Overcoming challenges in the UK's National Health Service.

Working in an eye clinic in Dewsbury, West Yorkshire (with its large South Asian migrant population) in the 1990s, Andy Cassels-Brown noticed the large number of young South Asian patients who presented with much more advanced keratoconus than their Caucasian counterparts, who tended to be detected much earlier. This indicated an inequality in access to eye care services which, we discovered, was made worse as the Asian patients frequently had preventable associated allergic conditions (such as allergic conjunctivitis or eczema) and a strikingly strong family history of keratoconus. Better access to eye care would permit earlier identification of family members with the condition and, these days, prevention of progression by means of cross-linking to stabilise the keratoconic cornea

Public policies, law and bioethics: : a framework for producing public health policy across the European Union

Unlike the duties of clinicians to patients, professional standards for ethical practice are not well defined in public health. This is mainly due to public health practice having to reconcile tensions between public and private interest(s). This involves at times being paternalistic, while recognising the importance of privacy and autonomy, and at the same time balancing the interests of some against those of others. The Public Health specialist operates at the macro level, frequently having to infer the wishes and needs of individuals that make up a population and may have to make decisions where the interests of people conflict. This is problematic when devising policy for small populations; however, it becomes even more difficult when there is responsibility for many communities or nation states. Under the Treaty on European Union, the European Commission was given a competence in public health. Different cultures will give different moral weight to protecting individual interests versus action for collective benefit. However, even subtle differences in moral preferences may cause problems in deriving public health policy within the European Union. Understanding the extent to which different communities perceive issues such as social cohesion by facilitating cultural dialogues will be vital if European institutions are to work towards new forms of citizenship. The aim of EuroPHEN was to derive a framework for producing common approaches to public health policy across Europe. Little work has been done on integrating ethical analysis with empirical research, especially on trade-offs between private and public interests. The disciplines of philosophy and public policy have been weakly connected. Much of the thinking on public health ethics has hitherto been conducted in the United States of America, and an ethical framework for public health within Europe would need to reflect the greater respect for values such as solidarity and integrity which are more highly valued in Europe. Towards this aim EuroPHEN compared the organisation of public health structures and public policy responses to selected public health problems in Member States to examine how public policy in different countries weighs competing claims of private and public interest. Ethical analysis was performed of tensions between the private and public interest in the context of various ethical theories, principles and traditions. During autumn 2003, 96 focus groups were held across 16 European Union Member States exploring public attitudes and values to public versus private interests. The groups were constructed to allow examination of differences in attitudes between countries and demographic groups (age, gender, smoking status, educational level and parental and marital status). Focus group participants discussed issues such as attitudes to community; funding of public services; rights and responsibilities of citizens; rules and regulations; compulsory car seat belts; policies to reduce tobacco consumption; Not-In-My-Back-Yard arguments; banning of smacking of children; legalising cannabis and parental choice with regards to immunisation. This project proposes a preliminary framework and stresses that a European policy of Public Health will have to adopt a complex, pluralistic and dynamic goal structure, capable of accommodating variations in what specific goals should be prioritised in the specific socio-economic settings of individual countries

The impact of care farms on quality of life, depression and anxiety among different population groups : a systematic review

Care farming (also called social farming) is the therapeutic use of agricultural and farming practices. Service users and communities supported through care farming include people with learning disabilities, mental and physical health problems, substance misuse, adult offenders, disaffected youth, socially isolated older people and the long term unemployed. Care farming is growing in popularity, especially around Europe. This review aimed to understand the impact of care farming on quality of life, depression and anxiety, on a range of service user groups. It also aimed to explore and explain the way in which care farming might work for different groups. By reviewing interview studies we found that people valued, among other things, being in contact with each other, and feeling a sense of achievement, fulfilment and belonging. Some groups seemed to appreciate different things indicating that different groups may benefit in different ways but, it is unclear if this is due to a difference in the types of activities or the way in which people take different things from the same activity. We found no evidence that care farms improved people’s quality of life and some evidence that they might improve depression and anxiety. Larger studies involving single service user groups and fully validated outcome measures are needed to prove more conclusive evidence about the benefits of care farming

Using a multi-stakeholder experience-based design process to co-develop the Creating Active Schools Framework

