Tag Archives: PIRU

The Responsibility Deal – Supersized Health Promotion

By Mark Petticrew

We can surely only get healthier, it would seem, when the public sector, academics and voluntary organisations team up with the food, drinks and leisure sectors to promote healthy living. That’s the claim behind the Government’s Public Health Responsibility Deal.

It has produced lots of practical pledges to help all of us live longer – from labelling drinks so they show alcohol strengths/unit to reducing food portions and supporting active travel. But the road to hell is, as the author and literary critic Samuel Johnson warned, paved with good intentions. So, how do we prove that the Responsibility Deal actually enhances our health and not just the reputations of its participants?

Not easily. We have, in recent years, witnessed some spectacular demonstrations of health improvements following public health interventions. For example, the legislation restricting smoking in public places fed rapidly and measurably through to reduced hospital admissions for heart attacks. In contrast to the simplicity of this success, evaluating the Responsibility Deal faces multiple levels of complexity.

For example, pledges to increase physical activity among young people might not produce health benefits for decades. And, even then, it would be difficult to attribute health gain to this particular intervention.

Likewise, if obesity rates fall, how does one know which, if any, of the many pledges concerning alcohol, food or physical exercise was a key factor? Furthermore, if one wanted to make things really tricky, remember that healthier behaviour in one aspect of life (walking to work) sometimes supports a compensatory shift to unhealthier behaviour in other aspects (a bag of doughnuts on the way home).

But all this complexity should not lead us, in despair, simply to bury our heads in the fridge. The first stage, of course, is verifying that the various promises are being kept. Then, one must build theoretical pathways of how each intervention might, in principle, lead to improved health outcomes.

Take, for example, the pledge to label at least 80 per cent of drinks with clear detail about alcoholic strength in units. We need to check that the consumer sees the label, can read it and can understand it.

Following that, we need to know whether such understanding really reduces alcoholic intake at home (and isn’t, for example, negated by compensatory heavier drinking in the pub). The next step is tracing potential impact of behaviour change on, for example, heart disease, liver damage and so on. At PIRU, which is advising on evaluation of the Responsibility Deal, we have started by building a logic model that graphically shows the potential pathways leading from each of the pledges to their theorised health outcomes. It’s so big that it’s not readable when printed at A4. It would probably squeeze onto a T-shirt – Supersize.

Our first paper, setting out the logic model, the thinking behind it and the implications for evaluation has been submitted for publication. Meanwhile, a second paper will summarise evidence from similar previous voluntary agreements from various sectors that could begin to help refine the pledges as well as the Responsibility Deal overall.

It’s the beginning of a potentially long and complex evaluation. We know that the factors that damage public health are many and that they interact. The menu offered by the Responsibility Deal for a healthier Britain is, likewise, complex. We’re working our way through it.

Dr Mark Petticrew is Professor of Public Health Evaluation at the London School of Hygiene and Tropical Medicine. He is the PIRU lead for the evaluation of public health interventions, including those that extend beyond the NHS.

Forging social care policy amid the white heat of a White Paper

By Martin Knapp

With the Government’s White Paper on Social Care expected soon, all eyes are turned to an area of just a few hundred square metres inWestminster. There, three major Government departments (Health, Treasury, Number 10) will be negotiating (perhaps fighting out) what policies will be included. Whilst we await details, we can expect the White Paper to cover future funding arrangements for long-term care and to set out what needs to be done to improve the delivery, quality and regulation of care and support. Proposals for better integration of health and social care are certain to feature.

The widely welcomed recommendations of the Dilnot Commission report from July 2011, setting out options for financing long-term care, would commit the Government to higher spending at precisely a time when budgets are being cut across the public sector. Many of the other suggestions outlined by the Coalition within months of coming to power – in its vision statement for social care published in November 2010 – might need to be reined in given the economic climate.

So how far can researchers help policy makers in this field? Can we help to deliver improvements in areas, such as the provision and financing of long-term care, that have challenged many of us before us?

PIRU’s role is building a platform of evidence to help the Department of Health to develop the Government’s proposals. We have, for example, been reviewing the evidence on levers that might be pulled to improve the quality of social care. Our literature review suggests that investment in staff training can offer some returns. Likewise, focussing on commissioning may make a difference. We are examining possible financial incentives. However, the evidence base is less than comprehensive in each of these areas.

