Observations of community-based multidisciplinary team meetings in health and social care for older people with long term conditions in England.

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.

Comparison of the impact of two national health and social care integration programmes on emergency hospital admissions.

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.

The recovery experience of people who were sex trafficked: the thwarted journey towards goal pursuit.

BACKGROUND: In 2010, a shelter programme was established in the Netherlands to provide social and health services for trafficked people. This article describes how service users in this programme conceptualized and experienced their own process of recovery. METHODS: In 2012, 14 people of non-Dutch nationality who had been trafficked for the purpose of sexual exploitation were interviewed at all three shelters of the programme. Data analysis followed a grounded theory approach. RESULTS: Participants felt a strong need to turn over a new leaf in life, leaving negative experiences of the past behind and moving towards a life with a job, a family and friends. In contrast with their willingness to work towards realizing that future, they experienced a lack of autonomy and a thwarted sense of agency in redressing their present situation. Together with the ostracized nature of their place in Dutch society this left them 'in limbo': a feeling of standing still, while wanting to move forward. This led participants to find it more difficult to deal with problems related to their pasts and futures. They particularly appreciated Dutch language training, vocational skills training and opportunities for volunteer work. CONCLUSIONS: Participants exhibited a strong desire to fulfil the basic psychological needs of competence, relatedness and autonomy, but were thwarted in pursuing these goals. Seemingly against all odds, while faced with several external regulators that limited their agency to change their situation, participants found ways to pursue these goals, through their enthusiasm for activities that helped them get closer to their envisioned futures (language and skills training and volunteer work). Identifying pathways toward attaining their goals allowed them to hope for a better future. That hope and pursuing their goals helped them to cope with the problems of their past and their worries about the future. Therefore, to facilitate service users' recovery in a post-trafficking setting, there is a need to provide them with opportunities to hope for, pursue and attain their personal goals within the structural boundaries of their situation. A future-orientated, strengths-based approach towards service provision and responsive and supportive environments help to do this.

Comorbidities and the referral pathway to access joint replacement surgery: an exploratory qualitative study.

BACKGROUND: Variation in access to joint replacement surgery has been widely reported but less attention has been given to the impact of comorbidities on the patient journey to joint replacement surgery. There is a lack of consensus amongst healthcare professionals and commissioners about how patients with comorbidities should be referred or selected for joint replacement surgery. It is therefore important to understand the views of healthcare professionals on the management, referral and selection of patients with comorbidities for joint replacement surgery. METHODS: An exploratory qualitative study involving semi-structured interviews with 20 healthcare professionals in England across the referral pathway to joint replacement surgery. They were asked to talk about their experiences of referring and selecting patients with comorbidities for joint replacement surgery. The interviews were audio-recorded and transcribed verbatim. Data analysis followed a thematic analysis approach based on the principles of grounded theory. RESULTS: In general, the presence of comorbidities was not seen as a barrier to being referred or selected for joint replacement but was seen as a challenge to manage the patients' journey across the referral pathway. Each professional group, concentrated on different aspects of the patients' condition which appeared to affect how they managed patients with comorbidities. This implied there was a disagreement about roles and responsibilities in the management of patients with comorbidities. None of the professionals believed it was their responsibility to address comorbidities in preparation for surgery. This disagreement was identified as a reason why some patients seem to 'get lost' in the referral system when they were considered to be unprepared for surgery. Patients were then potentially left to manage their own comorbidities before being reconsidered for joint replacement. CONCLUSIONS: At the clinician-level, comorbidities were not perceived as a barrier to accessing joint replacement surgery but at the pathway-level, it may create an implicit barrier such that patients with comorbidities may get 'lost' to the system. Further study is needed to explore the roles and responsibilities of professionals across the current orthopaedic referral pathway which may be less suitable for patients with comorbidities.

Supporting ALL victims of violence, abuse, neglect or exploitation: guidance for health providers.

Smaller groups of victims of violence, abuse, neglect or exploitation - such as male victims of intimate partner violence (IPV), victims of elder abuse, victims of abuse by carers, victims of parent abuse, victims of human trafficking, girls and boys below 18 years engaging in sex work, victims of sexual exploitation by gangs or groups and victims of honour based violence (such as forced marriages and female genital mutilation) - are often in contact with the health care system without being identified as such and frequently do not receive appropriate treatment. To address this problem, two things need to happen: 1) that ALL groups of victims of violence, abuse, neglect or exploitation are explicitly listed in policies and protocols, and 2) that both the similarities as well as the differences between the groups with regard to identification, support and referral - described in this article - are explained, so that health providers are appropriately supported in this important function.

