Synthesising and utilising complex evidence to inform policy in education and health.

Oslo, Norway, May 19 to 21, 200

Evidence-based health policymaking in Iraqi Kurdistan: Facilitators and barriers from the perspectives of policymakers and advisors

Background and objective: Evidence from research is underutilized in policy and practice in the majority of developing countries including Iraq. This aim of this study was to assess the role of research in health policy making in Iraqi Kurdistan context and identify the main barriers and facilitators for enhancing such role. Methods: This cross-sectional survey was carried out between November 2013 and March 2014 in the three governorates of the Iraqi Kurdistan Region, Erbil, Duhok and Sulaimaniyah. The study participants included 10 key health informants and three health advisors. Two types of combined questionnaires for health policy makers and health advisors were used for data collection. Results: Conferences and seminars were the main sources of scientific evidences identified by health policymakers (80%), followed by consultants (70%). Different jargons/discourse was the main obstacle in consulting researchers (90%), followed by lack of tradition in collaborating (70%). Collection of specialists/advisors, followed by professional associations, scientific committees and international organizations/UN agencies were the main groups identified by health advisors to build bridges between the scientific community and policymakers. Conclusion: Policymakers very rarely consult researchers directly in their decision making. There is poor networking among researchers, policy-makers, practitioners and representatives from civil society which has its negative impact on evidence-based policymaking. There is obviously a lack of any sort of program of funded research that can inform policymaking

From Programme Theory to Logic Models for Multispecialty Community Providers: A Realist Evidence Synthesis

Background: The NHS policy of constructing multispecialty community providers (MCPs) rests on a complex set of assumptions about how health systems can replace hospital use with enhanced primary care for people with complex, chronic or multiple health problems, while contributing savings to health-care budgets. Objectives: To use policy-makers’ assumptions to elicit an initial programme theory (IPT) of how MCPs can achieve their outcomes and to compare this with published secondary evidence and revise the programme theory accordingly. Design: Realist synthesis with a three-stage method: (1) for policy documents, elicit the IPT underlying the MCP policy, (2) review and synthesise secondary evidence relevant to those assumptions and (3) compare the programme theory with the secondary evidence and, when necessary, reformulate the programme theory in a more evidence-based way. Data sources: Systematic searches and data extraction using (1) the Health Management Information Consortium (HMIC) database for policy statements and (2) topically appropriate databases, including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Applied Social Sciences Index and Abstracts (ASSIA). A total of 1319 titles and abstracts were reviewed in two rounds and 116 were selected for full-text data extraction. We extracted data using a formal data extraction tool and synthesised them using a framework reflecting the main policy assumptions. Results: The IPT of MCPs contained 28 interconnected context–mechanism–outcome relationships. Few policy statements specified what contexts the policy mechanisms required. We found strong evidence supporting the IPT assumptions concerning organisational culture, interorganisational network management, multidisciplinary teams (MDTs), the uses and effects of health information technology (HIT) in MCP-like settings, planned referral networks, care planning for individual patients and the diversion of patients from inpatient to primary care. The evidence was weaker, or mixed (supporting some of the constituent assumptions but not others), concerning voluntary sector involvement, the effects of preventative care on hospital admissions and patient experience, planned referral networks and demand management systems. The evidence about the effects of referral reductions on costs was equivocal. We found no studies confirming that the development of preventative care would reduce demands on inpatient services. The IPT had overlooked certain mechanisms relevant to MCPs, mostly concerning MDTs and the uses of HITs. Limitations: The studies reviewed were limited to Organisation for Economic Co-operation and Development countries and, because of the large amount of published material, the period 2014–16, assuming that later studies, especially systematic reviews, already include important earlier findings. No empirical studies of MCPs yet existed. Conclusions: Multidisciplinary teams are a central mechanism by which MCPs (and equivalent networks and organisations) work, provided that the teams include the relevant professions (hence, organisations) and, for care planning, individual patients. Further primary research would be required to test elements of the revised logic model, in particular about (1) how MDTs and enhanced general practice compare and interact, or can be combined, in managing referral networks and (2) under what circumstances diverting patients from in-patient to primary care reduces NHS costs and improves the quality of patient experience

The practice of commissioning healthcare from a private provider: learning from an in-depth case study

