Health, welfare, and the state — the dangers of forgetting history

Recent public policy in the UK has been dominated by a discourse which asserts that public expenditure on universal health coverage and welfare is a burden on the productive economy and unaffordable in what has been deemed a time of austerity. There is a widely held assumption that universal welfare provision, as offered by most modern welfare states, is a luxury, only afforded since World War 2 by wealthier economies. According to this view, if the productive efficiency of the economy falters, then this luxury should be trimmed back aggressively. Reduction in universal welfare will relieve enterprise, capital, and so-called hard-working families from the burdens of taxation required to fund these unproductive public services and (by implication) those unproductive families—the poor. We argue from history that there should be an end to setting the goal of economic growth against that of welfare provision. A healthy and prospering society needs both. We suggest that they feed each other.The paper arose from discussions in the St John’s College Reading Group on Health Inequalities in Cambridge (http://www.joh.cam.ac.uk/st-john’s-reading-group-health-inequalities), which was supported by the Annual Fund of the College

Effect on cardiovascular disease risk factors of interventions to alter consultations between practitioners and patients with type 2 diabetes: A systematic review and meta-analysis of trials in primary care

$\textbf{Objective:}$ To examine the effect on cardiovascular (CVD) risk factors of interventions to alter consultations between practitioners and patients with type 2 diabetes. $\textbf{Search Strategy:}$ Electronic and manual citation searching to identify relevant randomized controlled trials (RCTs). $\textbf{Inclusion Criteria:}$ RCTs that compared usual care to interventions to alter consultations between practitioners and patients. The population was adults aged over 18 years with type 2 diabetes. Trials were set in primary care. $\textbf{Data extraction and synthesis:}$ We recorded if explicit theory-based interventions were used, how consultations were measured to determine whether interventions had an effect on these and calculated weighted mean differences for CVD risk factors including glycated haemoglobin (HbA$_{1c}$), systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol (TC), LDL cholesterol (LDL-C) and HDL cholesterol (HDL-C). $\textbf{Results:}$ We included seven RCTs with a total of 2277 patients with type 2 diabetes. A range of measures of the consultation was reported, and underlying theory to explain intervention processes was generally undeveloped and poorly applied. There were no overall effects on CVD risk factors; however, trials were heterogeneous. Subgroup analysis suggested some benefit among studies in which interventions demonstrated impact on consultations; statistically significant reductions in HbA$_{1c}$ levels (weighted mean difference, −0.53%; 95% CI: [−0.77, −0.28]; $P$<.0001; $I^{2}$ =46%). $\textbf{Conclusions:}$ Evidence of effect on CVD risk factors from interventions to alter consultations between practitioners and patients with type 2 diabetes was heterogeneous and inconclusive. This could be explained by variable impact of interventions on consultations. More research is required that includes robust measures of the consultations and better development of theory to elucidate mechanisms.HDM was an Academic Clinical Fellow, Andrew Cooper is funded by the University of Cambridge MRC Epidemiology Unit (grant code: MC_UU_12015/4), SJG is an NIHR Senior Investigator. The primary care unit is a member of the National Institute for Health Research (NIHR) School for Primary Care Research and supported by NIHR Research funds. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health

Costs and cost effectiveness of cardiovascular screening and intervention: The British family heart study

This article has been made available through the Brunel Open Access Publishing Fund and is available from the specified link - Copyright @ 1996 BMJ Publishing Group.Objective-To measure costs and cost effectiveness of the British family heart study cardiovascular screening and intervention programme.Design-Cost effectiveness analysis of randomised controlled trial. Clinical and resource use data taken from trial and unit cost data from external estimates.Setting-13 general practices across Britain.Subjects-4185 men aged 40-59 and their 2827 partners.Intervention-Nurse led programme using a family centred approach, with follow up according to degree of risk.Main outcome measures-Cost of the programme itself; overall short term cost to NHS; cost per 1% reduction in coronary risk at one year.Results-Estimated cost of putting the programme into practice for one year was pound 63 per person (95% confidence interval pound 60 to pound 65). The overall short term cost to the health service was pound 77 per man (pound 29 to pound 124) but only pound 13 per woman (-pound 48 to pound 74), owing to differences in utilisation of other health service resources. The cost per 1% reduction in risk was pound 5.08 per man (pound 5.92 including broader health service costs) and pound 5.78 per woman (pound 1.28 taking into account wider health service savings).Conclusions-The direct cost of the programme to a four partner practice of 7500 patients would be approximately pound 58 000. Annually, pound 8300 would currently be paid to a practice of this size working to the ma target on the health promotion bands, plus any additional reimbursement of practice staff salaries for which the practice qualified. The broader short term costs to the NHS may augment these costs for men but offset them considerably for women

Moving beyond individual choice in policies to reduce health inequalities: the integration of dynamic with individual explanations.