The Public Health Responsibility Deal: making the workplace healthier?

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.

'They treat us like machines': migrant workers' conceptual framework of labour exploitation for health research and policy.

BACKGROUND: The exploitation of migrant workers ranks high on global political agendas including the Sustainable Development Goals. Research on exploited workers, using assessment tools where exploitation is defined by professional experts, indicates serious health concerns and needs. Yet, migrant workers are rarely asked about their understanding of a phenomenon they may experience. Our study aimed to conceptualise 'labour exploitation' from the perspective of migrant workers employed in manual low-skilled jobs. METHODS: Twenty-seven Latin Americans working in London (UK) participated in Group Concept Mapping; a participatory mixed-method where qualitative data are collected to define a concept's content and then analysed using quantitative methods to generate a structured conceptual framework. Participants generated statements describing the concept content during brainstorming sessions, and structured them during sorting-rating exercises. Multi-Dimensional Scaling and Cluster Analysis were performed, generating a conceptual framework that clarified the dimensions, subdimensions and constituent statements of the concept of labour exploitation from migrant workers' perspectives. RESULTS: Three key dimensions were identified: 'poor employment conditions and lack of protection', covering contractual arrangements and employment relations; 'disposability and abuse of power' (or 'dehumanisation') covering mechanisms or means which make migrant workers feel disposable and abused; and 'health and safety and psychosocial hazards' encompassing issues from physical and psychosocial hazards to a lack of health and social protection. 'Dehumanisation' has not been included in mainstream tools assessing exploitation, despite its importance for study participants who also described harsh situations at work including sexual, physical and verbal abuse. CONCLUSION: Our study provides a conceptual framework of labour exploitation that gives voice to migrant workers and can be operationalised into a measure of migrant labour exploitation. It also calls for the dimension 'dehumanisation' and structural forms of coercion to be integrated into mainstream conceptualisations, and their workplace hazards to be urgently addressed.

The Public Health Responsibility Deal: how should such a complex public health policy be evaluated?

BACKGROUND: The Public Health Responsibility Deal (RD) in England was launched in 2011 as a public-private partnership which aims to 'tap into the potential for businesses and other influential organisations to make a significant contribution to improving public health by helping us to create this environment'. It has come under criticism from public health advocates and others, who have suggested that it will be ineffective or perhaps even harmful. Like many public health policies, there have also been demands to know whether it 'works'. METHODS: We conducted a scoping review and used this, supplemented with interviews with stakeholders, to develop a detailed logic model of the RD (presented here) to help understand its likely outcomes and the pathways by which these may be achieved as a basis for planning an evaluation. CONCLUSIONS: Evaluations of complex interventions require not just assessment of effects (including outcomes), but also a clear conceptualization of the intervention and its processes. The way the RD and the pledges made by participant organizations has been presented makes it difficult at this stage to evaluate whether the RD 'works' in terms of improving health. Instead, any evaluation needs to put together a jigsaw of evidence about processes, mechanisms and potential future health and non-health impacts, in part using the current scientific evidence. This task is ongoing.

Building a better understanding of labour exploitation's impact on migrant health: An operational framework.

BACKGROUND: There is limited evidence on labour exploitation's impact on migrant health. This population is, however, often employed in manual low-skilled jobs known for poor labour conditions and exploitation risks. The lack of a common conceptualisation of labour exploitation in health research impedes the development of research measuring its effects on migrant health and, ultimately, our understanding of migrants' health needs. AIM: To develop an operational conceptual framework of labour exploitation focusing on migrant workers in manual low-skilled jobs. METHODS: Non-probabilistic sampling was used to recruit multidisciplinary experts on labour exploitation. An online Group Concept Mapping (GCM) was conducted. Experts: 1) generated statements describing the concept 'labour exploitation' focusing on migrants working in manual low-skilled jobs; 2) sorted generated statements into groups reflecting common themes; and 3) rated them according to their importance in characterising a situation as migrant labour exploitation. Multidimensional Scaling and Cluster Analysis were used to produce an operational framework detailing the concept content (dimensions, statements, and corresponding averaged rating). FINDINGS: Thirty-two experts sorted and rated 96 statements according to their relative importance (1 "relatively unimportant" to 5 "extremely important"). The operational framework consists of four key dimensions of migrant labour exploitation, distributed along a continuum of severity revealed by the rating: 'Shelter and personal security' (rating: 4.47); 'Finance and migration' (4.15); 'Health and safety' (3.96); and 'Social and legal protection' (3.71). CONCLUSION: This study is the first to both generate an empirical operational framework of migrant labour exploitation, and demonstrate the existence of a "continuum from decent work to forced labour". The framework content can be operationalised to measure labour exploitation. It paves the way to better understand how different levels of exploitation affect migrant workers' health for global policymakers, health researchers, and professionals working in the field of migrant exploitation.

