data often rests with a few individuals who may lack sufficient time and appropriate skills. CONCLUSIONS There is a need to raise awareness of data availability and the potential value of these data, and to ensure that data systems are more accessible. Any skills gap at local level in how to process and use data needs to be addressed. This requires an identification of the best methods to improve support and education relating to AMR data systems.
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Affiliation(s)
- Mustafa Al-Haboubi
- Policy Innovation and Evaluation Research Unit, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, England.
| | - Andrew Trathen
- Policy Innovation and Evaluation Research Unit, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, England
| | - Nick Black
- Policy Innovation and Evaluation Research Unit, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, England
| | - Elizabeth Eastmure
- Policy Innovation and Evaluation Research Unit, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, England
| | - Nicholas Mays
- Policy Innovation and Evaluation Research Unit, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, England
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26
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Bennani H, Mateus A, Mays N, Eastmure E, Stärk KDC, Häsler B. Overview of Evidence of Antimicrobial Use and Antimicrobial Resistance in the Food Chain. Antibiotics (Basel) 2020; 9:E49. [PMID: 32013023 PMCID: PMC7168130 DOI: 10.3390/antibiotics9020049] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/25/2020] [Accepted: 01/27/2020] [Indexed: 01/06/2023] Open
Abstract
Antimicrobial resistance (AMR) is a global health problem. Bacteria carrying resistance genes can be transmitted between humans, animals and the environment. There are concerns that the widespread use of antimicrobials in the food chain constitutes an important source of AMR in humans, but the extent of this transmission is not well understood. The aim of this review is to examine published evidence on the links between antimicrobial use (AMU) in the food chain and AMR in people and animals. The evidence showed a link between AMU in animals and the occurrence of resistance in these animals. However, evidence of the benefits of a reduction in AMU in animals on the prevalence of resistant bacteria in humans is scarce. The presence of resistant bacteria is documented in the human food supply chain, which presents a potential exposure route and risk to public health. Microbial genome sequencing has enabled the establishment of some links between the presence of resistant bacteria in humans and animals but, for some antimicrobials, no link could be established. Research and monitoring of AMU and AMR in an integrated manner is essential for a better understanding of the biology and the dynamics of antimicrobial resistance.
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Affiliation(s)
- Houda Bennani
- Veterinary Epidemiology, Economics and Public Health Group, Department of Pathobiology and Population Sciences, Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield, Hertfordshire AL9 7TA, UK; (A.M.); (K.D.C.S.); (B.H.)
| | - Ana Mateus
- Veterinary Epidemiology, Economics and Public Health Group, Department of Pathobiology and Population Sciences, Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield, Hertfordshire AL9 7TA, UK; (A.M.); (K.D.C.S.); (B.H.)
| | - Nicholas Mays
- Policy Innovation Research Unit, Department of Health Services Research & Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK; (N.M.); (E.E.)
| | - Elizabeth Eastmure
- Policy Innovation Research Unit, Department of Health Services Research & Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK; (N.M.); (E.E.)
| | - Katharina D. C. Stärk
- Veterinary Epidemiology, Economics and Public Health Group, Department of Pathobiology and Population Sciences, Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield, Hertfordshire AL9 7TA, UK; (A.M.); (K.D.C.S.); (B.H.)
- SAFOSO AG, Waldeggstrasse 1, CH 3097 Liebefeld, Switzerland
| | - Barbara Häsler
- Veterinary Epidemiology, Economics and Public Health Group, Department of Pathobiology and Population Sciences, Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield, Hertfordshire AL9 7TA, UK; (A.M.); (K.D.C.S.); (B.H.)
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Cyhlarova E, Knapp M, Mays N. Responding to the mental health consequences of the 2015-2016 terrorist attacks in Tunisia, Paris and Brussels: implementation and treatment experiences in the United Kingdom. J Health Serv Res Policy 2019; 25:172-180. [PMID: 31769712 DOI: 10.1177/1355819619878756] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To explore whether the Screen and Treat Programme to support United Kingdom citizens potentially affected by terrorist attacks in Tunisia (2015), Paris (2015) and Brussels (2016) was effective in identifying and referring people to mental health services, to examine the programme's acceptability to users and to understand how agencies involved worked together. METHODS Individuals offered screening by the programme (n = 529) were invited to participate in the study and were sent a questionnaire. Follow-up interviews were conducted with questionnaire respondents who consented and with employees of agencies involved in the programme's planning and delivery. Seventy-seven people affected by the attacks completed questionnaires, 35 of those were also interviewed, and 1 further person only participated in an interview. Eleven people from agencies organizing and delivering the programme and five clinician-managers were also interviewed. RESULTS Most service users said the attacks had a major impact on their lives. Many reported anxiety, depression, difficulty going out or travelling, sleep problems, panic attacks, flashbacks and hyper-vigilance. A third had reduced their working hours and a similar proportion had taken sick leave. Two-thirds sought help from their General Practitioner (GP) before being contacted by the programme, but almost all thought their GP had not been helpful in dealing with post-traumatic stress disorder (PTSD) or referring to appropriate care. Several people were prescribed psychotropic medication; only a few were referred to mental health professionals. Many participants used help offered by organizations external to National Health Service, with mixed experiences. Waiting times for treatment varied from no delay to a few months. Most interviewees thought the programme should have started sooner and provided more information about sources of support. Most users found treatment received via the programme helpful. Professionals involved in organizing and delivering the programme thought that bureaucratic delays in setting it up were key limitations on effectiveness. Clinician interviewees thought an outreach approach was needed to identify at-risk individuals. CONCLUSIONS Users who took part in the programme were satisfied with their treatment, although many thought it should have been offered sooner. Funding and data sharing between agencies were the main barriers to timely contact with affected individuals. Self-referral, GP identification of PTSD and GP referral to appropriate care were regarded as ineffective, suggesting that people affected by similar future incidents should be supported better and assisted more promptly to access treatment.
