Publications by authors named "Sheena Asthana"

29 Publications

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Averting a public health crisis in England's coastal communities: a call for public health research and policy.

J Public Health (Oxf) 2021 May 13. Epub 2021 May 13.

Plymouth Institute of Health and Care Research (PIHR), University of Plymouth, Drake Circus, Plymouth PL4 8AA, UK.

Coastal communities have received little attention in the public health literature, perhaps because our mental maps tend to associate socio-economic deprivation and health inequalities with inner cities. Mapping a range of key health indicators at small area level, this paper reveals a distinct core-periphery pattern in disease prevalence, with coastal communities experiencing a high burden of ill health across almost all conditions included in the Quality and Outcomes Framework dataset. Other sources suggest poor outcomes for children and young people living in coastal areas. Low rates of participation in higher education contrast with high rates of hospitalisation for self-harm, alcohol and substance use. Reflecting a shift in the distribution of children living in poverty since the 1990s, this may be an early indicator of a future public health crisis in these communities. Exploring reasons for the health challenges facing the periphery, this perspective piece calls for more public health research that can accommodate the complex and interlinked problems facing coastal communities and a more concerted effort to align public health with economic, education, local government and transport policies at the national level.
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http://dx.doi.org/10.1093/pubmed/fdab130DOI Listing
May 2021

Link worker perspectives of early implementation of social prescribing: A 'Researcher-in-Residence' study.

Health Soc Care Community 2021 Feb 2. Epub 2021 Feb 2.

University of Plymouth, Plymouth, UK.

Social prescribing (SP) is increasing in popularity in the UK and can enable healthcare providers to respond more effectively to a range of non-clinical needs. With the NHS commitment to establish an SP link worker in all GP practices, there is a rapid increase in the number of SP schemes across the country. There is currently insufficient evidence concerning the implementation and acceptability of SP schemes. In this paper, we report our analysis of the descriptions of the experiences of SP link workers, regarding the early implementation of SP link workers in two SP programmes in the South West. Data were gathered using the 'Researcher in Residence' (RiR) model, where the researcher was immersed in the environments in which the SP was managed and delivered. The RiR undertook conversations with 11 SP link workers, 2 SP link worker managers and 1 SP counsellor over six months. The RiR visited seven link workers at their GP practices (service 1) and four at their head office (service 2). The RiR met with the link worker managers at their offices, and the RiR spoke with the SP counsellor on the telephone. Data from these conversations were analysed using Thematic Analysis and six codes were constructed to advance our understanding of the components of early implementation of the SP programmes. Training (particularly around mental health), workforce support, location and SP champions within GP practices were found to be key strategies of SP implementation, link worker involvement acting as a conduit for the impacts of these strategies. This paper suggests that the implementation of SP programmes can be improved by addressing each of these areas, alongside allowing link workers the flexibility and authority to respond to challenges as they emerge.
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http://dx.doi.org/10.1111/hsc.13295DOI Listing
February 2021

Capturing the Role of Context in Complex System Change: An Application of the Canadian Context and Capabilities for Integrating Care (CCIC) Framework to an Integrated Care Organisation in the UK.

Int J Integr Care 2020 Feb 11;20(1). Epub 2020 Feb 11.

University of Plymouth, UK.

Introduction: If integrated care approaches are to be properly adapted to local contexts, a better understanding is required of key determinants of implementation and how these might be appropriately supported.

Purpose: This study applied the Canadian Context and Capabilities for Integrating Care (CCIC) Framework to investigate factors influencing the implementation and outcomes of a complex integrated care change programme in Torbay and South Devon (TSD) and, more specifically, in one of five sub-localities, Coastal.

Methods: A case study method using embedded 'Researchers in Residence' to conduct action-based participatory research and deploying mixed qualitative methods.

Results: The relative importance of some domains differ between the English and Canadian studies. In this case study, physical features (structural and geographic) were found to be very pertinent to the relative success of the Coastal Locality, as were empowered clinical leadership, with readiness for change being expressed through processes and cultures that were risk-enabling, strengths-based, person-/outcome-focused.

