Impact of the introduction and withdrawal of financial incentives on the delivery of alcohol screening and brief advice in English primary health care : an interrupted time–series analysis

Aim To evaluate the impact of the introduction and withdrawal of financial incentives on alcohol screening and brief advice delivery in English primary care. Design Interrupted time–series using data from The Health Improvement Network (THIN) database. Data were split into three periods: (1) before the introduction of financial incentives (1 January 2006–31 March 2008); (2) during the implementation of financial incentives (1 April 2008–31 March 2015); and (3) after the withdrawal of financial incentives (1 April 2015–31 December 2016). Segmented regression models were fitted, with slope and step change coefficients at both intervention points. Setting England. Participants Newly registered patients (16+) in 500 primary care practices for 2006–16 (n = 4 278 723). Measurements The outcome measures were percentage of patients each month who: (1) were screened for alcohol use; (2) screened positive for higher‐risk drinking; and (3) were reported as having received brief advice on alcohol consumption. Findings There was no significant change in the percentage of newly registered patients who were screened for alcohol use when financial incentives were introduced. However, the percentage fell (P < 0.001) immediately when incentives were withdrawn, and fell by a further 2.96 [95% confidence interval (CI) = 2.21–3.70] patients per 1000 each month thereafter. After the introduction of incentives, there was an immediate increase of 9.05 (95% CI = 3.87–14.23) per 1000 patients screening positive for higher‐risk drinking, but no significant further change over time. Withdrawal of financial incentives was associated with an immediate fall in screen‐positive rates of 29.96 (95% CI = 19.56–40.35) per 1000 patients, followed by a rise each month thereafter of 2.14 (95% CI = 1.51–2.77) per 1000. Screen‐positive patients recorded as receiving alcohol brief advice increased by 20.15 (95% CI = 12.30–28.00) per 1000 following the introduction of financial incentives, and continued to increase by 0.39 (95% CI = 0.26–0.53) per 1000 monthly until withdrawal. At this point, delivery of brief advice fell by 18.33 (95% CI = 11.97–24.69) per 1000 patients and continued to fall by a further 0.70 (95% CI = 0.28–1.12) per 1000 per month. Conclusions Removing a financial incentive for alcohol prevention in English primary care was associated with an immediate and sustained reduction in the rate of screening for alcohol use and brief advice provision. This contrasts with no, or limited, increase in screening and brief advice delivery rates following the introduction of the scheme

The welfare state sources of bank instability : displacing the conditions of welfare state fiscal crisis under pressures of macroeconomic

The post-financial crisis decision-making of Britain's Labour Government represents an interesting case of the more general tensions embedded in welfare reform strategies under macroeconomic pressures of financialization. It continued to find additional sources of funding out of current taxation to finance enhanced levels of short-term frontline services, yet this was always against the backdrop of attempting to facilitate greater long-term affordability through negotiating the switch to increasingly self-sufficient welfare citizens. These twin policy objectives provided the backdrop for New Labour's opposition to the Bank of England's post-financial crisis arguments for forcibly separating banks' trading practices from their depository business. It was in this way that increasing welfare state sources of future bank instability became apparent. In Britain at least, attempts to juggle conflicting short-term and long-term policy priorities have resulted in the displacement of the most obvious manifestations of welfare state fiscal crisis into other areas of the public finances

Keeping up or Falling behind ? The Impact of Benefit and Tax Uprating on Incomes and Poverty

Each year, the government decides how much to raise benefits and tax allowances. In the UK, the basis for these upratings is rarely debated, yet has major long-term consequences for the relative living standards of different groups as well as for the public finances. This paper considers the medium-term implications of present uprating policies, which vary across parameters of the tax-benefit system. Continuing these policies for 20 years, other things staying the same, would result in a near doubling of the child poverty rate alongside a substantial gain to the public finances. At the same time, pensioners are largely protected by the earnings indexation of pensioner benefits including, in time, the basic state pension. We show how difficult it will be to meet the UK child poverty targets unless the greater inequality inherent in the current regime for uprating payments and allowances is redressed