FEDERAL PARLIAMENTARY COMMITTEE HEARINGS ON BILL C-71, THE TOBACCO ACT: EXAMINING WRITTEN AND ORAL STATEMENTS OF TOBACCO INDUSTRY STAKEHOLDERS

Introduction. This case study examined the tobacco industry as a stakeholder during the parliamentary hearings on a 1997 keystone piece of Canadian tobacco legislation—Bill C-71, the Tobacco Act—regulating the sale, manufacture, sponsorship and promotion of tobacco products. A significant amount of public participation was present in the hearings, in which the tobacco industry stakeholders (e.g., growers, manufacturers, distributors and retailers, allied manufacturing industries, and sponsored sport and cultural events organizers) provided more than half of all written and oral submissions to government. Background. The government introduced Bill C-71 after the 1995 Supreme Court of Canada sided with the tobacco industry in a decision to strike down the standing tobacco control legislation. Purpose. This study undertook the examination of the explicit and implicit meanings of statements within tobacco industry submissions to the Canadian government in order to understand how the tobacco industry attempted to influence tobacco control legislation during the policy development of Bill C-71. The research questions asked: 1) How were issues related to smoking and tobacco discussed in the texts?; and 2) What discursive tactics were used by the tobacco industry stakeholders to justify their positions? Methods. 77 tobacco industry oral and written submissions to the House of Commons Standing Committee on Health and the Senate Standing Committee on Legal and Constitutional Affairs were analysed using interpretive discourse analysis. The first level of analysis used a tool that drew on Potter & Wetherell (1994) and Rudman (2003). Foci were placed on how tactics were used within the texts to create roles, shape and forefront m particular identities, arguments against opposition, problems and solutions. The second level of analysis drew on the first level to examine the discursive tactics employed by tobacco industry stakeholders. The approach to analysis and interpretation o f discursive tactics involved detailed reading of texts as well as linking texts with broader contextual features, particularly sociopolitical and economic contextual factors (e.g., neoliberal economic policies, illegal market surge, judicial strike down of past legislation, and national cultural divide between Anglophone and Francophone populations). Findings. Six categories of discursive tactics were constructed through interaction with texts: 1) presentation of self (e.g., community-involved victim); 2) undermining government efforts (e.g., harm-causing, counter Canadian tradition, totalitarian); 3) tactical use of evidence (manipulation of counter evidence, presenting misleading studies); 4) use of intentional discourse types (legal, constitution and democracy-based); 5) evasion of health discourse (e.g., superficial support for health objectives, denying links to tobacco industry); and 6) increasing economic discourse (framing self as entrepreneur, consumer and market-based solutions). Conclusions. In this case study, many tactics were used to frame smoking and tobacco, and problems and solutions in ways aligned with neoliberal ideology or rationality, focusing on individual responsibility, freedom in the market place, entrepreneurship and minimizing a government role. Appeals to “reason”, “justice”, and “democracy” were made by all tobacco industry stakeholders to liken Bill C-71 to its predecessor and undermine government’s overall health objectives and specific regulations. Tobacco industry stakeholders portrayed government as the root of the problem of tobacco consumption and negative economic situation, thereby deflecting responsibility from IV themselves and evading health issues. Interestingly, many of these same arguments have been cited in literature since the early 1980s, suggesting that tactics are re-used and specific argument content is shaped by the context. Findings may assist health promoters identify and prepare for future opposition from the tobacco industry

Helping older people to use quality information to choose residential care

Context: The availability of data about the quality of care homes has increased in England since the late 1990s, as in other countries, but it is widely underused by people choosing providers. Objectives: To examine older people’s understandings of a high-quality care home, their preferences for quality indicators, and how they would use comparative quality information about care homes to select one for themselves or a relative. Method: Five group workshops were conducted with 27 older people with experience of social care services and relatives of care home residents in three local authority areas in England. Different methods were used to collect data: an open discussion, a card sorting exercise, and use of a scorecard to compare fictitious homes. Findings: The most popular indicators among participants in the workshops were linked to residents’ quality of life. Indicators we may think of as being about clinical issues were valued the least. The value of some indicators was more widely recognised after discussion highlighted their relevance to choosing a care home for someone. Comparing quality information was said to be useful to shortlist homes to visit and inform visits, and many strategies were used to manage the data to select a home. Concerns were raised about the trustworthiness of some data and sources. Limitations: The nature and scale of the work mean we cannot claim it to be a representative sample and this limits the generalisability of the findings. The findings are, nevertheless, illuminating in terms of factors to consider when making available information to assist in choosing a care home. Recruitment challenges for the workshops and the implications of the difficulties participants had managing the data are discussed. Implications: Quality indicators are likely to be ineffective at promoting comparison across care homes unless older people are supported to understand their significance. Policymakers and providers of quality indicators need to beware of user preferences, build in decision-making support, find ways to better communicate complex measures and encourage people to identify their own views before reviewing published indicators. Methodological implications for further work in this area are also considered

‘How does your health system work?’: a workshop at the WONCA Europe Conference 2012….