Conclusions: The CCIC Framework provided a useful tool capturing key elements of complex system change with key domains being transferable across settings, while also finding local variation in the UK. This would encourage its wider application so that further comparisons can be made of the ways in which different contextual and implementation properties impact upon delivery and outcomes.
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http://dx.doi.org/10.5334/ijic.5196DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7019199PMC
February 2020

Why does the NHS struggle to adopt eHealth innovations? A review of macro, meso and micro factors.

BMC Health Serv Res 2019 Dec 21;19(1):984. Epub 2019 Dec 21.

School of Law, Criminology and Government, University of Plymouth, Plymouth, UK.

Background: Having a tax-funded and supposedly 'National' Health Service (NHS), one might assume that the UK is well-positioned to roll out eHealth innovations at scale. Yet, despite a strong policy push, the English NHS has been limited in the extent to which it has exploited the potential of eHealth.

Main Body: This paper considers a range of macro, meso and micro factors influencing eHealth innovation in the English NHS.

Conclusions: While barriers to eHealth innovation exist at all scales, the fragmentation of the NHS is the most significant factor limiting adoption and diffusion. Rather than addressing problems of fragmentation, national policy seems to have intensified the digital divide. As the recently published NHS Long Term Plan places great emphasis on the role of digital transformation in helping health and care professionals communicate better and enabling people to access the care they need quickly and easily, the implications for the digital divide are likely to be significant for effectiveness, efficiency and equity.
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http://dx.doi.org/10.1186/s12913-019-4790-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6925468PMC
December 2019

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

Prim Health Care Res Dev 2019 09 24;20:e135. Epub 2019 Sep 24.

Professor, Community and Primary Care Research Group, Faculty of Health: Medicine, Dentistry and Human Sciences, Plymouth University, UK.

Aim: To evaluate the impact of 'holistic' link-workers on service users' well-being, activation and frailty, and their use of health and social care services and the associated costs.

Background: UK policy is encouraging social prescribing (SP) as a means to improve well-being, self-care and reduce demand on the NHS and social services. However, the evidence to support this policy is generally weak and poorly conceptualised, particularly in relation to frail, older people and patient activation. Torbay and South Devon NHS Foundation Trust, an integrated care organisation, commissioned a Well-being Co-ordinator service to support older adults (≥50 years) with complex health needs (≥2 long-term conditions), as part of its service redesign.

Methods: A before-and-after study measuring health and social well-being, activation and frailty at 12 weeks and primary, community and secondary care service use and cost at 12 months prior and after intervention.

Findings: Most of the 86 participants achieved their goals (85%). On average health and well-being, patient activation and frailty showed a statistically significant improvement in mean score. Mean activity increased for all services (some changes were statistically significant). Forty-four per cent of participants saw a decrease in service use or no change. Thirteen high-cost users (>£5000 change in costs) accounted for 59% of the overall cost increase. This was largely due to significant, rapid escalation in morbidity and frailty. Co-ordinators played a valuable key-worker role, improving the continuity of care, reducing isolation and supporting carers. No entry-level participant characteristic was associated with change in well-being or service use. Larger, better conceptualised, controlled studies are needed to strengthen claims of causality and develop national policy in this area.
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http://dx.doi.org/10.1017/S1463423619000598DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6764188PMC
September 2019

Social prescribing: where is the evidence?

Br J Gen Pract 2019 Jan;69(678):6-7

Faculty of Business, University of Plymouth, Plymouth.

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http://dx.doi.org/10.3399/bjgp19X700325DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6301369PMC
January 2019

The National Health Service (NHS) in 'crisis': the role played by a shift from horizontal to vertical principles of equity.

Health Econ Policy Law 2020 01 2;15(1):1-17. Epub 2018 Aug 2.

School of Law, Criminology and Government, University of Plymouth, Drake Circus, Plymouth, UK.