We are also reviewing research from abroad and in this country on the ways and benefits of achieving closer integration between health and social care. It’s a debate with a long history. However, no country has achieved satisfactory integration of these sectors – each has different challenges. Indeed, even when we look at other countries that have successfully moved further than us on this issue, the picture is clouded by other variables. For example, health and social care systems offer a number of different interfaces with welfare benefits and housing systems. So there are no easy answers.

A familiar plea from the academic community in such circumstances is to call for further research. More realistic advice amid the white heat of Government policy making is to advocate that considerable care be taken in the implementation process. Where evidence is lacking, it will be vital to make sure that consultation is thorough and combined with sound modelling of the impacts of change.

Martin Knapp is Professor of Social Policy, Director of the Personal Social Services Research Unit at the London School of Economics and Political Science, and Director of the NIHR School for Social Care Research.


Desperately seeking the Steve Jobs of healthcare modelling

by James Barlow  

We know that health services need a shake-up. How else can we meet ever increasing demand while holding down costs and improving quality and productivity? But shake-ups, involving novel combinations of technology, services and infrastructure, can do a lot of damage – and still fail to achieve their goals.

Pilots can help but may not reflect the resource-constrained realities of mainstream roll-out. We need better ways to link up the context, process, costs and outcomes of potential innovations at different system levels.

Simulation models can do just this, allowing experimentation with different courses of action in a safe, quick and cheap way. They often temper perspectives that tend to over-estimate the reliability of prediction and bring uncertainty out in the open.

Such models for healthcare planning have been developed since the 1960s, improving communication between diverse stakeholders by creating a shared representation of the whole system. Latterly, powerful computers plus improved graphics and animation have helped, increasing both the potential and accessibility of models. Yet, despite success stories and academic endorsement, the technique has yet to catch on with many clinicians, health managers and policy-makers.

What’s the hold-up? As in many fields that require the adoption of sophisticated communications technology, it’s the ‘Steve Jobs’ problem. Simulation modelling needs to be a lot easier for the non-technically minded, so it feels like a dream, not a scary nightmare. In short, models and their results should be accessible to stakeholders with no or limited experience of modelling.

The pressure is mounting for this development. There is an increasing push on academia, the health services and the health care consultancy industry to ensure that appropriate analytical tools are created, driven partly by the new Cumberland Initiative (www.cumberland-initiative.org). But policy makers, though accustomed to simulation modelling at a Whitehall level, have yet to recognise fully its potential more locally.

We need all these sectors to back a step-change in presentation and usability now if simulation modelling is to become truly embedded in healthcare decision-making at all levels. Sadly, we can’t recruit into healthcare planning the current generation of 10 year olds who would probably find all of this technology more intuitive and easier to use than do their parents. We also cannot afford to delay important changes in service delivery until those 10 year olds find themselves running the NHS.

James Barlow is Professor of Technology and Innovation Management at Imperial College London. He is a co-investigator with PIRU and Co-Director of the Health and Care Infrastructure Research and Innovation Centre.


Alternatives to the chemical cosh

By Bob Erens

There is wide concern about anti-psychotic drugs being prescribed far too readily for patients with dementia, particularly in care homes. The so-called ‘chemical cosh’ has been blamed by government-commissioned research for the premature deaths of 1,800 people a year.

And the side-effects on an estimated 180,000 UK dementia sufferers can be profound, including social withdrawal, accelerated cognitive decline as well as dizziness and unsteadiness that can lead to falls.

That’s why the Care Services Minister, Paul Burstow, wants a dramatic two-thirds reduction in prescription levels. But what can be offered instead for patients with dementia who may wander or become agitated or aggressive?

The Department of Health has asked PIRU to look at alternatives to these antipsychotic drugs. There are lots of potential options including massage, music therapy, light therapy, physical activity and exercise interventions, cognitive training interventions, better behaviour management therapy as well as specific training and education for care givers.

The big question is what works, in what circumstances and for which patients? We hope to come up with some answers and also identify the research gaps so that these drugs are used only as the last resort.

PIRU is bringing speed and expertise to reviewing a vast swathe of existing research (there are already over 30 literature reviews of more than 400 research papers). We should be able to nail down what is known and what requires further study. We have excellent partners at the EPPI-Centre, Institute of Education and at Collaborations for Leadership in Applied Health Research and Care: Cambridgeshire and Peterborough (CLAHRC CP).

The PIRU investment will be money well-spent if, at the end of our project, we can make a real difference to vulnerable people’s lives and help turn Paul Burstow’s laudable policy ambition into a practical reality. Our work could give doctors, nursing staff and carers the confidence to employ better treatments that enhance dignity and well-being during the twilight years of life.

Bob Erens is Deputy Director of PIRU