Influenza: cause or excuse? An analysis of flu's influence on worsening mortality trends in England and Wales, 2010-19.

BACKGROUND: England and Wales experienced a stagnation of previously improving life expectancy during the 2010s. Public bodies cited influenza as an important cause. SOURCES OF DATA: We used data from the Office for National Statistics to examine mortality attributed directly to influenza and to all influenza-like diseases for the total population of England and Wales 2010-19. Several combinations of ICD-10 codes were used to address the possibility of under-counting influenza deaths. AREAS OF AGREEMENT: Deaths from influenza and influenza-like diseases declined between 2010 and 2019, while earlier improvements in mortality from all causes of death were stalling and, with some causes, worsening. Our findings support existing research showing that influenza is not an important cause of the stalling of mortality rates 2010-19. AREAS OF CONTROVERSY: Influenza was accepted by many as an important cause of stalling life expectancy for much of the 2010s, while few in public office have accepted austerity as a key factor in the changes seen during that time. GROWING POINTS: This adds to the mounting evidence that austerity damaged health prior to COVID-19 and left the population more vulnerable when it arrived. AREAS FOR DEVELOPING TIMELY RESEARCH: Future research should explore why so many in public office were quick to attribute the change in trends in overall mortality in the UK in this period to influenza, and why many continue to do so through to 2023 and to deny the key role of austerity in harming population health.

Mind the implementation gap: a systems analysis of the NHS Long Term Workforce Plan to increase the number of doctors trained in the UK raises many questions.

BACKGROUND: The National Health Service (NHS) in England is facing a workforce crisis. A new Long Term Workforce Plan (LTWP) seeks to address this, setting out ambitious proposals to expand and reform domestic medical education and training in England. However, there are concerns about their feasibility. SOURCES OF DATA: In September 2023, over 60 individuals representing medical education and training in the UK participated in an exercise run by UK Medical Schools Council by using systems theory to identify risks. AREAS OF AGREEMENT: The UK does need more 'home grown' doctors, but the LTWP has important gaps, including lack of attention to postgraduate training, absence of reference to the need for more educators and capital investment and risk of inadequate clinical placement capacity, particularly in primary care settings. AREAS OF CONTROVERSY: There are unresolved differences in the understanding of a proposed medical apprenticeship model and no scheme has, as yet, been approved by the General Medical Council. Participants were unable to determine who the beneficiaries of this scheme will be (apart from the apprentices themselves). GROWING POINTS: While the LTWP represents a welcome, although overdue, commitment to address the NHS workforce crisis, we identified significant gaps that must be resolved. AREAS TIMELY FOR DEVELOPING RESEARCH: First, the development of the LTWP provides a case study that adds to literature on policymaking in the UK. Second, while we only examined the expansion of medical training, the method could be applied to other parts of the LTWP. Third, a prospective evaluation of its implementation is necessary.

AI and XAI second opinion: the danger of false confirmation in human-AI collaboration.

Can AI substitute a human physician's second opinion? Recently the Journal of Medical Ethics published two contrasting views: Kempt and Nagel advocate for using artificial intelligence (AI) for a second opinion except when its conclusions significantly diverge from the initial physician's while Jongsma and Sand argue for a second human opinion irrespective of AI's concurrence or dissent. The crux of this debate hinges on the prevalence and impact of 'false confirmation'-a scenario where AI erroneously validates an incorrect human decision. These errors seem exceedingly difficult to detect, reminiscent of heuristics akin to confirmation bias. However, this debate has yet to engage with the emergence of explainable AI (XAI), which elaborates on why the AI tool reaches its diagnosis. To progress this debate, we outline a framework for conceptualising decision-making errors in physician-AI collaborations. We then review emerging evidence on the magnitude of false confirmation errors. Our simulations show that they are likely to be pervasive in clinical practice, decreasing diagnostic accuracy to between 5% and 30%. We conclude with a pragmatic approach to employing AI as a second opinion, emphasising the need for physicians to make clinical decisions before consulting AI; employing nudges to increase awareness of false confirmations and critically engaging with XAI explanations. This approach underscores the necessity for a cautious, evidence-based methodology when integrating AI into clinical decision-making.