Background: The direction of health service policy in England is for more diversification in the design, commissioning and provision of health care services. The case study which is the subject of this paper was selected specifically because of the partnering with a private sector organisation to manage whole system redesign of primary care and to support the commissioning of services for people with long term conditions at risk of unplanned hospital admissions and associated service provision activities. The case study forms part of a larger Department of Health funded project on the practice of commissioning which aims to find the best means of achieving a balance between monitoring and control on the one hand, and flexibility and innovation on the other, and to find out what modes of commissioning are most effective in different circumstances and for different services. Methods: A single case study method was adopted to explore multiple perspectives of the complexities and uniqueness of a public-private partnership referred to as the “Livewell project”. 10 single depth interviews were carried out with key informants across the GP practices, the PCT and the private provider involved in the initiative. Results: The main themes arising from single depth interviews with the case study participants include a particular understanding about the concept of commissioning in the context of primary care, ambitions for primary care redesign, the importance of key roles and strong relationships, issues around the adoption and spread of innovation, and the impact of the current changes to commissioning arrangements. The findings identified a close and high trust relationship between GPs (the commissioners) and the private commissioning support and provider firm. The antecedents to the contract for the project being signed indicated the importance of leveraging external contacts and influence (resource dependency theory). Conclusions: The study has surfaced issues around innovation adoption in the healthcare context. The case identifies ‘negotiated order’, managerial performance of providers and disciplinary control as three media of power used in combination by commissioners. The case lends support for stewardship and resource dependency governance theories as explanations of the underpinning conditions for effective commissioning in certain circumstances within a quasi marketised healthcare system

NHS commissioning practice and health system governance: a mixed-methods realistic evaluation

Background By 2010 English health policy-makers had concluded that the main NHS commissioners [primary care trusts (PCTs)] did not sufficiently control provider costs and performance. After the 2010 general election, they decided to replace PCTs with general practitioner (GP)-controlled Clinical Commissioning Groups (CCGs). Health-care commissioners have six main media of power for exercising control over providers, which can be used in different combinations (‘modes of commissioning’). Objectives To: elicit the programme theory of NHS commissioning policy and empirically test its assumptions; explain what shaped NHS commissioning structures; examine how far current commissioning practice allowed commissioners to exercise governance over providers; examine how commissioning practices differ in different types of commissioning organisation and for specific care groups; and explain what factors influenced commissioning practice and the relationships between commissioners and providers. Design Mixed-methods realistic evaluation, comprising: Leximancer and cognitive frame analyses of policy statements to elicit the programme theory of NHS commissioning policy; exploratory cross-sectional analysis of publicly available managerial data about PCTs; systematic comparison of case studies of commissioning in four English sites – including commissioning for older people at risk of unplanned hospital admission; mental health; public health; and planned orthopaedic surgery – and of English NHS commissioning practice with that of a German sick-fund and an Italian region (Lombardy); action learning sets, to validate the findings and draw out practical implications; and two framework analyses synthesising the findings and testing the programme theory empirically. Results In the four English case study sites, CCGs were formed by recycling former commissioning structures, relying on and maintaining the existing GP commissioning leaderships. The stability of distributed commissioning depended on the convergence of commissioners’ interests. Joint NHS and local government commissioning was more co-ordinated at strategic than operational level. NHS providers’ responsiveness to commissioners reflected how far their interests converged, but also providers’ own internal ability to implement agreements. Commissioning for mental health services and to prevent recurrent unplanned hospital readmissions relied more on local ‘micro-commissioning’ (collaborative care pathway design) than on competition. Service commissioning was irrelevant to intersectoral health promotion, but not clinical prevention work. On balance, the possibility of competition did not affect service outcomes in the ways that English NHS commissioning policies assumed. ‘Commodified’ planned orthopaedic surgery most lent itself to provider competition. In all three countries, tariff payments increased provider activity and commissioners’ costs. To contain costs, commissioners bundled tariff payments into blocks, agreed prospective case loads with providers and paid below-tariff rates for additional cases. Managerial performance, negotiated order and discursive control were the predominant media of power used by English, German and Italian commissioners. Conclusions Commissioning practice worked in certain respects differently from what NHS commissioning policy assumed. It was often laborious and uncertain. In the four English case study sites financial and ‘real-side’ contract negotiations were partly decoupled, clinician involvement being least on the financial side. Tariff systems weakened commissioners’ capacity to choose providers and control costs. Commissioners adapted the systems to solve this problem. Our findings suggest a need for further research into whether or not differently owned providers (corporate, third sector, public, professional partnership, etc.) respond differently to health-care commissioners and, if so, what specific implications for commissioning practice follow. They also suggest that further work is needed to assess how commissioning practices impact on health system integration when care pathways have to be constructed across multiple providers that must tender competitively for work, perhaps against each other. Funding The National Institute for Health Research Health Services and Delivery Research programme