Background: UK and global policies recommend whole-school approaches to improve childrens’ inadequate physical activity (PA) levels. Yet, recent meta-analyses establish current interventions as ineffective due to suboptimal implementation rates and poor sustainability. To create effective interventions, which recognise schools as complex adaptive sub-systems, multi-stakeholder input is necessary. Further, to ensure ‘systems’ change, a framework is required that identifies all components of a whole-school PA approach. The study’s aim was to codevelop a whole-school PA framework using the double diamond design approach (DDDA).Methodology: Fifty stakeholders engaged in a six-phase DDDA workshop undertaking tasks within same stakeholder (n = 9; UK researchers, public health specialists, active schools coordinators, headteachers, teachers, active partner schools specialists, national organisations, Sport England local delivery pilot representatives and international researchers) and mixed (n = 6) stakeholder groupings. Six draft frameworks were created before stakeholders voted for one ‘initial’ framework. Next, stakeholders reviewed the ‘initial’ framework, proposing modifications. Following the workshop, stakeholders voted on eight modifications using an online questionnaire.Results: Following voting, the Creating Active Schools Framework (CAS) was designed. At the centre, ethos and practice drive school policy and vision, creating the physical and social environments in which five key stakeholder groups operate to deliver PA through seven opportunities both within and beyond school. At the top of the model, initial and in-service teacher training foster teachers’ capability, opportunity and motivation (COM-B) to deliver whole-school PA. National policy and organisations drive top-down initiatives that support or hinder wholeschool PA.Summary: To the authors’ knowledge, this is the first time practitioners, policymakers and researchers have codesigned a whole-school PA framework from initial conception. The novelty of CAS resides in identifying the multitude of interconnecting components of a whole-school adaptive sub-system; exposing the complexity required to create systems change. The framework can be used to shape future policy, research and practice to embed sustainable PA interventions within schools. To enact such change, CAS presents a potential paradigm shift, providing a map and method to guide future co-production by multiple experts of PA initiatives ‘with’ schools, while abandoning outdated traditional approaches of implementing interventions ‘on’ schools.</div

Using a multi-stakeholder experience-based design process to co-develop the Creating Active Schools Framework

Abstract: Background: UK and global policies recommend whole-school approaches to improve childrens’ inadequate physical activity (PA) levels. Yet, recent meta-analyses establish current interventions as ineffective due to suboptimal implementation rates and poor sustainability. To create effective interventions, which recognise schools as complex adaptive sub-systems, multi-stakeholder input is necessary. Further, to ensure ‘systems’ change, a framework is required that identifies all components of a whole-school PA approach. The study’s aim was to co-develop a whole-school PA framework using the double diamond design approach (DDDA). Methodology: Fifty stakeholders engaged in a six-phase DDDA workshop undertaking tasks within same stakeholder (n = 9; UK researchers, public health specialists, active schools coordinators, headteachers, teachers, active partner schools specialists, national organisations, Sport England local delivery pilot representatives and international researchers) and mixed (n = 6) stakeholder groupings. Six draft frameworks were created before stakeholders voted for one ‘initial’ framework. Next, stakeholders reviewed the ‘initial’ framework, proposing modifications. Following the workshop, stakeholders voted on eight modifications using an online questionnaire. Results: Following voting, the Creating Active Schools Framework (CAS) was designed. At the centre, ethos and practice drive school policy and vision, creating the physical and social environments in which five key stakeholder groups operate to deliver PA through seven opportunities both within and beyond school. At the top of the model, initial and in-service teacher training foster teachers’ capability, opportunity and motivation (COM-B) to deliver whole-school PA. National policy and organisations drive top-down initiatives that support or hinder whole-school PA. Summary: To the authors’ knowledge, this is the first time practitioners, policymakers and researchers have co-designed a whole-school PA framework from initial conception. The novelty of CAS resides in identifying the multitude of interconnecting components of a whole-school adaptive sub-system; exposing the complexity required to create systems change. The framework can be used to shape future policy, research and practice to embed sustainable PA interventions within schools. To enact such change, CAS presents a potential paradigm shift, providing a map and method to guide future co-production by multiple experts of PA initiatives ‘with’ schools, while abandoning outdated traditional approaches of implementing interventions ‘on’ schools

Overcoming challenges in the UK’s National Health Service

Working in an eye clinic in Dewsbury, West Yorkshire (with its large South Asian migrant population) in the 1990s, Andy Cassels-Brown noticed the large number of young South Asian patients who presented with much more advanced keratoconus than their Caucasian counterparts, who tended to be detected much earlier. This indicated an inequality in access to eye care services which, we discovered, was made worse as the Asian patients frequently had preventable associated allergic conditions (such as allergic conjunctivitis or eczema) and a strikingly strong family history of keratoconus. Better access to eye care would permit earlier identification of family members with the condition and, these days, prevention of progression by means of cross-linking to stabilise the keratoconic cornea

Interpretations of informed choice in antenatal screening: a cross-cultural, Q-methodology study

Informed choice is internationally recognised and accepted as an important aspect of ethical healthcare. In the UK, NHS antenatal screening policies state that their primary aim is to facilitate reproductive informed choices. These policies, implemented within a multiethnic population, are largely guided by the ethical principle of autonomy. This study was carried out in 2009 in the UK and used Q-methodology to explore diversity in the value attached to autonomous informed choice in antenatal screening for genetic disorders and similarities and differences in this value in women from different ethnic origins. Ninety-eight participants of African, British White, Caribbean, Chinese and Pakistani origin completed a 41-statement Q-sort in English, French, Mandarin or Urdu. Q-Factor analysis produced five statistically independent viewpoints of the value of informed choice: choice as an individual right; choice informed by religious values; choice as a shared responsibility; choice advised by health professionals; and choice within the family context. The findings show that women hold a variety of views on the nature of informed choice, and that, contradictory to policies of autonomous informed choice, many women seek and value the advice of health professionals. The findings have implications for the role of health professionals in facilitating informed choice, quality of care and equity of access