Access to treatment and the constitutional right to health in Germany: a triumph of hope over evidence?

Health technology assessment is frequently credited with making difficult resource allocation decisions in health care fairer, more rational and more transparent. In Germany, a constitutional 'right to health' allows patients to challenge decisions by sickness funds to withhold reimbursement of treatment excluded from public funding because of insufficient evidence of effectiveness. The ability to litigate was qualified by the Constitutional Court in its 2005 'Nikolaus decision' that sets out criteria to be applied to these cases. Treatment must be made available if (1) the condition is life-threatening, (2) no alternative treatment is available and (3) there is an indication that the treatment could benefit the patient. This paper examines how courts struggled to apply these criteria based on an analysis of cases of patients who sought treatment for cancer between 2005 and 2015, and explores the implications of applying a constitutional 'right to health' to treatment decisions

The Multiple Purposes of Policy Piloting and Their Consequences: Three Examples from National Health and Social Care Policy in England

AbstractIn England, policy piloting has become firmly established in almost all areas of public policy and is seen as good practice in establishing ‘what works’. However, equating piloting with evaluation can risk oversimplifying the relationship between piloting and policy-making.Using three case studies from health and social care – the Partnerships for Older People Projects (POPP) pilots, the Individual Budgets pilots and the Whole System Demonstrators (WSD) – the paper identifies multiple purposes of piloting, of which piloting for generating evidence of effectiveness was only one. Importantly, piloting was also aimed at promoting policy change and driving implementation, both in pilot sites and nationally. Indeed, policy makers appeared to be using pilots mainly to promote government policy, using evaluation as a strategy to strengthen the legitimacy of their decisions and to convince critical audiences. These findings highlight the ambiguous nature of piloting and thus question the extent to which piloting contributes to the agenda of evidence-based policy-making.</jats:p

The strategic uses of evidence in UK e-cigarettes policy debates

Background Current debates on e-cigarette policy in the UK are highly acrimonious and are framed in terms of evidence-based policymaking. Aims and objectives The article aims to understand the use of evidence in policymaking in the context of both political controversy and limited policy-relevant evidence via a case study of UK e-cigarette debates. Methods The study draws on a series of semi-structured interviews with policy actors to examine their positions on e-cigarette policy process and their use of evidence to support this. Findings Policy actors articulate a strong commitment to evidence-based policymaking and claim that their positions are evidence-based. Some actors also claim emerging consensus around their positon as a rhetorical tool in the debate. Respondents argued that actors adopting opposing policy positions fail to follow the evidence base. This is attributed to a lack of understanding or disregard for the relevant evidence for political or ideological reasons. Discussion Respondents adhere to a rationalist understanding of policymaking in which policy disputes can be settled by recourse to ‘the evidence’. Interpretative policy analysis suggests that multiple legitimate framings of policy issues, supported by different bodies of evidence, are possible. Policy differences are thus not due to bad faith but to policy actors framing the issue at stake in different terms and thus advocating different policy responses. Conclusions Process of ‘frame reflection’ may help to overcome the acrimony of current policy leading to more effective engagement by public health actors in the e-cigarettes policy debates.</jats:sec

What kind of home is your care home? A typology of personalised care provided in residential and nursing homes

This paper examines how care home managers in England conceptualised the approach to delivering personalised care in the homes they managed. We conducted interviews with care home managers and mapped the approaches they described on two distinct characterisations of personalised care prominent in the research and practitioner literature: the importance of close care relationships and the degree of resident choice and decision-making promoted by the care home. We derived three ‘types’ of personalised care in care homes. These conceptualise the care home as an ‘institution’, a ‘family’ and a ‘hotel’. We have added a fourth type, the ‘co-operative’, to propose a type that merges proximate care relationships with an emphasis on resident choice and decision-making. We conclude that each approach involves trade-offs and that the ‘family’ model may be more suitable for people with advanced dementia, given its emphasis on relationships. While the presence of a range of diverse approaches to personalising care in a care home market may be desirable as a matter of choice, access to care homes in England is likely to be constrained by availability and cost

Evidence Use in Health Policy Making: An International Public Policy Perspective

This open access book provides a set of conceptual, empirical, and comparative chapters that apply a public policy perspective to investigate the political and institutional factors driving the use of evidence to inform health policy in low, middle, and high income settings. The work presents key findings from the Getting Research Into Policy (GRIP-Health) project: a five year, six country, programme of work supported by the European Research Council. The chapters further our understanding of evidence utilisation in health policymaking through the application of theories and methods from the policy sciences. They present new insights into the roles and importance of factors such as issue contestation, institutional arrangements, logics of appropriateness, and donor influence to explore individual cases and comparative experiences in the use of evidence to inform health policy

