Local health and social care responses to implementing the national cold weather plan.

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.

Community Alcohol Partnerships with the alcohol industry: what is their purpose and are they effective in reducing alcohol harms?

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.

An evaluation of a public-private partnership to reduce artificial trans fatty acids in England, 2011-16.

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.

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?

OBJECTIVES: Alcohol is a significant source of dietary calories and is a contributor to obesity. Industry pledges to provide calorie information to consumers have been cited as reasons for not introducing mandatory ingredient labelling. As part of the Public Health Responsibility Deal (RD) in England, alcohol retailers and producers committed to providing consumers with information on the calorie content of alcoholic drinks. This study examines what was achieved following this commitment and considers the implications for current industry commitments to provide information on alcohol calories. STUDY DESIGN: Analysis of RD pledge delivery plans and progress reports. Assessment of calorie information in supermarkets and in online stores. METHODS: (i) Analysis of the content of pledge delivery plans and annual progress reports of RD signatories to determine what action they had committed to, and had taken, to provide calorie information. (ii) Analysis of the availability of calorie information on product labels; in UK supermarkets; and on online shopping sites and websites. RESULTS: No information was provided in any of 55 stores chosen to represent all the main UK supermarkets. Calorie information was not routinely provided on supermarkets' websites, or on product labels. CONCLUSIONS: One of the stated purposes of the RD was to provide consumers with the information to make informed health-related choices, including providing information on the calorie content of alcoholic drinks. This study indicates that this did not take place to any significant extent. The voluntary implementation of alcohol calorie labelling by industry needs to continue to be carefully monitored to determine whether and how it is done.

Public health vulnerability to wintertime weather: time-series regression and episode analyses of national mortality and morbidity databases to inform the Cold Weather Plan for England.

OBJECTIVES: To inform development of Public Health England's Cold Weather Plan (CWP) by characterizing pre-existing relationships between wintertime weather and mortality and morbidity outcomes, and identification of groups most at risk. STUDY DESIGN: Time-series regression analysis and episode analysis of daily mortality, emergency hospital admissions, and accident and emergency visits for each region of England. METHODS: Seasonally-adjusted Poisson regression models estimating the percent change in daily health events per 1 °C fall in temperature or during individual episodes of extreme weather. RESULTS: Adverse cold effects were observed in all regions, with the North East, North West and London having the greatest risk of cold-related mortality. Nationally, there was a 3.44% (95% CI: 3.01, 3.87) increase in all-cause deaths and 0.78% (95% CI: 0.53, 1.04) increase in all-cause emergency admissions for every 1 °C drop in temperature below identified thresholds. The very elderly and people with COPD were most at risk from low temperatures. A&E visits for fractures were elevated during heavy snowfall periods, with adults (16-64 years) being the most sensitive age-group. Since even moderately cold days are associated with adverse health effects, by far the greatest health burdens of cold weather fell outside of the alert periods currently used in the CWP. CONCLUSIONS: Our findings indicate that levels 0 ('year round planning') and 1 ('winter preparedness and action') are crucial components of the CWP in comparison to the alerts. Those most vulnerable during winter may vary depending on the type of weather conditions being experienced. Recommendations are made for the CWP.

Evaluation of the cold weather plan for England: modelling of cost-effectiveness.

OBJECTIVE: To determine the conditions under which the Cold Weather Plan (CWP) for England is likely to prove cost-effective in order to inform the development of the CWP in the short term before direct data on costs and benefits can be collected. STUDY DESIGN: Mathematical modelling study undertaken in the absence of direct epidemiological evidence on the effect of the CWP in reducing cold-related mortality and morbidity, and limited data or on its costs. METHODS: The model comprised a simulated temperature time series based on historical data; epidemiologically-derived relationships between temperature, and mortality and morbidity; and information on baseline unit costs of contacts with health care and community care services. Cost-effectiveness was assessed assuming varying levels of protection against cold-related burdens, coverage of the vulnerable population and willingness-to-pay criteria. RESULTS: Simulations showed that the CWP is likely to be cost effective under some scenarios at the high end of the willingness to pay threshold used by National Institute for Health and Care Excellence (NICE) in England, but these results are sensitive to assumptions about the extent of implementation of the CWP at local level, and its assumed effectiveness when implemented. The incremental cost-effectiveness ratio varied from £29,754 to £75,875 per Quality Adjusted Life Year (QALY) gained. Conventional cost-effectiveness (<£30,000/QALY) was reached only when effective targeting of at-risk groups was assumed (i.e. need for low coverage (∼5%) of the population for targeted actions) and relatively high assumed effectiveness (>15%) in avoiding deaths and hospital admissions. CONCLUSIONS: Although the modelling relied on a large number of assumptions, this type of modelling is useful for understanding whether, and in what circumstances, untested plans are likely to be cost-effective before they are implemented and in the early period of implementation before direct data on cost-effectiveness have accrued. Steps can then be taken to optimize the relevant parameters as far as practicable during the early implementation period.