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Affiliation(s)
- Eva Cyhlarova
- Senior Research Fellow, Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science, UK
| | - Martin Knapp
- Professor of Health and Social Care Policy, Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science; and Policy Innovation and Evaluation Research Unit, Department of Health Services Research & Policy, London School of Hygiene and Tropical Medicine, UK.,Director, NIHR School for Social Care Research, London, UK
| | - Nicholas Mays
- Professor of Health Policy, Director of Policy Innovation and Evaluation Research Unit, Department of Health Services Research & Policy, London School of Hygiene and Tropical Medicine, UK
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28
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Petticrew M, Douglas N, D'Souza P, Shi YM, Durand MA, Knai C, Eastmure E, Mays N. Community Alcohol Partnerships with the alcohol industry: what is their purpose and are they effective in reducing alcohol harms? J Public Health (Oxf) 2019; 40:16-31. [PMID: 28069991 DOI: 10.1093/pubmed/fdw139] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Indexed: 11/13/2022] Open
Abstract
Background Local initiatives to reduce alcohol harms are common. One UK approach, Community Alcohol Partnerships (CAPs), involves partnerships between the alcohol industry and local government, focussing on alcohol misuse and anti-social behaviour (ASB) among young people. This study aimed to assess the evidence of effectiveness of CAPs. Methods We searched CAP websites and documents, and databases, and contacted CAPs to identify evaluations and summarize their findings. We appraised these against four methodological criteria: (i) reporting of pre-post data; (ii) use of comparison area(s); (iii) length of follow-up; and (iv) baseline comparability of comparison and intervention areas. Results Out of 88 CAPs, we found three CAP evaluations which used controlled designs or comparison areas, and further data on 10 other CAPs. The most robust evaluations found little change in ASB, though few data were presented. While CAPs appear to affect public perceptions of ASB, this is not a measure of the effectiveness of CAPs. Conclusions Despite industry claims, the few existing evaluations do not provide convincing evidence that CAPs are effective in reducing alcohol harms or ASB. Their main role may be as an alcohol industry corporate social responsibility measure which is intended to limit the reputational damage associated with alcohol-related ASB.
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Affiliation(s)
- M Petticrew
- Policy Innovation Research Unit, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, LondonWC1H 9SH, UK
| | - N Douglas
- Policy Innovation Research Unit, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, LondonWC1H 9SH, UK
| | - P D'Souza
- Policy Innovation Research Unit, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, LondonWC1H 9SH, UK
| | - Y M Shi
- Policy Innovation Research Unit, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, LondonWC1H 9SH, UK
| | - M A Durand
- Policy Innovation Research Unit, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, LondonWC1H 9SH, UK
| | - C Knai
- Policy Innovation Research Unit, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, LondonWC1H 9SH, UK
| | - E Eastmure
- Policy Innovation Research Unit, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, LondonWC1H 9SH, UK
| | - N Mays
- Policy Innovation Research Unit, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, LondonWC1H 9SH, UK
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Erens B, Wistow G, Mays N, Manacorda T, Douglas N, Mounier-Jack S, Durand MA. Can health and social care integration make long-term progress? Findings from key informant surveys of the integration Pioneers in England. JICA 2019. [DOI: 10.1108/jica-05-2019-0020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
All areas in England are expected by National Health Service (NHS) England to develop integrated care systems (ICSs) by April 2021. ICSs bring together primary, secondary and community health services, and involve local authorities and the voluntary sector. ICSs build on previous pilots, including the Integrated Care Pioneers in 25 areas from November 2013 to March 2018. This analysis tracks the Pioneers’ self-reported progress, and the facilitators and barriers to improve service coordination over three years, longer than previous evaluations in England. The paper aims to discuss these issues.
Design/methodology/approach
Annual online key informant (KI) surveys, 2016–2018, are used for this study.
Findings
By the fourth year of the programme (2017), KIs had shifted from reporting plans to implementation of a wide range of initiatives. In 2018, informants reported fewer “significant” barriers to change than previously. While some progress in achieving local integration objectives was evident, it was also clear that progress can take considerable time. In parallel, there appears to have been a move away from aspects of personalised care associated with user control, perhaps in part because the emphasis of national objectives has shifted towards establishing large-scale ICSs with a particular focus on organisational fragmentation within the NHS.
Research limitations/implications
Because these are self-reports of changes, they cannot be objectively verified. Later stages of the evaluation will look at changes in outcomes and user experiences.
Originality/value
The current study shows clearly that the benefits of integrating health and social care are unlikely to be apparent for several years, and expectations of policy makers to see rapid improvements in care and outcomes are likely to be unrealistic.
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Pettigrew L, Mays N. Primary care networks: the risk of "mission creep" calls for focused ambition. BMJ 2019; 367:l5978. [PMID: 31615782 DOI: 10.1136/bmj.l5978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Luisa Pettigrew
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
| | - Nicholas Mays
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
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Dixon J, Trathen A, Wittenberg R, Mays N, Wistow G, Knapp M. Funding and planning for social care in later life: a deliberative focus group study. Health Soc Care Community 2019; 27:e687-e696. [PMID: 31199044 DOI: 10.1111/hsc.12768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 03/20/2019] [Accepted: 03/31/2019] [Indexed: 06/09/2023]
Abstract
This study examined people's perceptions and behaviours in relation to planning for their social care needs, and their values and priorities concerning how social care should be funded. Eight deliberative focus groups were conducted in May 2018 with 53 participants, aged 25-82 years, in London, Manchester and rural locations near York and Sheffield. Multiple uncertainties created barriers to planning for social care needs including not knowing how much to save, not thinking it possible for an average person to save enough to meet significant needs, reluctance to plan for something potentially unnecessary, lack of suitable and secure ways of saving, and a perception of social care policy as unsettled. Participants also had significant concerns that they would not be able to obtain good-quality care, regardless of resources. In addition, it was commonly thought unrealistic to expect families to provide more than low-intensity, supplementary care, while use of housing assets to pay for care was considered unfair, both for home-owners who could lose their assets and non-home-owners who were left reliant on the state although it was more acceptable where people were childless or had substantial assets. Participants thought any new arrangements should be inclusive, personally affordable, sustainable, transparent, good-quality and honest. They preferred to contribute regularly rather than find considerable sums of money at times of crisis, and preferred to risk-pool, with everyone obliged or heavily encouraged to contribute. Transparency was valued so those better at 'working the system' were not able to benefit unfairly and participants wanted to know that, if they contributed, they would be assured of good-quality care. Trust in Government and other institutions, however, was low. New funding arrangements should incorporate measures to increase transparency and trust, be clear about the responsibilities of individuals and the state, provide meaningful options to save, and place significant focus on improving actual and perceived care quality. For acceptability, proposals should be framed to emphasise their affective dimensions and positive values.