Explanations of the state of 'crisis' in the English National Health Service (NHS) generally focus on the overall level of health care funding rather than the way in which funding is distributed. Describing systematic patterns in the way different areas are experiencing crisis, this paper suggests that NHS organisations in older, rural and particularly coastal areas are more likely to be 'failing' and that this is due to the historic underfunding of such areas. This partly reflects methodological and technical shortcomings in NHS resource allocation formulae. It is also the outcome of a philosophical shift from horizontal (equal access for equal needs) to vertical (unequal access to equalise health outcomes) principles of equity. Insofar as health inequalities are determined by factors well beyond health care, we argue that this is an ineffective approach to addressing health inequalities. Moreover, it sacrifices equity in access to health care by failing to adequately fund the health care needs of older populations. The prioritisation of vertical over horizontal equity also conflicts with public perspectives on the NHS. Against this background, we ask whether the time has come to reassert the moral and philosophical case for the principle of equal access for equal health care need.
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http://dx.doi.org/10.1017/S1744133118000361DOI Listing
January 2020

Collaborative action for person-centred coordinated care (P3C): an approach to support the development of a comprehensive system-wide solution to fragmented care.

Health Res Policy Syst 2017 Nov 22;15(1):98. Epub 2017 Nov 22.

Community and Primary Care Research Group, Clinical Trails and Population Studies, Peninsula School of Medicine and Dentistry, Room N14, ITTC Building, Plymouth Science Park, Derriford, Plymouth, Devon, PL6 8BX, United Kingdom.

Background: Fragmented care results in poor outcomes for individuals with complexity of need. Person-centred coordinated care (P3C) is perceived to be a potential solution, but an absence of accessible evidence and the lack of a scalable 'blue print' mean that services are 'experimenting' with new models of care with little guidance and support. This paper presents an approach to the implementation of P3C using collaborative action, providing examples of early developments across this programme of work, the core aim of which is to accelerate the spread and adoption of P3C in United Kingdom primary care settings.

Methods: Two centrally funded United Kingdom organisations (South West Collaboration for Leadership in Applied Health Research and Care and South West Academic Health Science Network) are leading this initiative to narrow the gap between research and practice in this urgent area of improvement through a programme of service change, evaluation and research. Multi-stakeholder engagement and co-design are core to the approach. A whole system measurement framework combines outcomes of importance to patients, practitioners and health organisations. Iterative and multi-level feedback helps to shape service change while collecting practice-based data to generate implementation knowledge for the delivery of P3C. The role of the research team is proving vital to support informed change and challenge organisational practice. The bidirectional flow of knowledge and evidence relies on the transitional positioning of researchers and research organisations.

Results: Extensive engagement and embedded researchers have led to strong collaborations across the region. Practice is beginning to show signs of change and data flow and exchange is taking place. However, working in this way is not without its challenges; progress has been slow in the development of a linked data set to allow us to assess impact innovations from a cost perspective. Trust is vital, takes time to establish and is dependent on the exchange of services and interactions. If collaborative action can foster P3C it will require sustained commitment from both research and practice. This approach is a radical departure from how policy, research and practice traditionally work, but one that we argue is now necessary to deal with the most complex health and social problems.
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http://dx.doi.org/10.1186/s12961-017-0263-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5700670PMC
November 2017

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

Sociol Health Illn 2017 09 28;39(7):1019-1034. Epub 2017 Mar 28.

School of Government, Plymouth University, UK.

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.
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http://dx.doi.org/10.1111/1467-9566.12553DOI Listing
September 2017

Inequity in cardiovascular care in the English National Health Service (NHS): a scoping review of the literature.

Health Soc Care Community 2018 05 16;26(3):259-272. Epub 2016 Oct 16.

School of Geosciences, University of Edinburgh, Edinburgh, UK.

