Healthy Cities Phase V evaluation: further synthesizing realism.

In this article we reflect on the quality of a realist synthesis paradigm applied to the evaluation of Phase V of the WHO European Healthy Cities Network. The programmatic application of this approach has led to very high response rates and a wealth of important data. All articles in this Supplement report that cities in the network move from small-scale, time-limited projects predominantly focused on health lifestyles to the significant inclusion of policies and programmes on systems and values for good health governance. The evaluation team felt that, due to time and resource limitations, it was unable to fully exploit the potential of realist synthesis. In particular, the synthetic integration of different strategic foci of Phase V designation areas did not come to full fruition. We recommend better and more sustained integration of realist synthesis in the practice of Healthy Cities in future Phases.

Variations and value improvement in back pain care in one area of England.

The pursuit of value and equity have been put on a legal footing in the NHS with the arrival of the legal duty for all in the NHS to improve health and well-being of the population served, to provide fair access to high quality healthcare, and to use resources sustainably and efficiently. Recognising this we used analysis of variation to help us understand the degree to which we were fulfilling our new duty for people with back pain in Mid-Nottinghamshire and where there might be opportunities for value improvement.MSK Together is a group of clinical and managerial representatives from providers, purchasers, local government, and patients who work collectively to optimise the use of resources for people with MSK conditions in Mid-Nottinghamshire. Back pain is the third largest burden of disease in the locality, and the largest cause of disability, so it is of strategic importance to MSK Together-we wanted to know about, and act on, opportunities for value improvement across the population of people with back pain.In 2019/20, after adjusting for age and sex, we found a greater than three-fold variation among general practices in age-sex standardised rates of all hospital service usage for back pain conditions. When looking at a four-year period (2016/17-2019/20), the observed variation increased to eight-fold for (with narrow 95% confidence intervals). When looking at procedures (e.g., surgery or injections), the standardised variation among general practices was six-fold in 2019/20. The deprivation score of the general practice (a heterogenous measure given the mixed neighbourhoods many general practices serve) showed little correlation to the rates observed and did not appear to justify the variation.When we looked at the deprivation of the neighbourhood from which the individuals receiving back pain procedures came, there appeared to be a weak correlation in terms of lower rates of intervention in the least-deprived compared with the most-deprived communities. This correlation was not tested statistically. People receiving hospital services for back pain appeared to receive the first episode of care most often in their 40s (working age), compared with people from the least-deprived areas who received care most commonly in their 60s (approaching retirement).When we looked at the interventions provided in Mid-Nottinghamshire for back pain, 29 interventions were provided to 17,225 people. Using a recent NICE evaluation of cost-effectiveness of back pain interventions, we established that, of these 29 interventions, 16 have evidence of improving the quality of life, for nine there was no evidence of benefit or harm, for three there was evidence that they do not provide an improvement in quality of life, and for one there was possible evidence of harm. The total cost of interventions was estimated at £4.5 million and, using the evidence from the NICE review, the total quality adjusted life year (QALY) gain to the treated population of people with back pain was calculated to be 4,571 QALYs.After discussions among the MSK Together group, it was agreed that some interventions could be stopped or scaled down, and new interventions introduced (in particular, in more-deprived neighbourhoods). Within the same estimated cost envelope of £4.5 million, the QALY gain was predicted to increase to 7702 QALYs and, by targeting QALY-related interventions to people from deprived neighbourhoods, reduce inequity (and therefore health inequalities).Using variation helped us identify areas for improvement and generated a momentum for change among the MSK Together group. By examining what we were doing, the associated costs, and the likely QALY benefits (from research evidence), we identified lower value interventions to stop or reduce and new interventions to introduce, achieving greater health gain for people with back pain with no additional resource requirements.

Health impact assessment in a network of European cities.

The methodology of health impact assessment (HIA) was introduced as one of four core themes for Phase IV (2003-2008) of the World Health Organization European Healthy Cities Network (WHO-EHCN). Four objectives for HIA were set at the beginning of the phase. We report on the results of the evaluation of introducing and implementing this methodology in cities from countries across Europe with widely differing economies and sociopolitical contexts. Two main sources of data were used: a general questionnaire designed for the Phase IV evaluation and the annual reporting template for 2007-2008. Sources of bias included the proportion of non-responders and the requirement to communicate in English. Main barriers to the introduction and implementation of HIA were a lack of skill, knowledge and experience of HIA, the newness of the concept, the lack of a legal basis for implementation and a lack of political support. Main facilitating factors were political support, training in HIA, collaboration with an academic/public health institution or local health agency, a pre-existing culture of intersectoral working, a supportive national policy context, access to WHO materials about or expertise in HIA and membership of the WHO-EHCN, HIA Sub-Network or a National Network. The majority of respondents did not feel that they had had the resources, knowledge or experience to achieve all of the objectives set for HIA in Phase IV. The cities that appear to have been most successful at introducing and implementing HIA had pre-existing experience of HIA, came from a country with a history of applying HIA, were HIA Sub-Network members or had made a commitment to implementing HIA during successive years of Phase IV. Although HIA was recognised as an important component of Healthy Cities' work, the experience in the WHO-EHCN underscores the need for political buy-in, capacity building and adequate resourcing for the introduction and implementation of HIA to be successful.

Unwarranted variations in end-of-life care and the impact of using an electronic coordination system.

This study looks at the variations in end-of-life care in North-East Essex (eastern England) combining hospital records, official death records and the local electronic end-of-life coordination tool. These differences included dying in hospital (versus a general wish to die in the usual place of residence), and inequity in care provision: the place of death varying according to the cause of death (even for highly predictable conditions); and deprivation being associated with a greater likelihood of dying in hospital. There was a positive correlation between the use of an electronic end-of-life coordination system and dying in the preferred place of care. The results suggest two actions for policy makers. First, look at variations in end-of-life care so that areas of need can be identified. Second, use of an electronic end-of-life coordination tool is correlated with a reduction in unwarranted variation in the place of death.

The introduction of health impact assessment in the WHO European Healthy Cities Network.

The World Health Organization (WHO) has been a strong and persistent voice calling for the recognition of the role of health in development and of the impact of socio-economic development on health. Health impact assessment (HIA) is one mechanism that can be used to achieve this goal. The objective of this paper is to describe HIA practice in the WHO European Healthy Cities Network and present some of the initial learning from a collective approach to introducing this relatively new methodology into municipal business. One of the foundations for this was a European Union (EU)-funded project entitled Promoting and Supporting Integrated Approaches for Health and Sustainable Development at the Local Level across Europe (PHASE). For Phase IV of WHO European Healthy Cities, HIA was made one of four core themes, and a sub-network in HIA was set up to support the introduction and development of the methodology. The use of HIA by four cities in the Network-Belfast, Onex-Geneve, Helsingborg, Bologna-illustrates the challenges and successes experienced in the initial stages of Phase IV.