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Affiliation(s)
- Josie Dixon
- Care Policy and Evaluation Centre (CPEC), London School of Economics and Political Science, London, UK
| | - Andrew Trathen
- Policy Innovation and Evaluation Research Unit (PIRU), London School of Hygiene and Tropical Medicine, and London School of Economics and Political Science, London, UK
| | - Raphael Wittenberg
- Care Policy and Evaluation Centre (CPEC), London School of Economics and Political Science, London, UK
- Policy Innovation and Evaluation Research Unit (PIRU), London School of Hygiene and Tropical Medicine, and London School of Economics and Political Science, London, UK
| | - Nicholas Mays
- Policy Innovation and Evaluation Research Unit (PIRU), London School of Hygiene and Tropical Medicine, and London School of Economics and Political Science, London, UK
- Department of Health Services Research & Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Gerald Wistow
- Care Policy and Evaluation Centre (CPEC), London School of Economics and Political Science, London, UK
| | - Martin Knapp
- Care Policy and Evaluation Centre (CPEC), London School of Economics and Political Science, London, UK
- Policy Innovation and Evaluation Research Unit (PIRU), London School of Hygiene and Tropical Medicine, and London School of Economics and Political Science, London, UK
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Keeble E, Bardsley M, Durand MA, Hoomans T, Mays N. Area level impacts on emergency hospital admissions of the integrated care and support pioneer programme in England: difference-in-differences analysis. BMJ Open 2019; 9:e026509. [PMID: 31427314 PMCID: PMC6701574 DOI: 10.1136/bmjopen-2018-026509] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To examine whether any differential change in emergency admissions could be attributed to integrated care by comparing pioneer and non-pioneer populations from a pre-pioneer baseline period (April 2010 to March 2013) over two follow-up periods: to 2014/2015 and to 2015/2016. DESIGN Difference-in-differences analysis of emergency hospital admissions from English Hospital Episode Statistics. SETTING Local authorities in England classified as either pioneer or non-pioneer. PARTICIPANTS Emergency admissions to all NHS hospitals in England with local authority determined by area of residence of the patient. INTERVENTION Wave 1 of the integrated care and support pioneer programme announced in November 2013. PRIMARY OUTCOME MEASURE Change in hospital emergency admissions. RESULTS The increase in the pioneer emergency admission rate from baseline to 2014/2015 was smaller at 1.93% and significantly different from that of the non-pioneers at 4.84% (p=0.0379). The increase in the pioneer emergency admission rate from baseline to 2015/2016 was again smaller than for the non-pioneers but the difference was not statistically significant (p=0.1879). CONCLUSIONS It is ambitious to expect unequivocal changes in a high level and indirect indicator of health and social care integration such as emergency hospital admissions to arise as a result of the changes in local health and social care provision across organisations brought about by the pioneers in their early years. We should treat any sign that the pioneers have had such an impact with caution. Nevertheless, there does seem to be an indication from the current analysis that there were some changes in hospital use associated with the first year of pioneer status that are worthy of further exploration.
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Affiliation(s)
| | | | - Mary Alison Durand
- Policy Innovation and Evaluation Research Unit, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Ties Hoomans
- Policy Innovation and Evaluation Research Unit, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Nicholas Mays
- Policy Innovation and Evaluation Research Unit, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Hammond J, Mason T, Sutton M, Hall A, Mays N, Coleman A, Allen P, Warwick-Giles L, Checkland K. Exploring the impacts of the 2012 Health and Social Care Act reforms to commissioning on clinical activity in the English NHS: a mixed methods study of cervical screening. BMJ Open 2019; 9:e024156. [PMID: 30987985 PMCID: PMC6500278 DOI: 10.1136/bmjopen-2018-024156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Explore the impact of changes to commissioning introduced in England by the Health and Social Care Act 2012 (HSCA) on cervical screening activity in areas identified empirically as particularly affected organisationally by the reforms. METHODS Qualitative followed by quantitative methods. Qualitative: semi-structured interviews (with NHS commissioners, managers, clinicians, senior administrative staff from Clinical Commissioning Groups (CCGs), local authorities, service providers), observations of commissioning meetings in two metropolitan areas of England. Quantitative: triple-difference analysis of national administrative data. Variability in the expected effects of HSCA on commissioning was measured by comparing CCGs working with one local authority with CCGs working with multiple local authorities. To control for unmeasured confounders, differential changes over time in cervical screening rates (among women, 25-64 years) between CCGs more and less likely to have been affected by HSCA commissioning organisational change were compared with another outcome-unassisted birth rates-largely unaffected by HSCA changes. RESULTS Interviewees identified that cervical screening commissioning and provision was more complex and 'fragmented', with responsibilities less certain, following the HSCA. Interviewees predicted this would reduce cervical screening rates in some areas more than others. Quantitative findings supported these predictions. Areas where CCGs dealt with multiple local authorities experienced a larger decline in cervical screening rates (1.4%) than those dealing with one local authority (1.0%). Over the same period, unassisted deliveries decreased by 1.6% and 2.0%, respectively, in the two groups. CONCLUSIONS Arrangements for commissioning and delivering cervical screening were disrupted and made more complex by the HSCA. Areas most affected saw a greater decline in screening rates than others. The fact that this was identified qualitatively and then confirmed quantitatively strengthens this finding. The study suggests large-scale health system reforms may have unintended consequences, and that complex commissioning arrangements may be problematic.