Atomic mass dependence of \Xi^- and \overline{\Xi}^+ production in central 250 GeV \pi^- nucleon interactions

We present the first measurement of the atomic mass dependence of central \Xi^- and \overline{\Xi}^+ production. It is measured using a sample of 22,459 \Xi^-'s and \overline{\Xi}^+'s produced in collisions between a 250 GeV \pi^- beam and targets of beryllium, aluminum, copper, and tungsten. The relative cross sections are fit to the two parameter function \sigma_0 A^\alpha, where A is the atomic mass. We measure \alpha = 0.924+-0.020+-0.025, for Feynman-x in the range -0.09 < x_F < 0.15.Comment: 10 pages, revtex, 2 figures, submitted to Phys. Rev.

The ethics of uncertainty for data subjects

Modern health data practices come with many practical uncertainties. In this paper, I argue that data subjects’ trust in the institutions and organizations that control their data, and their ability to know their own moral obligations in relation to their data, are undermined by significant uncertainties regarding the what, how, and who of mass data collection and analysis. I conclude by considering how proposals for managing situations of high uncertainty might be applied to this problem. These emphasize increasing organizational flexibility, knowledge, and capacity, and reducing hazard

Search for CP Violation in the decays D+ -> K_S pi+ and D+ -> K_S K+

A high statistics sample of photo-produced charm from the FOCUS(E831) experiment at Fermilab has been used to search for direct CP violation in the decays D+->K_S pi+ and D+ -> K_S K+. We have measured the following asymmetry parameters relative to D+->K-pi+pi+: A_CP(K_S pi+) = (-1.6 +/- 1.5 +/- 0.9)%, A_CP(K_S K+) = (+6.9 +/- 6.0 +/- 1.5)% and A_CP(K_S K+) = (+7.1 +/- 6.1 +/- 1.2)% relative to D+->K_S pi+. The first errors quoted are statistical and the second are systematic. We also measure the relative branching ratios: \Gamma(D+->\bar{K0}pi+)/\Gamma(D+->K-pi+pi+) = (30.60 +/- 0.46 +/- 0.32)%, \Gamma(D+->\bar{K0}K+)/\Gamma(D+->K-pi+pi+) = (6.04 +/- 0.35 +/- 0.30)% and \Gamma(D+->\bar{K0}K+)/\Gamma(D+->\bar{K0}pi+) = (19.96 +/- 1.19 +/- 0.96)%.Comment: 4 pages, 3 figure

New FOCUS results on charm mixing and CP violation

We present a summary of recent results on CP violation and mixing in the charm quark sector based on a high statistics sample collected by photoproduction experiment FOCUS (E831 at Fermilab). We have measured the difference in lifetimes for the $D^0$ decays: $D^0 \to K^-\pi^+$ and $D^0 \to K^-K^+$. This translates into a measurement of the $y_{CP}$ mixing parameter in the \d0d0 system, under the assumptions that $K^-K^+$ is an equal mixture of CP odd and CP even eigenstates, and CP violation is negligible in the neutral charm meson system. We verified the latter assumption by searching for a CP violating asymmetry in the Cabibbo suppressed decay modes $D^+ \to K^-K^+\pi^+$, $D^0 \to K^-K^+$ and $D^0 \to \pi^-\pi^+$. We show preliminary results on a measurement of the branching ratio $\Gamma(D^{*+}\to \pi^+ (K^+\pi^-))/\Gamma(D^{*+}\to \pi^+ (K^-\pi^+))$.Comment: 9 pages, 6 figures, requires espcrc2.sty. Presented by S.Bianco at CPConf2000, September 2000, Ferrara (Italy). In this revision, fixed several stylistic flaws, add two significant references, fixed a typo in Tab.