There is a general understanding that socioeconomically disadvantaged people are also disadvantaged with respect to their access to NHS care. Insofar as considerable NHS funding has been targeted at deprived areas, it is important to better understand whether and why socioeconomic variations in access and utilisation exist. Exploring this question with reference to cardiovascular care, our aims were to synthesise and evaluate evidence relating to access to and/or use of English NHS services around (i) different points on the care pathway (i.e. presentation, primary management and specialist management) and (ii) different dimensions of inequality (socioeconomic, age- and gender-related, ethnic or geographical). Restricting our search period from 2004 to 2016, we were concerned to examine whether, compared to earlier research, there has been a change in the focus of research examining inequalities in cardiac care and whether the pro-rich bias reported in the late 1990s and early 2000s still applies today. We conducted a scoping study drawing on Arksey & O'Malley's framework. A total of 174 studies were included in the review and appraised for methodological quality. Although, in the past decade, there has been a shift in research focus away from gender and age inequalities in access/use and towards socioeconomic status and ethnicity, evidence that deprived people are less likely to access and use cardiovascular care is very contradictory. Patterns of use appear to vary by ethnicity; South Asian populations enjoying higher access, black populations lower. By contrast, female gender and older age are consistently associated with inequity in cardiovascular care. The degree of geographical variation in access/use is also striking. Finally, evidence of inequality increases with stage on the care pathway, which may indicate that barriers to access arise from the way in which health professionals are adjudicating health needs rather than a failure to seek help in the first place.
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http://dx.doi.org/10.1111/hsc.12384DOI Listing
May 2018

A qualitative study of diverse providers' behaviour in response to commissioners, patients and innovators in England: research protocol.

BMJ Open 2016 05 13;6(5):e010680. Epub 2016 May 13.

School of Government, Plymouth University, Plymouth, UK.

Introduction: The variety of organisations providing National Health Service (NHS)-funded services in England is growing. Besides NHS hospitals and general practitioners (GPs), they include corporations, social enterprises, voluntary organisations and others. The degree to which these organisational types vary, however, in the ways they manage and provide services and in the outcomes for service quality, patient experience and innovation, remains unclear. This research will help those who commission NHS services select among the different types of organisation for different tasks.

Research Questions: The main research questions are how organisationally diverse NHS-funded service providers vary in their responsiveness to patient choice, NHS commissioning and policy changes; and their patterns of innovation. We aim to assess the implications for NHS commissioning and managerial practice which follow from these differences.

Methods And Analysis: Systematic qualitative comparison across a purposive sample (c.12) of providers selected for maximum variety of organisational type, with qualitative studies of patient experience and choice (in the same sites). We focus is on NHS services heavily used by older people at high risk of hospital admission: community health services; out-of-hours primary care; and secondary care (planned orthopaedics or ophthalmology). The expected outputs will be evidence-based schemas showing how patterns of service development and delivery typically vary between different organisational types of provider.

Ethics, Benefits And Dissemination: We will ensure informants' organisational and individual anonymity when dealing with high profile case studies and a competitive health economy. The frail elderly is a key demographic sector with significant policy and financial implications. For NHS commissioners, patients, doctors and other stakeholders, the main outcome will be better knowledge about the relative merits of different kinds of healthcare provider. Dissemination will make use of strategies suggested by patient and public involvement, as well as DH and service-specific outlets.
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http://dx.doi.org/10.1136/bmjopen-2015-010680DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4874134PMC
May 2016

Acute care: The real reason for 'failing' hospitals.

Health Serv J 2013 Mar;123(6343):20-2

Plymouth University.

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March 2013

The medicalisation of health inequalities and the English NHS: the role of resource allocation.

Health Econ Policy Law 2013 Apr 4;8(2):167-83. Epub 2012 Sep 4.

Faculty of Health, Education and Society, University of Plymouth, Plymouth, UK.

Tackling health inequalities (HI) has become a key policy objective in England in recent years. Yet, despite the wide-ranging policy response of the 1997-2010 Labour Government, socio-economic variations in health continued to widen. In this paper, we seek to explore why. We propose that a meta-narrative has emerged in which the health problems facing England's most deprived areas, and the solution to those problems, have increasingly come to be linked to levels of National Health Service (NHS) funding. This has been, in part, a response to key shortcomings in previous rounds of resource allocation. The very significant sums of money allocated with respect to 'health inequalities' reflects and reinforces the belief that the NHS can and should play a central role in promoting health equity. This medicalisation of HI focuses attention on the role of individual risk factors that lend themselves to medical management, but effectively sidelines the macroprocesses of social inequality, legitimising the kind of society that neo-liberal government has produced in the United Kingdom - one in which health (like other assets) has become a matter of individual and not collective responsibility.
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http://dx.doi.org/10.1017/S1744133112000126DOI Listing
April 2013

Lansley is right: age trumps poverty.