BACKGROUND: A strong focus on individual choice and behaviour informs interventions designed to reduce health inequalities in the UK. We review evidence for wider mechanisms from a range of disciplines, demonstrate that they are not yet impacting on programmes, and argue for their systematic inclusion in policy and research. METHODS: We identified potential mechanisms relevant to health inequalities and their amelioration from different disciplines and analysed six policy documents published between 1976 and 2010 using Bacchi's 'What's the problem represented to be?' framework for policy analysis. RESULTS: We found substantial evidence of supra-individualistic and relational mechanisms relevant to health inequalities from sociology, history, biology, neuroscience, philosophy and psychology. Policy documents sometimes expressed these mechanisms in policy rhetoric but rarely in policy recommendations, which continue to focus on individual behaviour. DISCUSSION: Current evidence points to the potential of systematically applying broader thinking about causal mechanisms, beyond individual choice and responsibility, to the design, implementation and evaluation of policies to reduce health inequalities. We provide a set of questions designed to enable critique of policy discussions and programmes to ensure that these wider mechanisms are considered

Perceptions of self-rated health among stroke survivors: a qualitative study in the United Kingdom.

BACKGROUND: Self-rated health predicts health outcomes independently of levels of disability or mood. Little is known about what influences the subjective health experience of stroke survivors. Our aim was to investigate stroke survivors' perceptions of self-rated health, with the intention of informing the design of interventions that may improve their subjective health experience. METHODS: We conducted semi-structured interviews with a purposive sample of 28 stroke survivors recruited from a stroke unit and follow-up outpatient clinic, 4-6 months after stroke, to explore what factors are perceived to be part of self-rated health in the early stages of recovery. Qualitative data were analysed using a thematic analysis approach to identify underlying themes. RESULTS: Participants' accounts show that stroke survivors' perceptions of self-rated health are multifactorial, comprising physical, psychological and social components. Views on future recovery after stroke play a role in present health experience and are shaped by psychosocial resources that are influenced by past experiences of ill-health, dispositional outlook such as degree of optimism, a sense of control and views on ageing. CONCLUSIONS: Severity of physical limitations alone does not influence perceptions of self-rated health among stroke survivors. Self-rated health in stroke survivors is a multidimensional construct shaped by changes in health status occurring after the stroke, individual characteristics and social context. Understanding the factors stroke survivors themselves associate with better health will inform the development of effective approaches to improve rehabilitation and recovery after stroke.Nahal Mavaddat was supported by a Walport Clinical Lectureship in Primary Care Research from the University of Cambridge/National Institute of Health Research. Elizabeth Warburton was supported by the Biomedical Research Grant (NIHR BRC) to Cambridge. Euan Sadler and Christopher McKevitt acknowledge the support of the National Institute for Health Research (NIHR) Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London and the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London. Jenni Burt is funded by the National Institute of Health Research School for Primary Care Research

Impact of a physical activity intervention program on cognitive predictors of behaviour among adults at risk of Type 2 diabetes (ProActive randomised controlled trial)

Background: In the ProActive Trial an intensive theory-based intervention program was no more effective than theory-based brief advice in increasing objectively measured physical activity among adults at risk of Type 2 diabetes. We aimed to illuminate these findings by assessing whether the intervention program changed cognitions about increasing activity, defined by the Theory of Planned Behaviour, in ways consistent with the theory. Methods: N = 365 sedentary participants aged 30-50 years with a parental history of Type 2 diabetes were randomised to brief advice alone or to brief advice plus the intervention program delivered face-to-face or by telephone. Questionnaires at baseline, 6 and 12 months assessed cognitions about becoming more physically active. Analysis of covariance was used to test intervention impact. Bootstrapping was used to test multiple mediation of intervention impact. Results: At 6 months, combined intervention groups (face-to-face and telephone) reported that they found increasing activity more enjoyable (affective attitude, d = .25), and they perceived more instrumental benefits (e.g., improving health) (d = .23) and more control (d = .32) over increasing activity than participants receiving brief advice alone. Stronger intentions (d = .50) in the intervention groups than the brief advice group at 6 months were partially explained by affective attitude and perceived control. At 12 months, intervention groups perceived more positive instrumental (d = .21) and affective benefits (d = .29) than brief advice participants. The intervention did not change perceived social pressure to increase activity. Conclusion: Lack of effect of the intervention program on physical activity over and above brief advice was consistent with limited and mostly small short-term effects on cognitions. Targeting affective benefits (e.g., enjoyment, social interaction) and addressing barriers to physical activity may strengthen intentions, but stronger intentions did not result in more behaviour change. More powerful interventions which induce large changes in TPB cognitions may be needed. Other interventions deserving further evaluation include theory-based brief advice, intensive measurement of physical and psychological factors, and monitoring of physical activity. Future research should consider a wider range of mediators of physical activity change, assess participants' use of self-regulatory strategies taught in the intervention, and conduct experimental studies or statistical modelling prior to trial evaluation. © 2009 Hardeman et al; licensee BioMed Central Ltd

The feasibility of using pedometers and brief advice to increase activity in sedentary older women:a pilot study

