Equity of utilisation of cardiovascular care and mental health services in England: a cohort-based cross-sectional study using small-area estimation

Background: A strong policy emphasis on the need to reduce both health inequalities and unmet need in deprived areas has resulted in the substantial redistribution of English NHS funding towards deprived areas. This raises the question of whether or not socioeconomically disadvantaged people continue to be disadvantaged in their access to and utilisation of health care.Objectives: To generate estimates of the prevalence of cardiovascular disease (CVD) and common mental health disorders (CMHDs) at a variety of scales, and to make these available for public use via Public Health England (PHE). To compare these estimates with utilisation of NHS services in England to establish whether inequalities of use relative to need at various stages on the health-care pathway are associated with particular sociodemographic or other factors.Design: Cross-sectional analysis of practice-, primary care trust- and Clinical Commissioning Group-level variations in diagnosis, prescribing and specialist management of CVD and CMHDs relative to the estimated prevalence of those conditions (calculated using small-area estimation).Results: The utilisation of CVD care appears more equitable than the utilisation of care for CMHDs. In contrast to the reviewed literature, we found little evidence of underutilisation of services by older populations. Indeed, younger populations appear to be less likely to access care for some CVD conditions. Nor did deprivation emerge as a consistent predictor of lower use relative to need for either CVD or CMHDs. Ethnicity is a consistent predictor of variations in use relative to need. Rates of primarymanagement are lower than expected in areas with higher percentages of black populations for diabetes, stroke and CMHDs. Areas with higher Asian populations have higher-than-expected rates of diabetes presentation and prescribing and lower-than-expected rates of secondary care for diabetes. For both sets of conditions, there are pronounced geographical variations in use relative to need. For instance, the North East has relatively high levels of use of cardiac care services and rural (shire) areas have low levels of use relative to need. For CMHDs, there appears to be a pronounced ‘London effect’, with the number of people registered by general practitioners as having depression, or being prescribed antidepressants, being much lower in London than expected. A total of 24 CVD and 41 CMHD prevalence estimates have been provided to PHE and will be publicly available at a range of scales, from lower- and middle-layer super output areas through to Clinical Commissioning Groups and local authorities.Conclusions: We found little evidence of socioeconomic inequality in use for CVD and CMHDs relative to underlying need, which suggests that the strong targeting of NHS resources to deprived areas may well have addressed longstanding concerns about unmet need. However, ethnicity has emerged as a significant predictor of inequality, and there are large and unexplained geographical variations in use relative to need for both conditions which undermine the principle of equal access to health care for equal needs. The persistence of ethnic variations and the role of systematic factors (such as rurality) in shaping patterns ofutilisation deserve further investigation, as does the fact that the models were far better at explaining variation in use of CVD than mental health services.Funding: The National Institute for Health Research Health Services and Delivery Research programme

Loneliness and social networks of older adults in rural communities: a narrative synthesis systematic review

Introduction: Loneliness has significant impacts on the health of older adults. Social networks help to improve psychosocial and quality of life outcomes among older adults. A fifth of older adults live in rural communities, where geographic isolation poses challenges to health. The dynamics of social networks of older adults in rural communities has not been explored. Objective: To synthesize the literature related to loneliness and social networks of older adults in rural settings. Methods: A mixed-methods systematic review was conducted through searching six bibliographic databases to retrieve peer-reviewed literature with no time limits. We performed a methodological assessment of each study using a mixed method quality assessment tool. Findings are synthesized thematically. Results: A total of 50 studies (32 quantitative, 15 qualitative, and 3 mixed methods) were included in this review. Studies were conducted in 17 different countries, the majority from China (n = 12), the UK (n = 9), and USA (n = 9). Findings revealed that social networks of older adults consist of family, friends and neighbors and continue to be developed through participation in various physical and social activities such as walking groups and participation in religious events. Social networks offer informational, functional, psychological and social support to older adults. Through their social networks, older adults feel socially connected and cared for. Successful interventions to improve social networks and address loneliness were those developed in groups or one-on-one with the older adults. The key ingredient to the positive impact of these interventions on reducing social isolation and loneliness was the formation of a social connection and regular engagement with the older adults. However, the review did not find any explicitly reported theory or model on which these interventions are based. Conclusion: The prevalence of loneliness among older adults in rural areas needs urgent attention. Social network theory and methods can help in developing interventions to address social isolation and loneliness among older adults in rural communities