Agnogenic practices and corporate political strategy: the legitimation of UK gambling industry-funded youth education programmes.

Agnogenic practices-designed to create ignorance or doubt-are well-established strategies employed by health-harming industries (HHI). However, little is known about their use by industry-funded organizations delivering youth education programmes. We applied a previously published framework of corporate agnogenic practices to analyse how these organizations used them in three UK gambling industry-funded youth education programmes. Evidential strategies adopted previously by other HHI are prominent in the programmes' practitioner-facing materials, evaluation design and reporting and in public statements about the programmes. We show how agnogenic practices are employed to portray these youth education programmes as 'evidence-based' and 'evaluation-led'. These practices distort the already limited evidence on these educational initiatives while legitimizing industry-favourable policies, which prioritize commercial interests over public health. Given the similarities in political strategies adopted by different industries, these findings are relevant to research and policy on other HHI.

Preparing for the 'next pandemic': Why we need to escape from our silos.

The COVID-19 pandemic revealed major failings in many countries. We argue that one of the reasons, at global, national, and local levels, was that those involved were working in silos, unable to bring together the many diverse perspectives needed to respond to this complex problem. This is despite a growing recognition of the importance of adopting a Health For All Policies approach. Silo working, and the problems it creates, are not unique to health policy so there are opportunities to learn from those organisations that have tackled this issue.

The paradoxical surplus of health workers in Africa: The need for research and policy engagement.

In many countries in Africa, there is a 'paradoxical surplus' of under and unemployed nurses, midwives, doctors and pharmacists which exists amidst a shortage of staff within the formal health system. By 2030, the World Health Organisation Africa Region may find itself with a shortage of 6.1 million health workers alongside 700,000 un- or underemployed health staff. The emphasis in policy debates about human resources for health at most national and global levels is on staff shortage and the need to train more health workers. In contrast, these 'surplus' health workers are both understudied and underacknowledged. Little time is given over to understand the economic, political and social factors that have driven their emergence; the ways in which they seek to make a living; the governance challenges that they raise; nor potential interventions that could be implemented to improve employment rates and leverage their expertise. This short communication reflects on current research findings and calls for improved quantitative and qualitative research to support policy engagement at national, regional and global levels.

'Government don't know me and if I stop, they won't know': A qualitative study on the lived experiences of volunteer health workers in the Nigerian health system and their implications for the sustainable development goals.

BACKGROUND: Volunteer health workers play an important, but poorly understood role in the Nigerian health system. We report a study of their lived experiences, enabling us to understand their motivations, the nature of their work, and their relationships with formally employed health workers in Primary Healthcare Centres (PHCs) in Nigeria, the role of institutional incentives, and the implications for attaining the health-related sustainable development goals (SDGs) targets. METHODS: The study used ethnographic observation of PHCs in Enugu State, supplemented with in-depth interviews with volunteers, formally employed health workers and health managers. The analysis employed a combination of narrative and reflexive thematic approaches. FINDINGS: The lived experiences of most volunteers unfold in four stages as they move into and out of their volunteering status. The first stage signifies hope, arising from the ease with which they are accepted and integrated into the PHC space. The anger stage emerges when volunteers confront the marked disparity in their treatment compared to formal staff, despite their substantial contributions to healthcare. Then, the bargaining stage sets in, where they strive for recognition and respect by pursuing formal employment and advocating for fair treatment and improved stipends. A positive response, such as improved stipends, can reignite hope among volunteers. If not, most volunteers transition to the acceptance stage - the acknowledgement that their status may never be formalised, prompting many to lose hope and disengage. CONCLUSION: There should be a clear policy on recruitment, compensation, and protection of volunteers in the health systems, to enhance the contribution they can make to the achievement of the health-related SDG targets.

The role of global health partnerships in vaccine equity: A scoping review.

