The Impact of Working Beyond Traditional Retirement Ages on Mental Health: Implications for Public Health and Welfare Policy

Background: Many people now want or need to work longer due to increased life expectancy. In some countries statutory retirement ages deny older people free access to the labour market. It has been hypothesised that exclusion from employment may have negative effects on the mental health of older people. The global financial crisis has forced some countries to propose increasing the retirement age but the implications of this for population health are unclear. This paper reviews the evidence for the mental health impacts of working beyond retirement, and discusses the implications for future public health and welfare policy. Methods: A systematic literature review was conducted of studies that examined the effect of working or volunteering beyond traditional retirement ages on mental health outcomes. Results: Of the ten studies that met the inclusion criteria, none showed a negative impact of working beyond retirement age on mental health. Four studies showed that post-retirement working has a statistically significant positive effect on a range of mental health outcomes. Discussion: This review suggests that working beyond traditional retirement ages may be beneficial for mental health in some populations. The mechanisms by which this occurs are complex but are likely to be mediated by the maintenance of productive societal roles, continued income and social support. The benefits of post-retirement employment are unlikely to be universal as such factors will have varying effects depending on individual lifestyle, self-esteem and socioeconomic status. Although our research shows that allowing older people free access to the employment market may have important health benefits, flexible retirement strategies are needed to ensure that any national policy to increase statutory retirement age does not increase health and social inequalities in the elderly

The Evolution of Public Health Education and Training in the United Kingdom

The United Kingdom has a long and evolving history of public health education. From the initiation of formal standardised training for Medical Officers for Health in the early 1900s, to the current national public health training programme, public health education has adapted to the changing contexts of public health practice. Whilst the profession was originally only a medical specialty, subsequent re­­cognition of the skills and contribution of the wider public health workforce has led to changes in professional specialist training for public health, which is now open to non-medical applicants. This well-established professional training scheme allows the formal accreditation of competence in a broad range of public health skills. The academic component of public health training is provided by a rapidly growing number of postgraduate courses. Once confined to the UK’s first school of public health, the London School of Hygiene and Tropical Medicine and a handful of British Universities, the current 60 or so courses across the country are found in diverse university settings. Quality and standards in higher education are monitored by the Quality Assurance Agency for Higher Education but there are no other professional accreditation schemes for postgraduate courses in public health nationally. Public health education and training continues to face challenges in the UK, notably the current government plans for major restructuring of the National Health Service (NHS) which threatens the loss of traditional NHS training placements and has created uncertainty around how professional training might be structured in the future. Whilst the long established tradition of public health education and more recent adoption of competency-based approaches to training gives some flexibility to meet these challenges, insight and innovative responses are required to ensure that public health education and training are not destabilised by these challenges. Revisions of the curricula of postgraduate courses and the competencies required for professional accreditation along with provision of experience in the new locations where public health is to be practiced in the future will be key to ensuring that public health professionals are ready to tackle the key issues that confront them

Identifying and mapping measures of medication safety during transfer of care in a digital era: a scoping literature review

Background: Measures to evaluate high-risk medication safety during transfers of care should span different safety dimensions across all components of these transfers and reflect outcomes and opportunities for proactive safety management. // Objectives: To scope measures currently used to evaluate safety interventions targeting insulin, anticoagulants and other high-risk medications during transfers of care and evaluate their comprehensiveness as a portfolio. // Methods: Embase, Medline, Cochrane and CINAHL databases were searched using scoping methodology for studies evaluating the safety of insulin, anticoagulants and other high-risk medications during transfer of care. Measures identified were extracted into a spreadsheet, collated and mapped against three frameworks: (1) ‘Key Components of an Ideal Transfer of Care’, (2) work systems, processes and outcomes and (3) whether measures captured past harms, events in real time or areas of concern. The potential for digital health systems to support proactive measures was explored. // Results: Thirty-five studies were reviewed with 162 measures in use. Once collated, 29 discrete categories of measures were identified. Most were outcome measures such as adverse events. Process measures included communication and issue identification and resolution. Clinic enrolment was the only work system measure. Twenty-four measures captured past harm (eg, adverse events) and six indicated future risk (eg, patient feedback for organisations). Two real-time measures alerted healthcare professionals to risks using digital systems. No measures were of advance care planning or enlisting support. // Conclusion: The measures identified are insufficient for a comprehensive portfolio to assess safety of key medications during transfer of care. Further measures are required to reflect all components of transfers of care and capture the work system factors contributing to outcomes in order to support proactive intervention to reduce unwanted variation and prevent adverse outcomes. Advances in digital technology and its employment within integrated care provide opportunities for the development of such measures

A narrative account of the key drivers in the development of the Learning from Deaths policy.