Last week around 2000 general practitioners (GPs) met in Vienna to discuss the theme of The Art and Science of General Practice at the annual WONCA Europe Conference (4-7 July). Yet one of the most conversation-starting topics on the agenda could be argued was neither directly art, nor purely clinical science. Over 200 GPs from around the world participated in a workshop on health systems financing, and were intrigued to learn more about the methods used to collect, pool and spend funds in health systems. The audience ranged from medical students to senior members of the profession, and highlighted broad differences in the levels of understanding of how health systems function. Some questioned why it was the first time in their careers that they had been given the opportunity to get an overview of the theory behind the core principles of health systems financing

Insights from parents of a child with leukaemia and healthcare professionals about sharing illness and treatment information: A qualitative research study

Background Many parents report a strong desire to take on information-giving roles, and believe they are best positioned to discuss their child’s illness with their child. Healthcare professionals have a supporting role to reduce the burden on parents who feel responsible for conveying information to their child and other family members. Objective To examine parents’ and healthcare professionals’ perceptions of roles in receiving and communicating information when a child is diagnosed with and treated for acute lymphoblastic leukaemia. Design, setting and participants We used the principles of a grounded theory approach. This was a single site study, recruiting from a principal children’s cancer treatment centre in the United Kingdom. The sample included parents of children receiving and completed treatment for acute lymphoblastic leukaemia (n = 28), and healthcare professionals (n = 34). Methods Methods included individual interviews, face-to-face and telephone, focus groups, and an online forum. Findings Communication ‘touch points’ are many over the course of a child’s cancer journey. We describe often ‘mismatched’ communication encounters where those seeking information and those providing information have different goals. Healthcare professionals in the encounter have expertise at the outset while parents have less expertise, but this expertise grows over time and this can increase the perceptions of this ‘mismatch’ and create different challenges. Conclusions Considered in the context of middle range transition theory, we might suggest that parental foreground (seeking information directly) and background (passive actors) roles are the result of differing levels of uncertainty, and depend on the situation and preferences and child and family needs that may present differently over time in different contexts. Our work contributes to the emerging consensus that communication is more than a core set of skills that healthcare professionals just need to learn: clear specifications of mutual roles, responsibilities and a shared understanding of goals is also essential

Workplace-based knowledge exchange programmes between academics, policy-makers and providers of healthcare:a qualitative study

BACKGROUND: Workplace-based knowledge exchange programmes (WKEPs), such as job shadowing or secondments, offer potential for health and care providers, academics, and policy-makers to foster partnerships, develop local solutions and overcome key differences in practices. Yet opportunities for exchange can be hard to find and are poorly reported in the literature. OBJECTIVES: To understand the views of providers, academics and policy-makers regarding WKEPs, in particular, their motivations to participate in such exchanges and the perceived barriers and facilitators to participation. METHODS: A qualitative study involving semistructured interviews with 20 healthcare providers, academics and policy-makers in England. Rapid data collection and analysis techniques were employed. Interviews formed part of a wider scoping study that mapped the characteristics and existing literature related to WKEPs. RESULTS: Interviewees reported being motivated to develop, sponsor and/or participate in WKEPs with a clear purpose and defined outcomes that could demonstrate the value of the time out of work to their organisations. Perceived barriers included competitive application processes for national fellowships, a lack of knowing how to identify with whom to undertake an exchange (varying 'tribes'), and the burdens of time, costs and administration regarding arranging exchanges. WKEPs were reported to work best where there was a perceived sense of shared purpose, long-standing relationship and trust between organisations. Facilitators included existing confidentiality agreements and/or shared professional standards, as well as funding. CONCLUSION: WKEPs were reported to be valuable experiences but required significant organisational buy-in and cooperation to arrange and sustain. To benefit emerging partnerships, such as the new integrated care systems in England, more outcomes evaluations of existing WKEPs are needed, and research focused on overcoming barriers to participation, such as time and costs

Studying children's experiences in interactions with clinicians: identifying methods fit for purpose

Increased emphasis on the child’s voice and point of view in care and treatment has led to an expansion in the development of methods to access and identify their perspectives. Drawing on our experiences in a study of children with leukemia in hospital, this article explains the challenges and opportunities that arise in the use of five commonly used methods in a study of hospitalized children’s experiences with health care professionals, including the “Draw and Write” technique, a sticker activity, a paper–person exercise, informal interviews, and participant observation. Each of these methods was examined with regard to ease of use, data generation, and utility of data for accessing children’s perspectives and development of initial clinical guidance