Authors:
Sheena Asthana

Health Serv J 2012 May;122(6306):16-7

University of Plymouth.

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May 2012

Tensions between healthcare equity and health equity must be debated.

Authors:
Sheena Asthana

BMJ 2012 Jun 25;344:e4133. Epub 2012 Jun 25.

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http://dx.doi.org/10.1136/bmj.e4133DOI Listing
June 2012

General practitioner commissioning consortia and budgetary risk: evidence from the modelling of 'fair share' practice budgets for mental health.

J Health Serv Res Policy 2011 Apr;16(2):95-101

Faculty of Health, 1School of Computing and Mathematics, University of Plymouth, Plymouth, UK.

Objectives: To contribute to current policy debates regarding the devolution of commissioning responsibilities to locally-based consortia of general practices in England by assessing the potential magnitude and significance of budgetary risk for commissioning units of different sizes.

Methods: Predictive distributions of practice-level mental health care resource needs (used by the Department of Health to set 'fair-share' practice budgets) are aggregated to a range of hypothetical, but spatially-contiguous, consortia serving populations of up to 400,000 patients. The resulting joint distributions describe the extent to which the legitimate mental health needs of consortia populations are likely to vary. Budgetary risk is calculated as the likelihood that a consortia's resource needs will, in any given year, exceed its allocation (taken as the mean of its predictive distribution) by more than 1%, 3%, 5% or 10%. The relationship between population size and budgetary risk is then explored.

Results: If between 500 and 600 consortia are created in England (serving 87,000 to 104,000 patients) then, in order to meet the legitimate mental health needs of their patients, each year around 15 to 26 consortia will overspend by at least 5%, and one or two by at least 10%. The budgetary risk faced by consortia serving smaller/larger populations can be read off the graphs provided.

Conclusions: Unless steps are taken to mitigate budgetary risk, the devolution of decision-making and introduction of fixed budgets is likely to result in significant financial instability. It will be difficult to reconcile the policy objectives of devolved commissioning, best met through relatively small and fully accountable consortia, with the need for financial stability, which is best met by pooling risk across larger populations.
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http://dx.doi.org/10.1258/jhsrp.2010.010086DOI Listing
April 2011

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

Authors:
Sheena Asthana

Soc Sci Med 2011 Mar 6;72(6):815-20. Epub 2010 Nov 6.

Faculty of Health, University of Plymouth, Drake Circus, Plymouth, PL4 8AA, United Kingdom.

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.
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http://dx.doi.org/10.1016/j.socscimed.2010.10.020DOI Listing
March 2011

Setting health care capitations through diagnosis-based risk adjustment: a suitable model for the English NHS?

Health Policy 2011 Jul 19;101(2):133-9. Epub 2010 Nov 19.

Faculty of Health, University of Plymouth, Drake Circus, Plymouth, PL4 8AA, United Kingdom.

The English system of health resource allocation has been described as the apotheosis of the area-level approach to setting health care capitations. However, recent policy developments have changed the scale at which commissioning decisions are made (and budgets allocated) with important implications for resource allocation. Doubts concerning the legitimacy of applying area-based formulae used to distribute resources between Primary Care Trusts (PCTs) to the much smaller scale required by Practice Based Commissioning (PBC) led the English Department of Health (DH) to introduce a new approach to setting health care budgets. To this end, practice-level allocations for acute services are now calculated using a diagnosis-based capitation model of the kind used in the United States and several other systems of competitive social health insurance. The new Coalition Government has proposed that these budgets are directly allocated to GP 'consortia', the new commissioning bodies in the NHS. This paper questions whether this is an appropriate development for a health system in which the major objective of resource allocation is to promote equal opportunity of access for equal needs. The chief reservation raised is that of circularity and the perpetuation of resource bias, the concern being that an existing social, demographic and geographical bias in the use of health care resources will be reinforced through the use of historic utilisation data. Demonstrating that there are legitimate reasons to suspect that this will be the case, the paper poses the question whether health systems internationally should more openly address the key limitations of empirical methods that select risk adjusters on the basis of existing patterns of health service utilisation.
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http://dx.doi.org/10.1016/j.healthpol.2010.10.014DOI Listing
July 2011

Deprivation, demography, and the distribution of general practice: challenging the conventional wisdom of inverse care.