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Affiliation(s)
- Jonathan Hammond
- Division of Population Health, Health Services Research, and Primary Care, University of Manchester, Manchester, UK
- School of Health Sciences, University of Manchester, Manchester, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Thomas Mason
- Division of Population Health, Health Services Research, and Primary Care, University of Manchester, Manchester, UK
- School of Health Sciences, University of Manchester, Manchester, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK
| | - Matt Sutton
- Division of Population Health, Health Services Research, and Primary Care, University of Manchester, Manchester, UK
- School of Health Sciences, University of Manchester, Manchester, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Alex Hall
- School of Health Sciences, University of Manchester, Manchester, UK
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Nicholas Mays
- Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Anna Coleman
- Division of Population Health, Health Services Research, and Primary Care, University of Manchester, Manchester, UK
- School of Health Sciences, University of Manchester, Manchester, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | | | - Lynsey Warwick-Giles
- Division of Population Health, Health Services Research, and Primary Care, University of Manchester, Manchester, UK
- School of Health Sciences, University of Manchester, Manchester, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Kath Checkland
- Division of Population Health, Health Services Research, and Primary Care, University of Manchester, Manchester, UK
- School of Health Sciences, University of Manchester, Manchester, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Oliver K, Kothari A, Mays N. The dark side of coproduction: do the costs outweigh the benefits for health research? Health Res Policy Syst 2019; 17:33. [PMID: 30922339 PMCID: PMC6437844 DOI: 10.1186/s12961-019-0432-3] [Citation(s) in RCA: 236] [Impact Index Per Article: 47.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 03/07/2019] [Indexed: 01/17/2023] Open
Abstract
Background Coproduction, a collaborative model of research that includes stakeholders in the research process, has been widely advocated as a means of facilitating research use and impact. We summarise the arguments in favour of coproduction, the different approaches to establishing coproductive work and their costs, and offer some advice as to when and how to consider coproduction. Debate Despite the multiplicity of reasons and incentives to coproduce, there is little consensus about what coproduction is, why we do it, what effects we are trying to achieve, or the best coproduction techniques to achieve policy, practice or population health change. Furthermore, coproduction is not free risk or cost. Tensions can arise throughout coproduced research processes between the different interests involved. We identify five types of costs associated with coproduced research affecting the research itself, the research process, professional risks for researchers and stakeholders, personal risks for researchers and stakeholders, and risks to the wider cause of scholarship. Yet, these costs are rarely referred to in the literature, which generally calls for greater inclusion of stakeholders in research processes, focusing exclusively on potential positives. There are few tools to help researchers avoid or alleviate risks to themselves and their stakeholders. Conclusions First, we recommend identifying specific motivations for coproduction and clarifying exactly which outcomes are required for whom for any particular piece of research. Second, we suggest selecting strategies specifically designed to enable these outcomes to be achieved, and properly evaluated. Finally, in the absence of strong evidence about the impact and process of coproduction, we advise a cautious approach to coproduction. This would involve conscious and reflective research practice, evaluation of how coproduced research practices change outcomes, and exploration of the costs and benefits of coproduction. We propose some preliminary advice to help decide when coproduction is likely to be more or less useful.
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Affiliation(s)
- Kathryn Oliver
- Department of Public Health, Environments and Society, Faculty of Public Health Policy, London School of Hygiene and Tropical Medicine, London, UK.
| | - Anita Kothari
- School of Health Studies, Western University, London, ON, Canada
| | - Nicholas Mays
- Department of Health Services Research and Policy, Faculty of Public Health Policy, London School of Hygiene and Tropical Medicine, London, UK
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Affiliation(s)
- Rebecca E Glover
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine
| | | | - Nicholas Mays
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine
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Bekker MPM, Mays N, Kees Helderman J, Petticrew M, Jansen MWJ, Knai C, Ruwaard D. Comparative institutional analysis for public health: governing voluntary collaborative agreements for public health in England and the Netherlands. Eur J Public Health 2019; 28:19-25. [PMID: 30383254 PMCID: PMC6209813 DOI: 10.1093/eurpub/cky158] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Democratic institutions and state-society relations shape governance arrangements and expectations between public and private stakeholders about public health impact. We illustrate this with a comparison between the English Public Health Responsibility Deal (RD) and the Dutch 'All About Health…' (AaH) programme. As manifestations of a Whole-of-Society approach, in which governments, civil society and business take responsibility for the co-production of economic utility and good health, these programmes are two recent collaborative platforms based on voluntary agreements to improve public health. Using a 'most similar cases' design, we conducted a comparative secondary analysis of data from the evaluations of the two programmes. The underlying rationale of both programmes was that voluntary agreements would be better suited than regulation to encourage business and civil society to take more responsibility for improving health. Differences between the two included: expectations of an enforcing versus facilitative role for government; hierarchical versus horizontal coordination; big business versus civil society participants; top-down versus bottom-up formulation of voluntary pledges and progress monitoring for accountability versus for learning and adaptation. Despite the attempt in both programmes to base voluntary commitments on trust, the English 'shadow of hierarchy' and adversarial state-society relationships conditioned non-governmental parties to see the pledges as controlling, quasi-contractual agreements that were only partially lived up to. The Dutch consensual political tradition enabled a civil society-based understanding and gradual acceptance of the pledges as the internalization by partner organizations of public health values within their operations. We conclude that there are institutional limitations to the implementation of generic trust-building and learning-based models of change 'Whole-of-Society' approaches.