Modernisation as a professionalising strategy: the case of critical care in England.

There has been broad agreement about how to characterise the processes of 'modernisation' of the public sector in welfare societies, but rather less consensus on the impact of this modernisation on professionals. This paper takes critical care in England as a case study to explore how professionals in one setting account for the changes associated with modernisation. In contrast to reports from other arenas, critical care professionals were positive about the processes and outcomes of 'modernisation' in general, and there was a surprising lack of nostalgia in their accounts of organisational changes. However, joking comments suggested considerable scepticism about the initiatives explicitly associated with the national organisation that was charged with 'modernising' critical care, the Modernisation Agency. We suggest that the relative optimism of staff is in part explained by historical and political contingencies which meant that critical care, as a relatively new clinical specialty, benefited in tangible ways from modernisation. Further, all staff groups were able to attribute gains, rather than losses, in autonomy and authority to the modernisation of critical care. Their accounts suggest that modernisation can be a professionalising strategy, with responses to change being neither resistant nor compliant, but sceptically strategic.

Integrated Care in England - what can we Learn from a Decade of National Pilot Programmes?

INTRODUCTION: For more than a decade the English NHS has pursued integrated care through three national pilot programmes. The independent evaluators of these programmes here identify several common themes that inform the development of integrated care. DESCRIPTION: The three pilot programmes shared the aim of better coordination between hospital and community-based health services and between health and social care. Each programme recruited local pilot sites that designed specific interventions to support inter-professional and inter-organisational collaboration.The pilots were highly heterogenous and results varied both within and between the three programmes. While staff were generally positive about their achievements, pilots had mixed success especially in reducing unplanned hospital admissions. Common facilitators to achieving pilots' objectives included effective senior leadership and shared values, simple interventions and additional funding. Barriers included short timescales, poor professional engagement, information and data sharing problems, and conflicts with changing national policy. DISCUSSION: There was little stable or shared understanding of what 'integrated care' meant resulting in different practices and priorities. An increasing focus on reducing unplanned hospital use among national sponsors created a mismatch in expectations between local and national actors. CONCLUSION: Pilots in all three national programmes made some headway against their objectives but were limited in their impact on unplanned hospital admissions.

Area level impacts on emergency hospital admissions of the integrated care and support pioneer programme in England: difference-in-differences analysis.

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.

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.

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.

Progressive protocol in the bowel management of spinal cord injuries.

Research into bowel management in spinal cord injury is sparse. Specifically, the use of laxatives in this group, while widespread, is not supported by research evidence. A prospective study in which baseline and intervention data were collected from each subject was undertaken with 17 individuals. The baseline was the routine method of bowel management in the study unit. The intervention was the use of a progressive protocol which allowed the use of physical interventions and rectal stimulants prior to the use of laxative therapy if required. Though the response of individuals varied, the number of successful bowel management episodes employing laxatives was significantly less in the intervention phase, the proportion of glycerine suppository uses which were successful was significantly greater, the use of manual evacuation was significantly reduced and the duration of bowel management episodes was significantly less. These findings suggest that use of laxatives in bowel management is not essential for all newly spinal cord injured individuals, while the use of physical interventions in this population may be beneficial. The variable response of individuals to the progressive protocol highlights the need for individual assessment in the area of bowel. The findings of this small study must be validated by a larger study.

Health information on alcoholic beverage containers: has the alcohol industry's pledge in England to improve labelling been met?