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

BACKGROUND: The Public Health Responsibility Deal (RD) in England is a public-private partnership involving voluntary pledges between government, industry, and other organisations to improve public health by addressing alcohol, food, health at work, and physical activity. This paper analyses the RD physical activity (PA) pledges in terms of the evidence of their potential effectiveness, and the likelihood that they have motivated actions among organisations that would not otherwise have taken place. METHODS: We systematically reviewed evidence of the effectiveness of interventions proposed in four PA pledges of the RD, namely, those on physical activity in the community; physical activity guidelines; active travel; and physical activity in the workplace. We then analysed publically available data on RD signatory organisations' plans and progress towards achieving the physical activity pledges, and assessed the extent to which activities among organisations could be attributed to the RD. RESULTS: Where combined with environmental approaches, interventions such as mass media campaigns to communicate the benefits of physical activity, active travel in children and adults, and workplace-related interventions could in principle be effective, if fully implemented. However, most activities proposed by each PA pledge involved providing information or enabling choice, which has limited effectiveness. Moreover, it was difficult to establish the extent of implementation of pledges within organisations, given that progress reports were mostly unavailable, and, where provided, it was difficult to ascertain their relevance to the RD pledges. Finally, 15 % of interventions listed in organisations' delivery plans were judged to be the result of participation in the RD, meaning that most actions taken by organisations were likely already under way, regardless of the RD. CONCLUSIONS: Irrespective of the nature of a public health policy to encourage physical activity, targets need to be evidence-based, well-defined, measurable and encourage organisations to go beyond business as usual. RD physical activity targets do not adequately fulfill these criteria.

Direct enrichment of perchlorate-reducing microbial community for efficient electroactive perchlorate reduction in biocathodes.

Biological reduction of perchlorate (ClO4⁻) has emerged as a promising solution for the removal of perchlorate in contaminated water and soils. In this work, we demonstrate a simple process to enrich perchlorate-reducing microbial communities separately using acetate as electron donor and the municipal aerobic membrane bioreactor sludge as inoculum. Inoculation of cathodes in microbial fuel cells (MFCs) with these enrichments, and further electrochemical enrichment at constant resistance operation of the MFCs, led to perchlorate-reducing biocathodes with peak reduction rates of 0.095 mM/day (2 mg/m²/day). Analysis of the microbial diversity of perchlorate-reducing biocathodes using PCR-DGGE revealed unique community profiles when compared to the denitrifying biocathode communities. More importantly, the total time taken for enrichment of the electroactive communities was reduced from several months reported previously in literature to less than a month in this work.

Evaluating the implementation of a national clinical programme for diabetes to standardise and improve services: a realist evaluation protocol.