Br J Gen Pract 2008 Oct;58(555):720-6, 728; discussion 727-8

School of Law & Social Science, University of Plymouth, Plymouth.

It is generally believed that the most deprived populations have the worst access to primary care. Lord Darzi's review of the NHS responds to this conventional wisdom and makes a number of proposals for improving the supply of GP services in deprived communities. This paper argues that these proposals are based on an incomplete understanding of inverse care which underestimates the degree to which, relative to their healthcare needs, older populations experience low availability of primary care. Many deprived practices appear to have a better match between need and supply than practices serving affluent but ageing populations. However, practices serving the oldest and most deprived populations have the worst availability of all.
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http://dx.doi.org/10.3399/bjgp08X342372DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2553532PMC
October 2008

A formula for unfairness.

Health Serv J 2006 Nov;116(6032):18-9

School of Law and Social Studies, Plymouth University.

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November 2006

Developing an evidence base for policies and interventions to address health inequalities: the analysis of "public health regimes".

Milbank Q 2006 ;84(3):577-603

School of Sociology, Politics and Law, University of Plymouth, Drake Circus, Plymouth, UK.

Systematic reviews have become an important methodology in the United Kingdom by which research informs health policy, and their use now extends beyond evidence-based medicine to evidence-based public health and, particularly, health inequalities policies. This article reviews the limitations of systematic reviews as stand-alone tools for this purpose and suggests a complementary approach to make better use of the evidence. That is, systematic reviews and other sources of evidence should be incorporated into a wider analytical framework, the public health regime (defined here as the specific legislative, social, political, and economic structures that have an impact on both public health and the appropriateness and effectiveness of public health interventions adopted). At the national level this approach would facilitate analysis at all levels of the policy framework, countering the current focus on individual interventions. It could also differentiate at the international level between those policies and interventions that are effective in different contexts and are therefore potentially generalizable and those that depend on particular conditions for success.
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http://dx.doi.org/10.1111/j.1468-0009.2006.00459.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690255PMC
October 2006

What can rural agencies do to address the additional costs of rural services? A typology of rural service innovation.

Health Soc Care Community 2004 Nov;12(6):457-65

School of Sociology, Politics and Law, University of Plymouth, Plymouth, UK.

There is a national commitment to ensuring that, regardless of where patients live, they should be provided with an acceptable level of service in terms of quality, effectiveness and accessibility. Because of differences in the distributions of their populations, rural and urban areas present quite different challenges for the optimal design of health services and social care. However, this has not been fully acknowledged in the development of national policies to unify service standards. The problems of providing services in sparsely populated areas are not new. However, until the case for a rural premium in English health resource allocation is accepted, rural agencies must either tolerate lower levels of services (an option made difficult by the introduction of national service standards) or develop very different approaches to service delivery. To date, there has been little systematic knowledge about the extent of innovative rural practice, a paucity of evaluation of such initiatives and few opportunities to disseminate learning from one area to another. The present paper begins to address this deficit. Drawing upon a review of the formal literature and a comprehensive evaluation of projects developed within a rural Health Action Zone, it presents a typology of innovative responses at the health/social care interface. Examples of service innovations which fall into six broad categories are provided. These not only suggest possibilities for the transfer of good practice, but also the potential for future research.
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http://dx.doi.org/10.1111/j.1365-2524.2004.00518.xDOI Listing
November 2004

The emergent role of the link worker: a study in collaboration.

J Interprof Care 2004 Feb;18(1):17-28

ool of Sociology, politics and Law, University of Plymouth, Drake Circus, Plymouth PL4 8AA, UK.

Partnership working is integral to New Labour's approach to modernising health and social care services for vulnerable groups such as children with complex needs. This paper draws on an initiative from Cornwall and the Isles of Scilly in which strategic and operational change have been promoted across the health and social care community in order to provide co-ordinated assessment and care for children with complex needs and their families. The introduction of link workers has been central, key contacts for families and professionals alike who are drawn from a wide range of backgrounds. The political imperative for partnership, combined with the commitment and commonality of purpose of front-line staff, has proved sufficient to facilitate inter-professional working without many of the enabling factors that are often regarded as important, such as co-location or parity of status. However, a number of organisational barriers to sustainability remain and the degree to which a strong operational lead can secure the necessary breadth of strategic resource allocation and support remains questionable.
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http://dx.doi.org/10.1080/13561820410001639325DOI Listing
February 2004

The pursuit of equity in NHS resource allocation: should morbidity replace utilisation as the basis for setting health care capitations?