AIMS: In the United Kingdom, alcohol warning labels are the subject of a voluntary agreement between industry and government. In 2011, as part of the Public Health Responsibility Deal in England, the industry pledged to ensure that 80% of products would have clear, legible health warning labelling, although an analysis commissioned by Portman found that only 57.1% met best practice. We assessed what proportion of alcohol products now contain the required health warning information, and its clarity and placement. DESIGN: Survey of alcohol labelling data. SETTING: United Kingdom. PARTICIPANTS: Analysis of the United Kingdom's 100 top-selling alcohol brands (n = 156 individual products). MEASUREMENTS: We assessed the product labels in relation to the presence of five labelling elements: information on alcohol units, government consumption guidelines, pregnancy warnings, reference to the Drinkaware website and a responsibility statement. We also assessed the size, colour and placement of text, and the size and colouring of the pregnancy warning logo. FINDINGS: The first three (required) elements were present on 77.6% of products examined. The mean font size of the Chief Medical Officer's (CMO) unit guidelines (usually on the back of the product) was 8.17-point. The mean size of pregnancy logos was 5.95 mm. The pregnancy logo was on average smaller on wine containers. CONCLUSIONS: The UK Public Health Responsibility Deal alcohol labelling pledge has not been fully met. Labelling information frequently falls short of best practice, with font and logos smaller than would be accepted on other products with health effects.

Diageo's 'Stop Out of Control Drinking' Campaign in Ireland: An Analysis.

BACKGROUND: It has been argued that the alcohol industry uses corporate social responsibility activities to influence policy and undermine public health, and that every opportunity should be taken to scrutinise such activities. This study analyses a controversial Diageo-funded 'responsible drinking' campaign ("Stop out of Control Drinking", or SOOCD) in Ireland. The study aims to identify how the campaign and its advisory board members frame and define (i) alcohol-related harms, and their causes, and (ii) possible solutions. METHODS: Documentary analysis of SOOCD campaign material. This includes newspaper articles (n = 9), media interviews (n = 11), Facebook posts (n = 92), and Tweets (n = 340) produced by the campaign and by board members. All material was coded inductively, and a thematic analysis undertaken, with codes aggregated into sub-themes. RESULTS: The SOOCD campaign utilises vague or self-defined concepts of 'out of control' and 'moderate' drinking, tending to present alcohol problems as behavioural rather than health issues. These are also unquantified with respect to actual drinking levels. It emphasises alcohol-related antisocial behaviour among young people, particularly young women. In discussing solutions to alcohol-related problems, it focuses on public opinion rather than on scientific evidence, and on educational approaches and information provision, misrepresenting these as effective. "Moderate drinking" is presented as a behavioural issue ("negative drinking behaviours"), rather than as a health issue. CONCLUSIONS: The 'Stop Out of Control Drinking' campaign frames alcohol problems and solutions in ways unfavourable to public health, and closely reflects other Diageo Corporate Social Responsibility (CSR) activity, as well as alcohol and tobacco industry strategies more generally. This framing, and in particular the framing of alcohol harms as a behavioural issue, with the implication that consumption should be guided only by self-defined limits, may not have been recognised by all board members. It suggests a need for awareness-raising efforts among the public, third sector and policymakers about alcohol industry strategies.

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

AIMS: The English Public Health Responsibility Deal (RD) is a public-private partnership involving voluntary pledges between industry, government and other actors in various areas including alcohol, and designed to improve public health. This paper reviews systematically the evidence underpinning four RD alcohol pledges. METHODS: We conducted a systematic review of reviews of the evidence underpinning interventions proposed in four RD alcohol pledges, namely alcohol labelling, tackling underage alcohol sales, advertising and marketing alcohol, and alcohol unit reduction. In addition, we included relevant studies of interventions where these had not been covered by a recent review. RESULTS: We synthesized the evidence from 14 reviews published between 2002 and 2013. Overall, alcohol labelling is likely to be of limited effect on consumption: alcohol unit content labels can help consumers assess the alcohol content of drinks; however, labels promoting drinking guidelines and pregnancy warning labels are unlikely to influence drinking behaviour. Responsible drinking messages are found to be ambiguous, and industry-funded alcohol prevention campaigns can promote drinking instead of dissuading consumption. Removing advertising near schools can contribute to reducing underage drinking; however, community mobilization and law enforcement are most effective. Finally, reducing alcohol consumption is more likely to occur if there are incentives such as making lower-strength alcohol products cheaper. CONCLUSIONS: The most effective evidence-based strategies to reduce alcohol-related harm are not reflected consistently in the RD alcohol pledges. The evidence is clear that an alcohol control strategy should support effective interventions to make alcohol less available and more expensive.