Repositioning the Boundaries between Public and Private Healthcare Providers in the English NHS

Background and Objectives: Neoliberal ‘reform’ has in many countries shifted services across the boundary between the public and private sector. This policy re-opens the question of what structural and managerial differences, if any, differences of ownership make to healthcare providers. This paper examines the relationships between ownership, organisational structure and managerial regime within an elaboration of Donabedian’s reasoning about organisational structures. Using new data from England it considers: 1. How do the internal managerial g regimes of differently owned healthcare providers differ, or not? 2. In what respects did any such differences arise from differences in ownership or for other reasons? Methods: An observational systematic qualitative comparison of differently-owned providers was the strongest feasible research design. We systematically compared a maximum-variety sample (by ownership) of community health services (CHS); out-of-hours primary care (OOH); hospital planned orthopaedics and ophthalmology providers (N=12 cases). The framework of comparison was the ownership theory mentioned above. Findings: The relationships between ownership (one one hand) and organisation structures and managerial regimes (on the other), differed at different organisational levels. Top-level governance structures diverged by organisational ownership and objectives among the case-study organisations. All the case-study organisations irrespective of ownership had hierarchical, bureaucratic structures and managerial regimes for coordinating everyday service production, but to differing extents. In doctor-owned organisations the doctors’, but not other occupations’, work was controlled and coordinated in a more-or-less democratic, self-governing ways. Conclusion: Ownership does make important differences to healthcare providers’ top-level governance structures and accountabilities; and to work coordination activity, but with different patterns at different organisational levels. These findings have implications for understanding the legitimacy, governance and accountability of healthcare organisations, the distribution and use of power within them, and system-wide policy interventions, for instance to improve care coordination; and for the correspondingly required foci of healthcare organisational research

Does a social prescribing ‘holistic’ link-worker for older people with complex, multi-morbidity improve well-being and frailty and reduce health and social care use and costs? A 12-month before and after evaluation

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Bridging the discursive gap between lay and medical discourse in care coordination

For older people with multiple chronic co-morbidities, strategies to coordinate care depend heavily on information exchange. We analyse the information-sharing difficulties arising from differences between patients’ oral narratives and medical sense-making; and whether a modified form of ‘narrative medicine’ might mitigate them. We systematically compared 66 general practice patients’ own narratives of their health problems and care with the contents of their clinical records. Data were collected in England during 2012–13. Patients’ narratives differed from the accounts in their medical record, especially the summary, regarding mobility, falls, mental health, physical frailty and its consequences for accessing care. Parts of patients’ viewpoints were never formally encoded, parts were lost when clinicians de-coded it, parts supplemented, and sometimes the whole narrative was re-framed. These discrepancies appeared to restrict the patient record's utility even for GPs for the purposes of risk stratification, case management, knowing what other care-givers were doing, and coordinating care. The findings suggest combining the encoding/decoding theory of communication with inter-subjectivity and intentionality theories as sequential, complementary elements of an explanation of how patients communicate with clinicians. A revised form of narrative medicine might mitigate the discursive gap and its consequences for care coordination

Liberating the NHS? A commentary on the Lansley White Paper, "Equity and Excellence"

In July 2010, the new Coalition Government unveiled its plans to make major changes to the English National Health Service (NHS). This paper, which provides a commentary on the NHS White Paper, Equity and Excellence: Liberating the NHS, casts doubt upon the extent to which the proposals will bring about the fundamental reform that the Government intends, not least because both the British public and GP commissioners (who are expected to play a central role in transforming the NHS) appear to have a limited appetite for radical market reform. The paper also identifies a number of unintended risks, including the large transitional costs and organisational turbulence resulting from further NHS reorganisation; and the fact that key aspects of the White Paper proposals could result in significant financial instability. Given the real world limitations to translating a rhetoric of localism and democratic legitimacy into reality and a lack of hard evidence about the benefits of market reform, the Government would be well advised to take a more cautious approach to health policy formulation and implementation and to ensure that any further changes to the NHS are based on evidence, piloting and evaluation.NHS White paper UK Policy