The emergence of global health partnerships (GHPs) towards the end of the twentieth century reflected concerns about slow progress in access to essential medicines, including vaccines. These partnerships bring together governments, private philanthropic foundations, NGOs, and international agencies. Those in the vaccine field seek to incentivise the development and manufacture of new vaccines, raise funds to pay for them and develop and support systems to deliver them to those in need. These activities became more critical during the COVID-19 pandemic, with the COVAX Facility Initiative promoting global vaccine equity. This review identifies lessons from previous experiences with GHPs. Findings contribute to understanding the emergence of GHPs, the mechanisms they leverage to support global access to vaccines, and the inherent challenges associated with their implementation. Using Arksey and O'Malley's method, we conducted a scoping review to identify and synthesise relevant articles. We analysed data thematically to identify barriers and opportunities for success. We included 68 eligible articles of 3,215 screened. Most (65 [95%]) were discussion or review articles describing partnerships or programmes they supported, and three (5%) were commentaries. Emerging themes included policy responses (e.g., immunisation mandates), different forms of partnerships arising in vaccine innovation (e.g., product development partnerships, public-private partnerships for access), and influence on global governance decision-making processes (e.g., the rising influence of foundations, diminishing authority of WHO, lack of accountability and transparency, creation of disease silos). If global health partnerships are to maximise their contributions, they should: (1) increase transparency, especially regarding their impacts; (2) address the need for health systems strengthening; and (3) address disincentives for cooperative vaccine research and development partnerships and encourage expansion of manufacturing capacity in low and middle-income countries.

The path to a European Health Union.

The European Union has historically left health policy decisions to individual member states, cooperating only on issues like cross-border healthcare and medicine safety. However, the COVID-19 pandemic underscored the need for collective action across borders. In response, in October 2020, European Commission President Ursula von der Leyen called for the creation of a "European Health Union". This initiative aims to enhance the protection of European citizens' health, bolster pandemic preparedness, and strengthen healthcare systems. So far, the initiative has not led to major contestation. This might be because the proposals under this heading have been rather piecemeal and are not generally seen as being part of a comprehensive vision for identifying areas where EU intervention benefit national health policy. In this contribution we propose a path forward in terms of content and process for developing a more comprehensive vision on the policy content and the process. In so doing, we are not debating the need for a European Health Union. We take for granted that the existing European Health Union presents an opportunity to deliver, now and in the future, the added benefit of harmonizing, centralizing, or coordinating health-related laws, institutions, policies and actions at EU level.

Meeting the challenges of the 21st century: the fundamental importance of trust for transformation.

BACKGROUND: This paper is one of a collection on challenges facing health systems in the future. One obvious challenge is how to transform to meet changing health needs and take advantage of emerging treatment opportunities. However, we argue that effective transformations are only possible if there is trust in the health system. MAIN BODY: We focus on three of the many relationships that require trust in health systems, trust by patients and the public, by health workers, and by politicians. Unfortunately, we are seeing a concerning loss of trust in these relationships and, for too long, the importance of trust to health policymaking and health system functioning has been overlooked and under-valued. We contend that trust must be given the attention, time, and resources it warrants as an indispensable element of any health system and, in this paper, we review why trust is so important in health systems, how trust has been thought about by scholars from different disciplines, what we know about its place in health systems, and how we can give it greater prominence in research and policy. CONCLUSION: Trust is essential if health systems are to meet the challenges of the 21st century but it is too often overlooked or, in some cases, undermined.

We Need a Combination of Approaches to Evaluate Health System Resilience Comment on "Re-evaluating Our Knowledge of Health System Resilience During COVID-19: Lessons From the First Two Years of the Pandemic".

Health system resilience has become a desirable health system attribute in the current permacrisis environment. The article by Saulnier and colleagues reviews the literature on health system resilience and refines the concept, pinpointing dimensions of resilience governance that have not reached consensus, or that are missing from the literature. In this commentary we complement the findings by discussing different conceptual frameworks for understanding resilience and introducing resilience testing, a method to assess health system resilience using a hypothetical shock scenario. Resilience testing is a mixed-methods approach that combines a review of existing data with a structured workshop, where health system experts collaboratively assess the resilience of their health system. The new method is proposed as a tool for policy-making, as the results can identify attributes of the current health system that may hinder or boost a resilient response to the next crisis.

Exposure to volatile organic compounds in offices and in residential and educational buildings in the European Union between 2010 and 2023: A systematic review and health risk assessment.