An evaluation of the Public Health Responsibility Deal: Informants' experiences and views of the development, implementation and achievements of a pledge-based, public-private partnership to improve population health in England.

OBJECTIVES: The Coalition Government's Public Health Responsibility Deal (RD) was launched in England in 2011 as a public-private partnership designed to improve public health in the areas of food, alcohol, health at work and physical activity. As part of a larger evaluation, we explored informants' experiences and views about the RD's development, implementation and achievements. METHODS: We conducted 44 semi-structured interviews with 50 interviewees, purposively sampled from: RD partners (businesses, public sector and non-governmental organisations); individuals with formal roles in implementing the RD; and non-partners and former partners. Data were analysed thematically: NVivo (10) software was employed to manage the data. RESULTS: Key motivations underpinning participation were corporate social responsibility and reputational enhancement. Being a partner often involved making pledges related to work already underway or planned before joining the RD, suggesting limited 'added value' from the RD, although some pledge achievements (e.g., food reformulation) were described. Benefits included access to government, while drawbacks included resource implications and the risk of an 'uneven playing field' between partners and non-partners. CONCLUSIONS: To ensure that voluntary agreements like the RD produce gains to public health that would not otherwise have occurred, government needs to: increase participation and compliance through incentives and sanctions, including those affecting organisational reputation; create greater visibility of voluntary agreements; and increase scrutiny and monitoring of partners' pledge activities.

Increasing autonomy in publically owned services.

PURPOSE: The purpose of this paper is to explore government efforts to enhance the autonomy of community health services (CHS) in England through the creation of Foundation Trusts status. It considers why some CHS elected to become nascent Community Foundation Trusts (CFTs) while others had not and what advantages they thought increased levels of autonomy offered. DESIGN/METHODOLOGY/APPROACH: Data are drawn from the evaluation of the Department of Health's CFT pilot programme. Participants were purposively selected from pilot sites, as well as from comparator non-pilot organisations. A total of 44 staff from 14 organisations were interviewed. FINDINGS: The data reveals that regardless of the different pathways that organisations were on, they all shared the same goal, a desire for greater autonomy, but specifically within the NHS. Additionally, irrespective of their organisational form most organisations were considering an almost identical set of initiatives as a means to improve service delivery and productivity. RESEARCH LIMITATIONS/IMPLICATIONS: Despite the expectations of policy makers no CFTs were established during the course of the study, so it is not possible to find out what the effect of such changes were. Nevertheless, the authors were able to investigate the attitudes of all the providers of CHS to the plans to increase their managerial autonomy, whether simply by separating from PCTs or by becoming CFTs. ORIGINALITY/VALUE: As no CFTs have yet been formed, this study provides the only evidence to date about increasing autonomy for CHS in England.

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

BACKGROUND AND AIMS: The Public Health Responsibility Deal (RD) in England is a public-private partnership involving voluntary pledges between industry, government and other organizations, with the aim of improving public health. This paper aims to evaluate what action resulted from the RD alcohol pledges. METHODS: We analysed publically available data on organizations' plans and progress towards achieving key alcohol pledges of the RD. We assessed the extent to which activities pledged by signatories could have been brought about by the RD, as opposed to having happened anyway (the counterfactual), using a validated coding scheme designed for the purpose. RESULTS: Progress reports were submitted by 92% of signatories in 2013 and 75% of signatories in 2014, and provided mainly descriptive feedback rather than quantifiable performance metrics. Approximately 14% of 2014 progress reports were identical to those presented in 2013. Most organizations (65%) signed pledges that involved actions to which they appear to have been committed already, regardless of the RD. A small but influential group of alcohol producers and retailers reported taking measures to reduce alcohol units available for consumption in the market. However, where reported, these measures appear to involve launching and promoting new lower-alcohol products rather than removing units from existing products. CONCLUSIONS: The RD is unlikely to have contributed significantly to reducing alcohol consumption, as most alcohol pledge signatories appear to have committed to actions that they would have undertaken anyway, regardless of the RD. Irrespective of this, there is considerable scope to improve the clarity of progress reports and reduce the variability of metrics provided by RD pledge signatories.