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Affiliation(s)
- Marleen P M Bekker
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health, Medicine and Life Sciences (CAPHRI), Maastricht University, Maastricht, The Netherlands.,Chair group Health and Society, Center for Space, Place and Society, Wageningen University and Research, Wageningen, The Netherlands
| | - Nicholas Mays
- Policy Innovation Research Unit, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Jan Kees Helderman
- Department of Public Administration, Institute for Management Research, Radboud University, Nijmegen, The Netherlands
| | - Mark Petticrew
- Policy Innovation Research Unit, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Maria W J Jansen
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health, Medicine and Life Sciences (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Cecile Knai
- Policy Innovation Research Unit, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Dirk Ruwaard
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health, Medicine and Life Sciences (CAPHRI), Maastricht University, Maastricht, The Netherlands
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Knai C, Petticrew M, Douglas N, Durand MA, Eastmure E, Nolte E, Mays N. The Public Health Responsibility Deal: Using a Systems-Level Analysis to Understand the Lack of Impact on Alcohol, Food, Physical Activity, and Workplace Health Sub-Systems. Int J Environ Res Public Health 2018; 15:ijerph15122895. [PMID: 30562999 PMCID: PMC6313377 DOI: 10.3390/ijerph15122895] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 12/03/2018] [Accepted: 12/05/2018] [Indexed: 11/16/2022]
Abstract
The extent to which government should partner with business interests such as the alcohol, food, and other industries in order to improve public health is a subject of ongoing debate. A common approach involves developing voluntary agreements with industry or allowing them to self-regulate. In England, the most recent example of this was the Public Health Responsibility Deal (RD), a public⁻private partnership launched in 2011 under the then Conservative-led coalition government. The RD was organised around a series of voluntary agreements that aim to bring together government, academic experts, and commercial, public sector and voluntary organisations to commit to pledges to undertake actions of public health benefit. This paper brings together the main findings and implications of the evaluation of the RD using a systems approach. We analysed the functioning of the RD exploring the causal pathways involved and how they helped or hindered the RD; the structures and processes; feedback loops and how they might have constrained or potentiated the effects of the RD; and how resilient the wider systems were to change (i.e., the alcohol, food, and other systems interacted with). Both the production and uptake of pledges by RD partners were largely driven by the interests of partners themselves, enabling these wider systems to resist change. This analysis demonstrates how and why the RD did not meet its objectives. The findings have lessons for the development of effective alcohol, food and other policies, for defining the role of unhealthy commodity industries, and for understanding the limits of industry self-regulation as a public health measure.
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Affiliation(s)
- Cécile Knai
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15⁻17 Tavistock Place, London WC1H 9SH, UK.
| | - Mark Petticrew
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15⁻17 Tavistock Place, London WC1H 9SH, UK.
| | - Nick Douglas
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15⁻17 Tavistock Place, London WC1H 9SH, UK.
| | - Mary Alison Durand
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15⁻17 Tavistock Place, London WC1H 9SH, UK.
| | - Elizabeth Eastmure
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15⁻17 Tavistock Place, London WC1H 9SH, UK.
| | - Ellen Nolte
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15⁻17 Tavistock Place, London WC1H 9SH, UK.
| | - Nicholas Mays
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15⁻17 Tavistock Place, London WC1H 9SH, UK.
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Pettigrew LM, Kumpunen S, Rosen R, Posaner R, Mays N. Lessons for 'large-scale' general practice provider organisations in England from other inter-organisational healthcare collaborations. Health Policy 2018; 123:51-61. [PMID: 30509873 DOI: 10.1016/j.healthpol.2018.10.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 09/26/2018] [Accepted: 10/29/2018] [Indexed: 11/30/2022]
Abstract
Policymakers in England are increasingly encouraging the formation of 'large-scale' general practice provider collaborations with the expectation that this will help deliver better quality services and generate economies of scale. However, solid evidence that these expectations will be met is limited. This paper reviews evidence from other inter-organisational healthcare collaborations with similarities in their development or anticipated impact to identify lessons. Medline. SSCI, Embase and HMIC database searches identified a range of initiatives which could provide transferable evidence. Iterative searching was undertaken to identify further relevant evidence. Thematic analysis was used to identify areas to consider in the development of large-scale general practice providers. Framework analysis was used to identify challenges which may affect the ability of such providers to achieve their anticipated impact. A narrative approach was used to synthesise the evidence. Trade-offs exist in 'scaling-up' between mandated and voluntary collaboration; networks versus single organisations; small versus large collaborations; and different types of governance structures in terms of sustainability and performance. While positive impact seems plausible, evidence suggests that it is not a given that clinical outcomes or patient experience will improve, nor that cost savings will be achieved as a result of increasing organisational size. Since the impact and potential unintended consequences are not yet clear, it would be advisable for policymakers to move with caution, and be informed by ongoing evaluation.
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Affiliation(s)
- Luisa M Pettigrew
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK; Nuffield Trust, 59 New Cavendish Street, London, W1G 7LP, UK.
| | | | - Rebecca Rosen
- Nuffield Trust, 59 New Cavendish Street, London, W1G 7LP, UK
| | - Rachel Posaner
- Library & Information Service, Health Services Management Centre, University of Birmingham, Park House, 40 Edgbaston Park Road, Birmingham, B15 2RT, UK
| | - Nicholas Mays
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK; Nuffield Trust, 59 New Cavendish Street, London, W1G 7LP, UK
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Knai C, Petticrew M, Mays N, Capewell S, Cassidy R, Cummins S, Eastmure E, Fafard P, Hawkins B, Jensen JD, Katikireddi SV, Mwatsama M, Orford J, Weishaar H. Systems Thinking as a Framework for Analyzing Commercial Determinants of Health. Milbank Q 2018; 96:472-498. [PMID: 30277610 PMCID: PMC6131339 DOI: 10.1111/1468-0009.12339] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Policy Points: Worldwide, more than 70% of all deaths are attributable to noncommunicable diseases (NCDs), nearly half of which are premature and apply to individuals of working age. Although such deaths are largely preventable, effective solutions continue to elude the public health community. One reason is the considerable influence of the “commercial determinants of health”: NCDs are the product of a system that includes powerful corporate actors, who are often involved in public health policymaking. This article shows how a complex systems perspective may be used to analyze the commercial determinants of NCDs, and it explains how this can help with (1) conceptualizing the problem of NCDs and (2) developing effective policy interventions.