OBJECTIVE: In recent years there has been a proliferation of patient safety policies in the United Kingdom triggered by well publicized failures in health care. The Learning from Deaths (LfD) policy was implemented in response to failures at Southern Health National Health Service (NHS) Foundation Trust. This study aims to develop a narrative to enable the understanding of the key drivers involved in its evolution and implications for future national patient safety policy development. METHODS: A qualitative study was undertaken using documentary analysis and semi-structured interviews (n = 12) with policymakers from organizations involved in the design, implementation and assurance of LfD at a system level. Kingdon's Multiple Streams Approach was used to frame the policymaking process. RESULTS: The publication of the Southern Health independent review and subsequent highlighting by the Care Quality Commission of a fragmented approach to learning from deaths across the NHS opened a 'policy window.' Under the influence of the families affected by patient safety failures and the then Secretary of State, acting as 'policy entrepreneurs,' recently developed methods for mortality review were combined with mechanisms to enhance transparency and governance. This rapidly created a framework designed to ensure NHS organizations identified remedial safety problems and could be accountable for addressing them. CONCLUSIONS: The development of LfD exhibits several common features with other patient safety policies in the NHS. It was triggered by a crisis and the need for a prompt political response and attempts to address a range of concerns related to safety. In common with other safety policies, LfD contains inherent tensions related to its primary purpose, which may hinder its impact. In the absence of formal evaluations of these policies, deeper understanding of the policymaking process offers the possibility of identifying potential barriers to goal achievement

Avoidability of hospital deaths and association with hospital-wide mortality ratios: retrospective case record review and regression analysis.

OBJECTIVES: To determine the proportion of avoidable deaths (due to acts of omission and commission) in acute hospital trusts in England and to determine the association with the trust's hospital-wide standardised mortality ratio assessed using the two commonly used methods--the hospital standardised mortality ratio (HSMR) and the summary hospital level mortality indicator (SHMI). DESIGN: Retrospective case record review of deaths. SETTING: 34 English acute hospital trusts (10 in 2009 and 24 in 2012/13) randomly selected from across the spectrum of HSMR. MAIN OUTCOME MEASURES: Avoidable death, defined as those with at least a 50% probability of avoidability in view of trained medical reviewers. Association of avoidable death proportion with the HSMR and the SHMI assessed using regression coefficients, to estimate the increase in avoidable death proportion for a one standard deviation increase in standardised mortality ratio. PARTICIPANTS: 100 randomly selected hospital deaths from each trust. RESULTS: The proportion of avoidable deaths was 3.6% (95% confidence interval 3.0% to 4.3%). It was lower in 2012/13 (3.0%, 2.4% to 3.7%) than in 2009 (5.2%, 3.8% to 6.6%). This difference is subject to several factors, including reviewers' greater awareness in 2012/13 of orders not to resuscitate, patients being perceived as sicker on admission, minor differences in review form questions, and cultural changes that might have discouraged reviewers from criticising other clinicians. There was a small but statistically non-significant association between HSMR and the proportion of avoidable deaths (regression coefficient 0.3, 95% confidence interval -0.2 to 0.7). The regression coefficient was similar for both time periods (0.1 and 0.3). This implies that a difference in HSMR of between 105 and 115 would be associated with an increase of only 0.3% (95% confidence interval -0.2% to 0.7%) in the proportion of avoidable deaths. A similar weak non-significant association was observed for SHMI (regression coefficient 0.3, 95% confidence interval -0.3 to 1.0). CONCLUSIONS: The small proportion of deaths judged to be avoidable means that any metric based on mortality is unlikely to reflect the quality of a hospital. The lack of association between the proportion of avoidable deaths and hospital-wide SMRs partly reflects methodological shortcomings in both metrics. Instead, reviews of individual deaths should focus on identifying ways of improving the quality of care, whereas the use of standardised mortality ratios should be restricted to assessing the quality of care for conditions with high case fatality for which good quality clinical data exist

Approaches to improving patient safety in integrated care: a scoping review.