BACKGROUND: Over the last three decades in response to the growing burden of diabetes, countries worldwide have developed national and regional multifaceted programmes to improve the monitoring and management of diabetes and to enhance the coordination of care within and across settings. In Ireland in 2010, against a backdrop of limited dedicated strategic planning and engrained variation in the type and level of diabetes care, a national programme was established to standardise and improve care for people with diabetes in Ireland, known as the National Diabetes Programme (NDP). The NDP comprises a range of organisational and service delivery changes to support evidence-based practices and policies. This realist evaluation protocol sets out the approach that will be used to identify and explain which aspects of the programme are working, for whom and in what circumstances to produce the outcomes intended. METHODS/DESIGN: This mixed method realist evaluation will develop theories about the relationship between the context, mechanisms and outcomes of the diabetes programme. In stage 1, to identify the official programme theories, documentary analysis and qualitative interviews were conducted with national stakeholders involved in the design, development and management of the programme. In stage 2, as part of a multiple case study design with one case per administrative region in the health system, qualitative interviews are being conducted with frontline staff and service users to explore their responses to, and reasoning about, the programme's resources (mechanisms). Finally, administrative data will be used to examine intermediate implementation outcomes such as service uptake, acceptability, and fidelity to models of care. DISCUSSION: This evaluation is using the principles of realist evaluation to examine the implementation of a national programme to standardise and improve services for people with diabetes in Ireland. The concurrence of implementation and evaluation has enabled us to produce formative feedback for the NDP while also supporting the refinement and revision of initial theories about how the programme is being implemented in the dynamic and unstable context of the Irish healthcare system.

Geographical resource allocation in the English National Health Service, 1971-1994: the tension between normative and empirical approaches.

The policy response to the problem of developing a geographical resource allocation formula sensitive to relative population needs for hospital and community health services resources in the National Health Service demonstrates a continuing tension between normative and empirical solutions. Since 1988, the balance has shifted in favour of a more empirical approach to identifying and weighting population needs indicators in response to concerns about the theoretically justified, but essentially approximate, nature of the Resource Allocation Working Party formula introduced in 1977-1978. However, judgements and assumptions about the nature of 'need' have still to be made in order to construct a usable resource allocation formula since empirical data on what is cannot provide a complete guide to what ought to be a fair distribution of resources in relation to need.

Relation between all cause standardised mortality ratios and two indices of deprivation at regional and district level in England.

The use of mortality data in the form of standardised mortality ratios (SMRs) to measure the need for health care resources in the Resource Allocation Working Party (RAWP) formula in England has been criticised for underestimating the wider effects of adverse socioeconomic conditions on need, particularly in inner city areas. To assess this criticism, we explored the relationships at NHS Regional and District levels in England between two indicators of illness from the 1981 Census, two contrasting indices of deprivation based on the 1981 Census (the Jarman 8 Underprivileged Area (UPA) score and Townsend's Index of Material Deprivation) and their constituent variables, and all cause SMRs for 1982-3. All cause SMRs were highly correlated at Regional and District level with permanent and temporary sickness rates. At Regional level, three of the Thames Regions showed relatively high deprivation scores in relation to their SMRs, in comparison to the remaining Regions where the relative level of deprivation closely matched the Region's mortality ranking. District level analyses of the relations between SMRs and the deprivation indices and their constituent variables showed that the Thames/non-Thames dichotomy was accounted for by the 14 Districts in inner London. These findings suggest that although there may be a prima facie case for including an allowance for deprivation in RAWP, it is still not clear how the deprivation variables available in the Census relate empirically to the need for additional health service resources. The analysis raises questions about the appropriate definition of need in this context and whether the Census is a suitable source for the construction of a deprivation weighting for use in national RAWP.

Interregional variations in measures of health from the Health and Lifestyle Survey and their relation with indicators of health care need in England.

STUDY OBJECTIVE: The aim was to assess the extent to which a range of routinely available need indicators which have been suggested for use in NHS spatial resource allocation formulas were associated geographically in England with the different dimensions of population health status collected in the 1985/86 Health and Lifestyle Survey (HLS). DESIGN: Regional health authorities were ranked according to each of the HLS health variables which varied significantly between authorities. The HLS health variables were regressed on a selection from the range of routinely available morbidity and socioeconomic indicators available from the 1981 census. The potential need indicators were also regressed on the health variables. SETTING: The analyses were undertaken at individual level and at regional health authority level in England. SUBJECTS: The study comprised the English component of the HLS random sample representative of the population in private households in Great Britain. MAIN RESULTS: The different HLS health variables did not yield consistent regional health authority rankings. Among the variables, forced expiratory volume in one second (FEV1) and self assessed health appeared to be associated with most of the other health and need variables except longstanding illness. Longstanding illness was not strongly associated with any of the other HLS health variables but appeared to show some association with three deprivation indices constructed from the 1981 Census. CONCLUSIONS: There may be a case for including a measure of chronic ill health in the new NHS system of capitated finance in addition to the all cause standardised mortality ratio which is used currently as a measure of need for health care.