Context The high burden of noncommunicable diseases (NCDs) is politically salient and eminently preventable. However, effective solutions largely continue to elude the public health community. Two pressing issues heighten this challenge: the first is the public health community's narrow approach to addressing NCDs, and the second is the involvement of corporate actors in policymaking. While NCDs are often conceptualized in terms of individual‐level risk factors, we argue that they should be reframed as products of a complex system. This article explores the value of a systems approach to understanding NCDs as an emergent property of a complex system, with a focus on commercial actors. Methods Drawing on Donella Meadows's systems thinking framework, this article examines how a systems perspective may be used to analyze the commercial determinants of NCDs and, specifically, how unhealthy commodity industries influence public health policy. Findings Unhealthy commodity industries actively design and shape the NCD policy system, intervene at different levels of the system to gain agency over policy and politics, and legitimize their presence in public health policy decisions. Conclusions It should be possible to apply the principles of systems thinking to other complex public health issues, not just NCDs. Such an approach should be tested and refined for other complex public health challenges.
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Affiliation(s)
- Cécile Knai
- London School of Hygiene and Tropical Medicine
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Robinson JJ, Mays N, Fraser A. Improving research and policy interactions requires a better understanding of what works in different contexts. Isr J Health Policy Res 2018; 7:60. [PMID: 30285901 PMCID: PMC6169011 DOI: 10.1186/s13584-018-0256-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 09/12/2018] [Indexed: 11/10/2022] Open
Abstract
There is keen interest in many jurisdictions in finding ways to improve the way that research evidence informs policy. One possible mechanism for this is to embed academics within government agencies either as advisers or full staff members. Our commentary argues that, in addition to considering the role of academics in government as proposed by Glied and colleagues, we need to understand better how research and policy interactions function across policy sectors. We believe more comparative research is needed to understand if and why academics from certain disciplines are more likely to be recruited to work in some policy sectors rather than others. We caution against treating government as monolithic by advocating the same model for collaborative interaction between academics and government. Lastly, we contend that contextualized research is needed to illuminate important drivers of research and policy interactions before we can recommend what is likely to be more and less effective in different policy sectors.
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Affiliation(s)
- Joshua J. Robinson
- Department of Health Services Research & Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Nicholas Mays
- Department of Health Services Research & Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Alec Fraser
- Department of Health Services Research & Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
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Bonell C, Meiksin R, Mays N, Petticrew M, McKee M. Defending evidence informed policy making from ideological attack. BMJ 2018. [DOI: 10.1136/bmj.k3827] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Heffernan C, Jones L, Ritchie B, Erens B, Chalabi Z, Mays N. Local health and social care responses to implementing the national cold weather plan. J Public Health (Oxf) 2018; 40:461-466. [PMID: 28977541 DOI: 10.1093/pubmed/fdx120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Indexed: 11/14/2022] Open
Abstract
Background The Cold Weather Plan (CWP) for England was launched by the Department of Health in 2011 to prevent avoidable harm to health by cold weather by enabling individuals to prepare and respond appropriately. This study sought the views of local decision makers involved in the implementation of the CWP in the winter of 2012/13 to establish the effects of the CWP on local planning. It was part of a multi-component independent evaluation of the CWP. Methods Ten LA areas were purposively sampled which varied in level of deprivation and urbanism. Fifty-two semi-structured interviews were held with health and social care managers involved in local planning between November 2012 and May 2013. Results Thematic analysis revealed that the CWP was considered a useful framework to formalize working arrangements between agencies though local leadership varied across localities. There were difficulties in engaging general practitioners, differences in defining vulnerable individuals and a lack of performance monitoring mechanisms. Conclusions The CWP was welcomed by local health and social care managers, and improved proactive winter preparedness. Areas for improvement include better integration with general practice, and targeting resources at socially isolated individuals in cold homes with specific interventions aimed at reducing social isolation and building community resilience.
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Affiliation(s)
- C Heffernan
- Policy Innovation Research Unit (PIRU), Faculty of Public Health & Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, UK
| | - L Jones
- Department of Applied Health Research, University College London, 1-19 Torrington Place, London, UK
| | - B Ritchie
- Evidence Based Practice Unit, University College London and Anna Freud National Centre for Children and Families, 21 Maresfield Gardens, London, UK
| | - B Erens
- Policy Innovation Research Unit (PIRU), Faculty of Public Health & Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, UK
| | - Zaid Chalabi
- Department of Social and Environmental Health Research, Faculty of Public Health & Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, UK
| | - N Mays
- Policy Innovation Research Unit (PIRU), Faculty of Public Health & Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, UK
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Knai C, James L, Petticrew M, Eastmure E, Durand MA, Mays N. An evaluation of a public-private partnership to reduce artificial trans fatty acids in England, 2011-16. Eur J Public Health 2018; 27:605-608. [PMID: 28339665 DOI: 10.1093/eurpub/ckx002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background The Public Health Responsibility Deal (RD) is a public-private partnership in England involving voluntary pledges between government, and business and other public organizations to improve public health. One such voluntary pledge refers to the reduction of trans fatty acids (TFAs) in the food supply in England by either pledging not to use artificial TFAs or pledging artificial TFA removal. This paper evaluates the RD's effectiveness at encouraging signatory organizations to remove artificially produced TFAs from their products. Methods We analysed publically available data submitted by RD signatory organizations. We analysed their plans and progress towards achieving the TFAs pledge, comparing 2015 progress reports against their delivery plans. We also assessed the extent to which TFAs reductions beyond pre-2011 levels could be attributed to the RD. Results Voluntary reformulation via the RD has had limited added value, because the first part of the trans fat pledge simply requires organizations to confirm that they do not use TFAs and the second part, that has the potential to reduce use, has failed to attract the participation of food producers, particularly those producing fast foods and takeaways, where most remaining use of artificial TFAs is located. Conclusions The contribution of the RD TFAs pledges in reducing artificial TFAs from England's food supply beyond pre-2011 levels appears to be negligible. This research has wider implications for the growing international evidence base voluntary food policy, and offers insights for other countries currently undertaking work to remove TFAs from their food supply.