OBJECTIVES: This scoping review aimed to establish the approaches employed to improving patient safety in integrated care for community-dwelling adults with long-term conditions. DESIGN: Scoping review. SETTING: All care settings. SEARCH STRATEGY: Systematic searches of seven academic and grey literature databases for studies published between 2000 and 2021. At the full-text review stage both the first and second reviewer (SW) independently assessed full texts against the eligibility criteria and any discrepancies were discussed. RESULTS: Overall, 24 studies were included in the review. Two key priorities for safety across care boundaries for adults with long-term conditions were falls and medication safety. Approaches for these priorities were implemented at different levels of an integrated care system. At the micro-level, approaches involved care primarily in the home setting provided by multi-disciplinary teams. At the meso-level, the focus was on planning and designing approaches at the managerial/organisational level to deliver multi-disciplinary care. At the macro-level, system-wide approaches included integrated care records, training and education and the development of care pathways involving multiple organisations. Across the included studies, evaluation of these approaches was undertaken using a wide range of process and outcome measures to capture patient harm and contributory factors associated with falls and medication safety. CONCLUSIONS: For integrated care initiatives to fulfil their promise of improving care for adults with long-term conditions, approaches to improve patient safety need to be instituted across the system, at all levels to support the structural and relational aspects of integrated care as well as specific risk-related safety improvements

"Prelude to the School to Come. . ." Introduction to the Special Issue

First paragraph: In several interviews, Michel Foucault expressed a dislike of any polemics that insists on making those who disagree into enemies, silencing other possibilities by invoking an authority that undercuts the authority and right to speak of others. A problematisation, for Foucault, is the opposite of a polemic (see Foucault 1985). A problematisation raises questions; it focuses on the problem at hand rather than insisting on a party line. It takes risks, questions rights and disrupts legitimacy. Polemics often leads to an impasse, as polemicists focus on the consolidation of established truth claims or on negating the argument of their opponent. Problematization, however, can open up the potential for a rethinking of the very terms and grounds of argument, knowledge and understanding

Farmer Health and Adaptive Capacity in the Face of Climate Change and Variability. Part 1: Health as a Contributor to Adaptive Capacity and as an Outcome from Pressures Coping with Climate Related Adversities

This paper examines the role farmers’ health plays as an element of adaptive capacity. The study examines which of twenty aspects of adaptation may be related to overall health outcomes, controlling for demographic and on-farm-factors in health problems. The analysis is based on 3,993 farmers’ responses to a national survey of climate risk and adaptation. Hierarchical linear regression modelling was used examine the extent to which, in a multivariate analysis, the use of adaptive practices was predictively associated with self-assessed health, taking into account the farmer’s rating of whether their health was a barrier to undertaking farm work. We present two models, one excluding pre-existing health (model 1) and one including pre-existing health (model 2). The first model accounted for 21% of the variance. In this model better health was most strongly predicted by an absence of on-farm risk, greater financial viability, greater debt pressures, younger age and a desire to continue farming. Social capital (trust and reciprocity) was moderately associated with health as was the intention to adopt more sustainable practices. The second model (including the farmers’ health as a barrier to undertaking farm work) accounted for 43% of the variance. Better health outcomes were most strongly explained, in order of magnitude, by the absence of pre-existing health problems, greater access to social support, greater financial viability, greater debt pressures, a desire to continue farming and the condition of on-farm resources. Model 2 was a more parsimonious model (only nine predictors, compared with 15 in model 1), and explained twice as much variance in health outcomes. These results suggest that (i) pre-existing health problems are a very important factor to consider when designing adaptation programs and policies and (ii) these problems may mediate or modify the relationship between adaptation and health

Scoping review exploring the impact of digital systems on processes and outcomes in the care management of acute kidney injury and progress towards establishing learning healthcare systems.

OBJECTIVES: Digital systems have long been used to improve the quality and safety of care when managing acute kidney injury (AKI). The availability of digitised clinical data can also turn organisations and their networks into learning healthcare systems (LHSs) if used across all levels of health and care. This review explores the impact of digital systems i.e. on patients with AKI care, to gauge progress towards establishing LHSs and to identify existing gaps in the research. METHODS: Embase, PubMed, MEDLINE, Cochrane, Scopus and Web of Science databases were searched. Studies of real-time or near real-time digital AKI management systems which reported process and outcome measures were included. RESULTS: Thematic analysis of 43 studies showed that most interventions used real-time serum creatinine levels to trigger responses to enable risk prediction, early recognition of AKI or harm prevention by individual clinicians (micro level) or specialist teams (meso level). Interventions at system (macro level) were rare. There was limited evidence of change in outcomes. DISCUSSION: While the benefits of real-time digital clinical data at micro level for AKI management have been evident for some time, their application at meso and macro levels is emergent therefore limiting progress towards establishing LHSs. Lack of progress is due to digital maturity, system design, human factors and policy levers. CONCLUSION: Future approaches need to harness the potential of interoperability, data analytical advances and include multiple stakeholder perspectives to develop effective digital LHSs in order to gain benefits across the system