Decision-making criteria among European patients: exploring patient preferences for primary care services

Background: Health economics preference-based techniques, such as discrete choice experiments (DCEs), are often used to inform public health policy on patients’ priorities when choosing health care. Although there is general evidence about patients’ satisfaction with general-practice (GP) care in Europe, to our knowledge no comparisons are available that measure patients’ preferences in different European countries, and use patients’ priorities to propose policy changes. Methods: A DCE was designed and used to capture patients’ preferences for GP care in Germany, England and Slovenia. In the three countries, 841 eligible patients were identified across nine GP practices. The DCE questions compared multiple health-care practices (including their ‘current GP practice’), described by the following attributes: ‘information’ received from the GP, ‘booking time’, ‘waiting time’ in the GP practice, ‘listened to’, as well as being able to receive the ‘best care’ available for their condition. Results were compared across countries looking at the attributes’ importance and rankings, patients’ willingness-to-wait for unit changes to the attributes’ levels and changes in policy. Results: A total of 692 respondents (75% response rate) returned questionnaires suitable for analysis. In England and Slovenia, patients were satisfied with their ‘current practice’, but they valued changes to alternative practices. All attributes influenced decision-making, and ‘best care’ or ‘information’ were more valued than others. In Germany, almost all respondents constantly preferred their ‘current practice’, and other factors did not change their preference. Conclusion: European patients have strong preference for their ‘status quo’, but alternative GP practices could compensate for it and offer more valued care

The impact of new forms of large-scale general practice provider collaborations on England's NHS: a systematic review.

BACKGROUND: Over the past decade, collaboration between general practices in England to form new provider networks and large-scale organisations has been driven largely by grassroots action among GPs. However, it is now being increasingly advocated for by national policymakers. Expectations of what scaling up general practice in England will achieve are significant. AIM: To review the evidence of the impact of new forms of large-scale general practice provider collaborations in England. DESIGN AND SETTING: Systematic review. METHOD: Embase, MEDLINE, Health Management Information Consortium, and Social Sciences Citation Index were searched for studies reporting the impact on clinical processes and outcomes, patient experience, workforce satisfaction, or costs of new forms of provider collaborations between general practices in England. RESULTS: A total of 1782 publications were screened. Five studies met the inclusion criteria and four examined the same general practice networks, limiting generalisability. Substantial financial investment was required to establish the networks and the associated interventions that were targeted at four clinical areas. Quality improvements were achieved through standardised processes, incentives at network level, information technology-enabled performance dashboards, and local network management. The fifth study of a large-scale multisite general practice organisation showed that it may be better placed to implement safety and quality processes than conventional practices. However, unintended consequences may arise, such as perceptions of disenfranchisement among staff and reductions in continuity of care. CONCLUSION: Good-quality evidence of the impacts of scaling up general practice provider organisations in England is scarce. As more general practice collaborations emerge, evaluation of their impacts will be important to understand which work, in which settings, how, and why

Workplace-based knowledge exchange programmes between academics, policy-makers and providers of healthcare: a qualitative study.

BACKGROUND: Workplace-based knowledge exchange programmes (WKEPs), such as job shadowing or secondments, offer potential for health and care providers, academics, and policy-makers to foster partnerships, develop local solutions and overcome key differences in practices. Yet opportunities for exchange can be hard to find and are poorly reported in the literature. OBJECTIVES: To understand the views of providers, academics and policy-makers regarding WKEPs, in particular, their motivations to participate in such exchanges and the perceived barriers and facilitators to participation. METHODS: A qualitative study involving semistructured interviews with 20 healthcare providers, academics and policy-makers in England. Rapid data collection and analysis techniques were employed. Interviews formed part of a wider scoping study that mapped the characteristics and existing literature related to WKEPs. RESULTS: Interviewees reported being motivated to develop, sponsor and/or participate in WKEPs with a clear purpose and defined outcomes that could demonstrate the value of the time out of work to their organisations. Perceived barriers included competitive application processes for national fellowships, a lack of knowing how to identify with whom to undertake an exchange (varying 'tribes'), and the burdens of time, costs and administration regarding arranging exchanges. WKEPs were reported to work best where there was a perceived sense of shared purpose, long-standing relationship and trust between organisations. Facilitators included existing confidentiality agreements and/or shared professional standards, as well as funding. CONCLUSION: WKEPs were reported to be valuable experiences but required significant organisational buy-in and cooperation to arrange and sustain. To benefit emerging partnerships, such as the new integrated care systems in England, more outcomes evaluations of existing WKEPs are needed, and research focused on overcoming barriers to participation, such as time and costs