Relative costs and cost-effectiveness of extracorporeal shock-wave lithotripsy versus percutaneous nephrolithotomy in the treatment of renal and ureteric stones.

This paper presents empirical data from the United Kingdom National Health Service on the comparative mean hospital costs per patient of first generation extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PCN) in the treatment of kidney stones. These results were subjected to a sensitivity analysis and related to evidence on the health effects of the two approaches to treatment. The hospital costs of PCN were found to be lower than for ESWL in the empirical comparison and in most but not all the scenarios developed in the sensitivity analysis. The direction of the comparison was reversed when a high throughput was assumed for ESWL and a significantly higher per diem cost for PCN than ESWL. The relative cost-effectiveness of the two modes of treatment depended on whether successful treatment was defined in terms of rendering the patient free of stones (the traditional endpoint of treatment) or the rate at which patients returned to their normal activities.

Expanding the roles of outpatient pharmacists: effects on health services utilisation, costs, and patient outcomes.

BACKGROUND: In recent years pharmacists' roles have expanded from simply packaging and dispensing medications to working with other health care professionals and the public. OBJECTIVES: To assess the effects of expanding outpatient pharmacists' roles on health services utilisation, the costs of health services, and patient outcomes. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, MEDLINE, EMBASE, Pharmline, International Pharmaceutical Abstracts and reference lists of articles up to December 1995. We also searched the published abstracts of three meetings and hand searched five journals and two bibliographies. SELECTION CRITERIA: Randomised trials, controlled clinical trials, controlled before-and-after studies and interrupted time series analyses of interventions comparing 1. Pharmacist services targeted at patients versus services delivered by other health professionals; 2. Pharmacist services targeted at patients versus no intervention; 3. Pharmacist services targeted at health professionals versus services delivered by other health professionals; and 4. Pharmacist services targeted at health professionals versus no intervention. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality. MAIN RESULTS: Fourteen studies were included involving more than 1991 patients. In the one study identified for comparison 1 the relative changes in professional outcome measures ranged from a 24% increase in clinic visits to a 16% decrease in hospital admissions. Relative differences in patient outcome measures were not statistically significant. Seven studies were identified for comparison 2. Four measured process of care and demonstrated decreases in health services utilisation from -67% for hospital admissions to -564% for total ambulatory care visits, as well as decreases in the numbers and costs of drugs compared to control patients. Five measured patient outcomes and consistently reported improvements in the targeted patient condition. In the one study identified for comparison 3 the intervention delivered by the pharmacist was less successful than that delivered by physician counsellors in decreasing inappropriate antibiotic prescribing. All six studies identified for comparison 4 demonstrated that the pharmacist intervention produced the intended effect on physician prescribing practices. These studies did not measure patient outcomes. REVIEWER'S CONCLUSIONS: The limited number of studies analysed support the expanded roles of pharmacists in patient counselling and physician education. However, doubts about the generalisability of the studies, the poorly defined nature of the interventions tested, and the lack of studies including cost assessments and patient outcome data indicate that more rigorous research is needed to document the effects of outpatient pharmacist interventions.

Legitimate decision making: the Achilles' heel of solidaristic health care systems.

The future sustainability of 'solidaristic' or universal publicly financed health systems is frequently said to be threatened by lack of resources as rising demand collides with the growing reluctance of the better-off to pay for services mainly used by others. Competitive health care arrangements are also regarded as threatening solidarity. By contrast, I argue that the main threat to the sustainability of such systems lies in the inability of so-called 'advanced' societies to develop institutions that are capable of acceptably reconciling inevitably scarce resources with individual and collective desires to have all the health care we want. Many 'advanced' societies lack, or fail to incorporate into their health systems, the range of intermediate institutions that could potentially help in more effectively reconciling individual wants with collectively determined levels of resources.

The British quasi-market in health care: a balance sheet of the evidence.