Soc Sci Med 2004 Feb;58(3):539-51

Department of Social Policy and Social Work, University of Plymouth, Drake Circus, Plymouth PL4 8AA, UK.

Although the English NHS has been described as a world leader in pioneering methods of distributing expenditure in relation to population needs, concerns about the legitimacy of using the current utilisation-based model to allocate health service resources are mounting. In this paper, we present a critical review of NHS resource allocation in England and demonstrate the feasibility and impact of using direct health estimates as a basis for setting health care capitations. Comparing target allocations for the inpatient treatment of coronary heart disease in a sample of 34 primary care trusts in contrasting locations in England, we find that a morbidity-based model would result in a significant shift in hospital resources away from deprived areas, towards areas with older demographic profiles and towards rural areas. Discussing the findings in relation to a wider policy context that is generally concerned to direct more health care resources towards the poor, the paper concludes by calling for greater clarity between the goals of health care equity and health equity. Whilst the former demands that the legitimate needs of demographically older populations for more health care resources are acknowledged, the goal of health equity requires real political commitment to resource broader social policy initiatives.
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http://dx.doi.org/10.1016/s0277-9536(03)00217-xDOI Listing
February 2004

Allocating resources for health and social care: the significance of rurality.

Health Soc Care Community 2003 Nov;11(6):486-93

Department of Social Policy and Social Work, University of Plymouth, Plymouth, UK.

Whilst an allowance is made for sparsity in the allocation of resources for social care services in England, rurality is not a significant factor in health resource allocation. This lack of consistency in resource allocation criteria has become increasingly visible as health and social services departments are required to work in partnership across a range of areas. Differences in funding mechanisms also raise the question of why it is legitimate to make adjustments for rurality in the distribution of some public services, but not for others. Against this background, the present paper considers the case for a rural premium in health resource allocation which, it proposes, can be made on four grounds. First, there is evidence that the current National Health Service (NHS) formula introduces systematic biases in favour of urban areas in the way in which it expresses 'need' for healthcare. Secondly, the way in which the current system compensates for unavoidable variations in the costs of providing services takes insufficient account of the additional costs associated with rural service provision. Thirdly, with a growing emphasis on the need to attain national quality standards, rural primary care trusts and social services departments can no longer tolerate lower levels of services. Finally, a case for a rural premium can be made on the basis of precedent. England is the only country in the UK that does not make a major adjustment for rurality in its NHS formula. The paper concludes that the English NHS resource allocation system has done little to counter marked service deprivation in rural areas. Given evidence that rural local authorities also spend less on social care services and direct provision, this raises serious questions about the extent to which the needs of vulnerable people in English rural areas are being adequately served.
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http://dx.doi.org/10.1046/j.1365-2524.2003.00454.xDOI Listing
November 2003

Themes in British health geography at the end of the century: a review of published research 1998-2000.

Soc Sci Med 2002 Jul;55(1):167-73

Plymouth University, UK.

This paper provides a succinct overview of some recent trends in geography of health in Britain since 1998. We consider how the research we have reviewed illuminates the relationships between geographies of health and three fundamental processes which are widely recognized as being important for contemporary human geography as a whole: globalization, urbanization and polarization. We also consider the contribution of health geography to agendas in cultural geography agenda which we refer to here as 'geographies of imagination'. These perspectives all relate to dynamic and diverse processes operating in Britain and throughout the world. We explore how health geography is responding to change, and what the agenda for future research will be. By considering these themes, we also seek to show how the geography of health is contributing to a wider discourse, shared to some extent in human geography as a whole, and we discuss the themes which are likely to feature in the future health geography research agenda.
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http://dx.doi.org/10.1016/s0277-9536(01)00211-8DOI Listing
July 2002