Chronic exposure to indoor volatile organic compounds (VOCs) can result in several adverse effects including cancers. We review reports of levels of VOCs in offices and in residential and educational buildings in the member states of the European Union (EU) published between 2010 and 2023. We use these data to assess the risk to population health by estimating lifetime exposure to indoor VOCs and resulting non-cancer and cancer risks and, from that, the burden of cancer attributable to VOC exposure and associated economic losses. Our systematic review identified 1783 articles, of which 184 were examined in detail, with 58 yielding relevant data. After combining data on VOC concentrations separately for EU countries and building types, non-cancer and cancer risks were assessed in terms of hazard quotient and lifetime excess cancer risk (LECR) using probabilistic Monte Carlo Simulations. The LECR was used to estimate disability adjusted life years (DALYs) from VOC-related cancers and associated costs. We find that the LECR associated with formaldehyde exposure was above the acceptable risk level (ARL) in France and Germany and that of from exposure to benzene was also above the ARL in Spanish females. The sum of DALYs and related costs/1,000,000 population/year from exposure to acetaldehyde, benzene, formaldehyde, tetrachloroethylene, and trichloroethylene were 4.02 and €41,010, respectively, in France, those from exposure to acetaldehyde, benzene, carbon tetrachloride, formaldehyde, and trichloroethylene were 3.91 and €39,590 in Germany, and those from exposure to benzene were 0.1 and €1030 in Spain. Taken as a whole, these findings show that indoor exposure to VOCs remains a public health concern in the EU. Although the EU has set limits for certain VOCs, further measures are needed to restrict the use of these chemicals in consumer products.

Placing Trust at the Heart of Health Policy and Systems.

Trusted interactions are crucial in health systems. Trust facilitates effective healthcare by encouraging patients to seek and adhere to treatment, enabling teamwork among health professionals, reducing miscommunication and medical errors, and fostering innovation and resilience. The COVID-19 pandemic underscored the importance of trust, highlighting the challenges in establishing and maintaining it, especially during crises when trust in authorities and health systems is vital for compliance and safety. However, trust is complex, varying with context and experiences, and is dynamic, easily lost but hard to regain. Despite its importance, trust is often overlooked in health policy and difficult to measure. Health systems and policy-makers must recognize the importance of trust, measure it effectively, understand how it is built or eroded, and act to maintain and restore it. This involves acknowledging the past experiences of marginalized groups, involving communities in decision-making, and ensuring transparency and integrity in health practices and policies.

Expanding eligibility and improving quality of cervical cancer screening in Estonia: The 2021 reforms.

Estonia has one of the highest death rates from cervical cancer in the European Union despite having had a population-based screening programme for over 15 years. In 2021, this high disease burden, alongside a new national cancer prevention plan, prompted a series of cervical cancer screening programme reforms to address low screening uptake and evidence of variable screening test quality. The reforms had three main elements: expansion of eligibility to all women aged 30-65 regardless of insurance status; increasing test provision by enabling family physicians to take screening samples and introducing self-sampling; and improving testing procedures, replacing cytology with HPV testing as the primary screening test. Although the impact of these changes is yet to be seen, early signs suggest increased programme participation. However, at 51 %, further action to address barriers to uptake will likely be necessary. If Estonia is to avoid another period of policy dormancy, as happened between 2006 and 2021, greater clarity on screening programme accountability is required. The establishment of the National Cancer Screening Group may enable this. The first test will be the delivery of an end-to-end evaluation of the reformed programme, with an emphasis on equity of access. The next step will be to develop and deliver solutions that respond to these needs.

Relationship Between Social Support and Clinical Outcomes: An Evaluation of Participant-Nominated Treatment Supporters in the HOPE 4 Intervention.

BACKGROUND: The HOPE 4 trial (Heart Outcomes Prevention and Evaluation 4) investigated the effectiveness of a comprehensive, collaborative model of care, implemented in Colombia and Malaysia, which aimed to reduce cardiovascular disease risk in individuals with hypertension. One component of this intervention was the nomination of a treatment supporter, where participants could select a family member or friend to assist them with their care. The purpose of this study was to investigate the impact of these individuals on participant outcomes, as well as the relationship dynamics between participants and their treatment supporter. METHODS: Participants in the HOPE 4 intervention group with baseline and 12 months of follow-up were included for analysis. They were divided into Every Visit (n=339) and