OBJECTIVES: To summarise the findings from a comprehensive review of research on the effects of the three main elements of the quasi-market reforms of the UK National Health Service (NHS) introduced in 1991/92: General practices becoming fundholders by volunteering to purchase elective care for their patients; Health authorities becoming purchasers of emergency, unplanned and elective services, together with a range of alternatives to fundholding operating under their auspices; The conversion of providers of hospital and community health services to NHS trusts separate from their local health authorities. METHODS: Published and unpublished studies which included any data on the impact of the three main planks of the quasi-market changes, produced between 1991 and late 1998, were identified using a combination of electronic databases, library catalogues at the King's Fund, London, bibliographies, reference lists of individual studies, a survey of NHS directors of public health and consultations with subject area experts. Each main element of the quasi-market was assessed in relation to its impact on: efficiency (primarily productivity); equity; quality; choice and responsiveness; and accountability. RESULTS: There was relatively little measurable change that could be related unequivocally to the core mechanisms of the quasi-market. CONCLUSIONS: The incentives were generally too weak and the constraints too strong to generate the consequences predicted by either proponents or critics of the quasi-market. On the other hand, the way in which the NHS operates was changed irrevocably by the reforms.

The experience of caring for former long-stay psychiatric patients.

This study investigated the experiences and the mental health status of the informal carers (usually relatives) of 38 former long-stay psychiatric patients. According to the GHQ-12, 45 per cent of carers were classified as minor psychiatric 'cases'. Women were significantly more likely than men to experience poor mental health. Most carers reported personal and social restrictions, but cases were significantly more likely than non-cases to report personal, physical and financial burden.

A three- to six-year follow-up of former long-stay residents of mental handicap hospitals in Northern Ireland.

OBJECTIVES: Little is known about the first cohorts of long-stay hospital residents with learning disabilities who moved to the community. This study describes the pattern of residential reprovision for all former long-stay residents discharged from the three mental handicap hospitals in Northern Ireland between 1987 and 1990 (N = 283) as well as describing aspects of quality of life for a smaller sample of people. METHOD: The study employs a retrospective survey design and the method and findings are discussed within a quality of life framework. Information about destinational outcomes between 1987 and 1993 was collected for each former resident. Several instruments were also used to assess material, emotional and social well-being and development and activity for a 40 per cent sample of people (114/283) discharged from hospital during 1987-1990 and followed up in 1993. RESULTS: Approximately 70 per cent of residents were discharged to, and subsequently remained in, highly supported settings such as residential and nursing homes. Only 3 per cent were discharged to 'independent living' with their own families or foster families. Few of the sample had 'major' problems with daily living skills and serious behavioural problems were uncommon. Former patients were also more satisfied with their new homes and reported feeling happier, healthier and more independent since discharge. However, social networks were poor and there was no evidence to suggest that people were undertaking new or 'ordinary' daytime activities. CONCLUSION: Although the material needs of former hospital residents (many of whom may have been 'cream skimmed' from the long-stay population) appeared to be met and they were content with their new homes in the community, they had a limited choice of mainly private sector accommodation and few opportunities for personal and social development.

The impact of the UK NHS purchaser-provider split on the 'rational' introduction of new medical technologies.

This article uses evidence from case studies of the introduction of three new medical technologies to explore the impact of the UK NHS purchaser--provider split on the diffusion of new medical technologies. A desirable policy objective is assumed to be the 'rational' diffusion of medical technologies according to evidence that they are clinically and cost effective. Theoretical mechanisms are identified through which diffusion could be controlled, and the case studies are used to explore the extent to which rational technology diffusion occurs in practice in the NHS. They illustrate the influence of purchasers and providers on the introduction and early use of new technologies and explore the extent to which research about clinical and cost effectiveness is used to inform decisions about technology adoption. The results demonstrate the limited influence of purchasers and the short term clinical and organisational objectives pursued by providers in relation to technology adoption. It is suggested that initiatives to promote rational technology diffusion might be most effective if they are focused on decision making in providers, and if they aim to balance the influence on decisions of administrative and financial information about the technologies with more systematic use of research about clinical and cost effectiveness.