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Affiliation(s)
- C Knai
- Faculty of Public Health and Policy, Policy Innovation Research Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - L James
- Faculty of Public Health and Policy, Policy Innovation Research Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - M Petticrew
- Faculty of Public Health and Policy, Policy Innovation Research Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - E Eastmure
- Faculty of Public Health and Policy, Policy Innovation Research Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - M A Durand
- Faculty of Public Health and Policy, Policy Innovation Research Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - N Mays
- Faculty of Public Health and Policy, Policy Innovation Research Unit, London School of Hygiene and Tropical Medicine, London, UK
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Douglas N, Knai C, Petticrew M, Eastmure E, Durand MA, Mays N. How the food, beverage and alcohol industries presented the Public Health Responsibility Deal in UK print and online media reports. Critical Public Health 2018. [DOI: 10.1080/09581596.2018.1467001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- Nick Douglas
- Faculty of Public Health and Policy, Policy Innovation Research Unit, London School of Hygiene & Tropical Medicine , London, UK
| | - Cecile Knai
- Faculty of Public Health and Policy, Policy Innovation Research Unit, London School of Hygiene & Tropical Medicine , London, UK
| | - Mark Petticrew
- Faculty of Public Health and Policy, Policy Innovation Research Unit, London School of Hygiene & Tropical Medicine , London, UK
| | - Elizabeth Eastmure
- Faculty of Public Health and Policy, Policy Innovation Research Unit, London School of Hygiene & Tropical Medicine , London, UK
| | - Mary Alison Durand
- Faculty of Public Health and Policy, Policy Innovation Research Unit, London School of Hygiene & Tropical Medicine , London, UK
| | - Nicholas Mays
- Faculty of Public Health and Policy, Policy Innovation Research Unit, London School of Hygiene & Tropical Medicine , London, UK
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Knai C, Scott C, D'Souza P, James L, Mehrotra A, Petticrew M, Eastmure E, Durand MA, Mays N. The Public Health Responsibility Deal: making the workplace healthier? J Public Health (Oxf) 2018; 39:373-386. [PMID: 27302202 DOI: 10.1093/pubmed/fdw047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background The Public Health Responsibility Deal (RD) in England is a public-private partnership which aims to improve public health by addressing issues such as health at work. This paper analyses the RD health at work pledges in terms of their likely effectiveness and added value. Methods A review of evidence on the effectiveness of the RD 'health at work' pledges to improve health in the workplace; analysis of publically available data on signatory organizations' plans and progress towards achieving the pledges; and assessment of the likelihood that workplace activities pledged by signatories were brought about by participating in the RD. Results The 'health at work' pledges mostly consist of information sharing activities, and could be more effective if made part of integrated environmental change at the workplace. The evaluation of organizations' plans and progress suggests that very few actions (7%) were motivated by participation in the RD, with most organizations likely (57%) or probably (36%) already engaged in the activities they listed before joining the RD. Conclusions The RD's 'health at work' pledges are likely to contribute little to improving workplace health as they stand but could contribute more if they were incorporated into broader, coherent workplace health strategies.
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Affiliation(s)
- Cécile Knai
- Policy Innovation Research Unit, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Courtney Scott
- Policy Innovation Research Unit, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Preethy D'Souza
- EPPI-Centre, Social Science Research Unit, Institute of Education, University College London, 18 Woburn Square, London, WC1H 0NR, UK
| | - Lesley James
- Policy Innovation Research Unit, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Anushka Mehrotra
- South Lewisham Practice, 50 Connisborough Crescent, London SE6 2SP, UK
| | - Mark Petticrew
- Policy Innovation Research Unit, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Elizabeth Eastmure
- Policy Innovation Research Unit, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Mary Alison Durand
- Policy Innovation Research Unit, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Nicholas Mays
- Policy Innovation Research Unit, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
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Pettigrew LM, Kumpunen S, Mays N, Rosen R, Posaner R. The impact of new forms of large-scale general practice provider collaborations on England's NHS: a systematic review. Br J Gen Pract 2018; 68:e168-e177. [PMID: 29440013 PMCID: PMC5819982 DOI: 10.3399/bjgp18x694997] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 08/31/2017] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Over the past decade, collaboration between general practices in England to form new provider networks and large-scale organisations has been driven largely by grassroots action among GPs. However, it is now being increasingly advocated for by national policymakers. Expectations of what scaling up general practice in England will achieve are significant. AIM To review the evidence of the impact of new forms of large-scale general practice provider collaborations in England. DESIGN AND SETTING Systematic review. METHOD Embase, MEDLINE, Health Management Information Consortium, and Social Sciences Citation Index were searched for studies reporting the impact on clinical processes and outcomes, patient experience, workforce satisfaction, or costs of new forms of provider collaborations between general practices in England. RESULTS A total of 1782 publications were screened. Five studies met the inclusion criteria and four examined the same general practice networks, limiting generalisability. Substantial financial investment was required to establish the networks and the associated interventions that were targeted at four clinical areas. Quality improvements were achieved through standardised processes, incentives at network level, information technology-enabled performance dashboards, and local network management. The fifth study of a large-scale multisite general practice organisation showed that it may be better placed to implement safety and quality processes than conventional practices. However, unintended consequences may arise, such as perceptions of disenfranchisement among staff and reductions in continuity of care. CONCLUSION Good-quality evidence of the impacts of scaling up general practice provider organisations in England is scarce. As more general practice collaborations emerge, evaluation of their impacts will be important to understand which work, in which settings, how, and why.