Background: People over the age of 70 carry the greatest burden of chronic disease, disability and health care use. Participation in physical activity is crucial for health, and walking accounts for much of the physical activity undertaken by sedentary individuals. Pedometers are a useful motivational tool to encourage increased walking and they are cheap and easy to use. The aim of this pilot study was to evaluate the feasibility of the use of pedometers plus a theory-based intervention to assist sedentary older women to accumulate increasing amounts of physical activity, mainly through walking. Methods: Female participants over the age of 70 were recruited from primary care and randomised to receive either pedometer plus a theory-based intervention or a theory-based intervention alone. The theory-based intervention consisted of motivational techniques, goal-setting, barrier identification and self-monitoring with pedometers and daily diaries. The pedometer group were further randomised to one of three target groups: a 10%, 15% or 20% monthly increase in step count to assess the achievability and acceptability of a range of targets. The primary outcome was change in daily activity levels measured by accelerometry. Secondary outcome measures were lower limb function, health related quality of life, anxiety and depression. Results: 54 participants were recruited into the study, with an average age of 76. There were 9 drop outs, 45 completing the study. All participants in the pedometer group found the pedometers easy to use and there was good compliance with diary keeping (96% in the pedometer group and 83% in the theory-based intervention alone group). There was a strong correlation (0.78) between accelerometry and pedometer step counts i.e. indicating that walking was the main physical activity amongst participants. There was a greater increase in activity (accelerometry) amongst those in the 20% target pedometer group compared to the other groups, although not reaching statistical significance (p = 0.192). Conclusion: We have demonstrated that it is feasible to use pedometers and provide theory-based advice to community dwelling sedentary older women to increase physical activity levels and a larger study is planned to investigate this further.Publisher PDFPeer reviewe

Identifying future models for delivering genetic services: a nominal group study in primary care

BACKGROUND: To enable primary care medical practitioners to generate a range of possible service delivery models for genetic counselling services and critically assess their suitability. METHODS: Modified nominal group technique using in primary care professional development workshops. RESULTS: 37 general practitioners in Wales, United Kingdom too part in the nominal group process. The practitioners who attended did not believe current systems were sufficient to meet anticipated demand for genetic services. A wide range of different service models was proposed, although no single option emerged as a clear preference. No argument was put forward for genetic assessment and counselling being central to family practice, neither was there a voice for the view that the family doctor should become skilled at advising patients about predictive genetic testing and be able to counsel patients about the wider implications of genetic testing for patients and their family members, even for areas such as common cancers. Nevertheless, all the preferred models put a high priority on providing the service in the community, and often co-located in primary care, by clinicians who had developed expertise. CONCLUSION: There is a need for a wider debate about how healthcare systems address individual concerns about genetic concerns and risk, especially given the increasing commercial marketing of genetic tests

Does self monitoring of blood glucose as opposed to urinalysis provide additional benefit in patients newly diagnosed with type 2 diabetes receiving structured education? The DESMOND SMBG randomised controlled trial protocol

BackgroundThe benefit of self-monitoring of blood glucose (SMBG) in people with type 2 diabetes on diet or oral agents other than sulphonylureas remains uncertain. Trials of interventions incorporating education about self-monitoring of blood glucose have reported mixed results. A recent systematic review concluded that SMBG was not cost-effective. However, what was unclear was whether a cheaper method of self-monitoring (such as urine glucose monitoring) could produce comparable benefit and patient acceptability for less cost.Methods/DesignThe DESMOND SMBG trial is comparing two monitoring strategies (blood glucose monitoring and urine testing) over 18 months when incorporated into a comprehensive self-management structured education programme. It is a multi-site cluster randomised controlled trial, conducted across 8 sites (7 primary care trusts) in England, UK involving individuals with newly diagnosed Type 2 diabetes.The trial has 80% power to demonstrate equivalence in mean HbA1c (the primary end-point) at 18 months of within &plusmn; 0.5% assuming 20% drop out and 20% non-consent. Secondary end-points include blood pressure, lipids, body weight and psychosocial measures as well as a qualitative sub-study.Practices were randomised to one of two arms: participants attend a DESMOND programme incorporating a module on self-monitoring of either urine or blood glucose. The programme is delivered by accredited educators who received specific training about equipoise. Biomedical data are collected and psychosocial scales completed at baseline, and 6, 12, and 18 months post programme. Qualitative research with participants and educators will explore views and experiences of the trial and preferences for methods of monitoring.DiscussionThe DESMOND SMBG trial is designed to provide evidence to inform the debate about the value of self-monitoring of blood glucose in people with newly diagnosed type 2 diabetes. Strengths include a setting in primary care, a cluster design, a health economic analysis, a comparison of different methods of monitoring while controlling for other components of training within the context of a quality assured structured education programme and a qualitative sub-study

Wake up, wake up! It's me! It's my life! patient narratives on person-centeredness in the integrated care context: a qualitative study

Person-centered care emphasizes a holistic, humanistic approach that puts patients first, at the center of medical care. Person-centeredness is also considered a core element of integrated care. Yet typologies of integrated care mainly describe how patients fit within integrated services, rather than how services fit into the patient's world. Patient-centeredness has been commonly defined through physician's behaviors aimed at delivering patient-centered care. Yet, it is unclear how 'person-centeredness' is realized in integrated care through the patient voice. We aimed to explore patient narratives of person-centeredness in the integrated care context