Facilitators of, and barriers to, personalisation in care homes in England: evidence from Care Quality Commission inspection reports

The personalisation of residential care services is based on three broad principles of valuing personal identity, empowering resident decision-making and fostering care relationships. We analysed 50 Care Quality Commission care home inspection reports to identify factors that the reports indicate facilitate or hinder the delivery of personalised residential care in England. Findings suggest that the provision of personalised services is affected by staff skills, attitudes and availability, as well as the quality of care home leadership. Future care policy should consider addressing external pressures facing the care home sector, including inadequate funding and too few staff, to mitigate barriers to delivering high-quality, personalised care

Reporting COVID-19 deaths in Austria, France, Germany, Italy, Portugal and the UK

The reporting of deaths associated with the SARS-CoV-2 virus has had a high policy profile during the COVID-19 pandemic. This in turn is related to how deaths are counted. In this paper we focus on six European countries: Austria, France, Germany, Italy, Portugal and the United Kingdom and seek to address the following research questions: How do countries vary in terms of legislative provision, recording of deaths and reporting deaths? And what limits the comparability of data across countries? The methods comprised an analysis of policy documents in each of the six countries. Our findings reveal differences between countries in terms of legislative provision, recording deaths, and reporting deaths. These differences have an impact on the comparability of data on deaths associated with COVID-19 across countries. Our findings suggest that there is a case for data collection and statistics to be harmonised, which would facilitate accurate comparison between countries. However, reporting is also related to testing capacity for COVID-19, so this is not simply a question of comparable data being available, rather a question of the overall functioning of the public health system

Explaining low uptake of direct payments in residential care: findings from the evaluation of the Direct Payments in Residential Care Trailblazers

In 2012, the Government invited local councils in England to participate in a pilot programme to test direct payments in residential care. While the programme was set up to allow for comprehensive summative evaluation, the uptake of direct payments in residential care was substantially lower than anticipated, with only 40 people in receipt of one at the end of the programme. Drawing on qualitative data collected for the evaluation, this paper aims to understand better the barriers to implementing direct payments in residential care. Evidence from the use of direct payments in domiciliary care identified gatekeeping by council frontline staff as a major barrier for service users to access direct payments. Our findings suggest that, whilst selectivity of both service users and providers was an integral part of the programme design, gatekeeping does not fully explain the poor take-up. Other factors played a part, such as lack of clarity about the benefits of direct payments for care home residents, the limited range and scope of choice of services for residents, and concerns from care providers about the financial impact of direct payments on their financial sustainability

Private health insurance in Germany and Chile: two stories of co-existence, segmentation and conflict

Abstract Background In Germany and Chile, substitutive private health insurance has been shaped by its co-existence with statutory social health insurance. Despite differences in the way choice is available to users in the health insurance regimes of Chile and Germany, the way in which each country has managed choice between private health insurance and statutory social health insurance provides a unique opportunity to comparatively assess the consequences of such an arrangement that has been previously underexamined. Methods We conducted a Most Similar Systems Design comparative policy analysis of the co-occurring private health insurance and statutory social health insurance systems in Germany and Chile. We describe and review the origins and development of the German and Chilean health care insurance systems with an emphasis on the substitutive co-existence between private health insurance and statutory social health insurance. We provide a critique of the market performance of the private health insurance regime in each country followed by a comparative assessment of the impact of private health insurance on financial protection, equity, and risk segmentation. Results Segmentation of insurance markets in both Germany and Chile has had significant consequences for equity, fairness, and financial protection. Due to market failures in health insurance and differences in the regulatory frameworks governing public and private insurers, the choice of public or private coverage has produced strong incentives for private insurers to select for risks, compromising equity in health care funding, heightening the financial risk borne by public insurers and lowering incentives for private insurers to operate efficiently. Conclusions The degree of conflict arising from the substitutive parallel private health insurance system and the statutory social health insurance system varies between Germany and Chile, though policy goals remain similar. Recent reforms in both countries have attempted to improve the financial protection of the privately insured through regulation; nevertheless, concerns about risk segmentation remain largely unresolved