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Affiliation(s)
- Luisa M Pettigrew
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London
| | | | - Nicholas Mays
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London
| | | | - Rachel Posaner
- Library and Information Service, Health Services Management Centre, University of Birmingham, Birmingham
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Petticrew M, Knai C, Mays N. Re: Letter to the Editor of Public Health in response to 'Provision of information to consumers about the calorie content of alcoholic drinks: did the responsibility deal pledge by alcohol retailers and producers increase the availability of calorie information?'. Public Health 2017; 154:184-185. [PMID: 29217309 DOI: 10.1016/j.puhe.2017.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 10/23/2017] [Indexed: 11/17/2022]
Affiliation(s)
- M Petticrew
- Policy Innovation Research Unit, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine (LSHTM), 15-17 Tavistock Place, London WC1H 9SH, UK.
| | - C Knai
- Policy Innovation Research Unit, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine (LSHTM), 15-17 Tavistock Place, London WC1H 9SH, UK
| | - N Mays
- Policy Innovation Research Unit, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine (LSHTM), 15-17 Tavistock Place, London WC1H 9SH, UK
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Mounier-Jack S, Mayhew SH, Mays N. Integrated care: learning between high-income, and low- and middle-income country health systems. Health Policy Plan 2017; 32:iv6-iv12. [PMID: 29194541 PMCID: PMC5886259 DOI: 10.1093/heapol/czx039] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2017] [Indexed: 11/15/2022] Open
Abstract
Over the past decade, discussion of integrated care has become more widespread and prominent in both high- and low-income health care systems (LMICs). The trend reflects the mismatch between an increasing burden of chronic disease and local health care systems which are still largely focused on hospital-based treatment of individual clinical episodes and also the long-standing proliferation of vertical donor-funded disease-specific programmes in LMICs which have disrupted horizontal, or integrated, care. Integration is a challenging concept to define, in part because of its multiple dimensions and varied scope: from integrated clinical care for individual patients to broader systems integration-or linkage-involving a wide range of interconnected services (e.g. social services and health care). In this commentary, we compare integrated care in high- and lower-income countries. Although contexts may differ significantly between these settings, there are many common features of how integration has been understood and common challenges in its implementation. We discuss the different approaches to, scope of, and impacts of, integration including barriers and facilitators to the processes of implementation. With the burden of disease becoming more alike across settings, we consider what gains there could be from comparative learning between these settings which have constituted two separate strands of research until now.
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Affiliation(s)
| | | | - Nicholas Mays
- Department of Health Services Research and Policy, Health Policy and Reproductive Health, London School of Hygiene & Tropical Medicine, London, UK
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Hammond J, Lorne C, Coleman A, Allen P, Mays N, Dam R, Mason T, Checkland K. The spatial politics of place and health policy: Exploring Sustainability and Transformation Plans in the English NHS. Soc Sci Med 2017; 190:217-226. [DOI: 10.1016/j.socscimed.2017.08.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 06/13/2017] [Accepted: 08/09/2017] [Indexed: 11/15/2022]
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Green SA, Bell D, Mays N. Identification of factors that support successful implementation of care bundles in the acute medical setting: a qualitative study. BMC Health Serv Res 2017; 17:120. [PMID: 28173796 PMCID: PMC5297157 DOI: 10.1186/s12913-017-2070-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 02/03/2017] [Indexed: 11/17/2022] Open
Abstract
Background Clinical guidelines offer an accessible synthesis of the best evidence of effectiveness of interventions, providing recommendations and standards for clinical practice. Many guidelines are relevant to the diagnosis and management of the acutely unwell patient during the first 24–48 h of admission. Care bundles are comprised of a small number of evidence-based interventions that when implemented together aim to achieve better outcomes than when implemented individually. Care bundles that are explicitly developed from guidelines to provide a set of related evidence-based actions have been shown to improve the care of many conditions in emergency, acute and critical care settings. This study aimed to review the implementation of two distinct care bundles in the acute medical setting and identify the factors that supported successful implementation. Methods Two initiatives that had used a systematic approach to quality improvement to successfully implement care bundles within the acute medical setting were selected as case studies. Contemporaneous data generated during the initiatives included the review reports, review minutes and audio recordings of the review meetings at different time points. Data were subject to deductive analysis using three domains of the Consolidated Framework for Implementation Research to identify factors that were important in the implementation of the care bundles. Results Several factors were identified that directly influenced the implementation of the care bundles. Firstly, the availability of resources to support initiatives, which included training to develop quality improvement skills within the team and building capacity within the organisation more generally. Secondly, the perceived sustainability of changes by stakeholders influenced the embedding new care processes into existing clinical systems, maximising their chance of being sustained. Thirdly, senior leadership support was seen as critical not just in supporting implementation but also in sustaining longer-term changes brought about by the initiative. Lastly, practitioner incentives were identified as potential levers to engage junior doctors, a crucial part of the acute medical work force and essential to the initiatives, as there is currently little recognition or reward for involvement Conclusions The factors identified have been shown to be supportive in the successful implementation of care bundles as a mechanism for implementing clinical guidelines. Addressing these factors at a practitioner and organisational level, alongside the use of a systematic quality improvement approach, should increase the likelihood that care bundles will be implemented successfully to deliver evidence based changes in the acute medical setting.
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Affiliation(s)
- Stuart A Green
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, W1H 9SH, UK. .,NIHR CLAHRC Northwest London, Imperial College London, Chelsea and Westminster Hospital, Fulham Road, London, SW10 9NH, UK.
| | - Derek Bell
- NIHR CLAHRC Northwest London, Imperial College London, Chelsea and Westminster Hospital, Fulham Road, London, SW10 9NH, UK
| | - Nicholas Mays
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, W1H 9SH, UK
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