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Abstract Advocacy for people using health and social care services is widely promoted but its theoretical foundation is under-developed and its impact poorly conceptualised. This paper explores the liberatory potential of independent advocacy, using Fricker's concept of 'epistemic injustice' as a framework. People experiencing mental distress are particularly vulnerable to epistemic injustices as a consequence of deeply embedded social stigma resulting in a priori assumptions of irrationality and unreliability such that their knowledge is often discounted or downgraded. The mental health service user/survivor movement is at the forefront of validating personal experience and narrative to secure a different ontological and epistemological basis for mental distress. A foundational strand of this is advocacy to enable people to give voice to their experience. The case of independent mental health advocacy (IMHA) services under mental health legislation in England, provides an opportunity to critically examine whether advocacy can promote epistemic justice as a result of the legally sanctioned encounter between clinical assessment and subjective experience, pivoting on judgements about risk. This paper draws on empirical data from a national evaluation of IMHA services, which included 90 individual interviews with people subject to detention and three focus groups with mental health service users. Fricker's concept of epistemic injustice is used as a lens to investigate how this type of advocacy might mitigate forms of epistemic injustice, and thereby promote greater social justice in mental health. The concept of epistemic injustice provides a valuable theoretical basis for understanding the worth of advocacy in addressing testimonial injustice as well as its relative weakness in overcoming hermeneutical injustice. The challenge of independent advocacy to the dominant discourse within mental health is considered and questions raised about the place of advocacy in modern democratic mental health systems. Highlights • Analyses service user accounts of independent mental health advocacy (IMHA). • The concept of 'epistemic injustice' is used to identify if IMHA promotes equality. • The epistemic agency of those detained under MH legislation is compromised. • IMHA promotes testimonial justice but has limited impact on hermeneutic injustice. • Epistemic injustice is helpful in advancing more democratic mental health services. [ABSTRACT FROM AUTHOR]

Abstract Geographical deprivation indices such as the English Index of Multiple Deprivation (IMD) have been widely used in healthcare research and planning since the mid-1980s. However, such indices normally provide a measure of disadvantage for the whole population and can be inflexible to adaptation for specific geographies or purposes. This can be an issue, as the measurement of deprivation is subjective and situationally relative, and the type of deprivation experienced within rural areas may differ from that experienced by urban residents. The objective of this study was to develop a Rural Deprivation Index (RDI) using the English county of Norfolk as a case study, but with a view to adopting a flexible approach that could be used elsewhere. It is argued that the model developed in this research gives clarity to the process of populating an index and weighting it for a specific purpose such as rural deprivation. This is achieved by 'bundling' highly correlated indicators that are applicable to both urban and rural deprivation into one domain, and creating a separate domain for indicators relevant to the setting of interest, in this case rural areas. A further domain is proposed to account for population differences in rural areas. Finally, a method was developed to measure variability in deprivation within small areas. The RDI results in more rural areas in Norfolk falling in the most deprived quintile, particularly those classified as 'Rural town and fringe in sparse settings'; these areas also have high levels of heterogeneity of deprivation when using the variability measure created. This model proposed has the potential to provide a starting point for those who wish to create a summary deprivation measure taking into account rurality, or other local geographic factors, and as part of a range of approaches that can be used to allocate, or apply for, resources. Highlights • National indices of deprivation typically poorly represent rural disadvantage. • Paper presents new method to better depict deprivation in rural settings. • Depicts granularity of rural disadvantage better than English deprivation index. • Resulting index valuable for rural health and social service planning. [ABSTRACT FROM AUTHOR]

Geographical deprivation indices such as the English Index of Multiple Deprivation (IMD) have been widely used in healthcare research and planning since the mid-1980s. However, such indices normally provide a measure of disadvantage for the whole population and can be inflexible to adaptation for specific geographies or purposes. This can be an issue, as the measurement of deprivation is subjective and situationally relative, and the type of deprivation experienced within rural areas may differ from that experienced by urban residents. The objective of this study was to develop a Rural Deprivation Index (RDI) using the English county of Norfolk as a case study, but with a view to adopting a flexible approach that could be used elsewhere. It is argued that the model developed in this research gives clarity to the process of populating an index and weighting it for a specific purpose such as rural deprivation. This is achieved by 'bundling' highly correlated indicators that are applicable to both urban and rural deprivation into one domain, and creating a separate domain for indicators relevant to the setting of interest, in this case rural areas. A further domain is proposed to account for population differences in rural areas. Finally, a method was developed to measure variability in deprivation within small areas. The RDI results in more rural areas in Norfolk falling in the most deprived quintile, particularly those classified as 'Rural town and fringe in sparse settings'; these areas also have high levels of heterogeneity of deprivation when using the variability measure created. This model proposed has the potential to provide a starting point for those who wish to create a summary deprivation measure taking into account rurality, or other local geographic factors, and as part of a range of approaches that can be used to allocate, or apply for, resources. • National indices of deprivation typically poorly represent rural disadvantage. • Paper presents new method to better depict deprivation in rural settings. • Depicts granularity of rural disadvantage better than English deprivation index. • Resulting index valuable for rural health and social service planning. [ABSTRACT FROM AUTHOR]

This paper examines the impact that the Great Recession had on individuals’ health behaviours and risk factors such as diet choices, smoking, alcohol consumption, and Body Mass Index, as well as on intermediate health outcomes in England. We exploit data on about 9000 households from the Health Survey for England for the period 2001–2013 and capture the change in macroeconomic conditions using regional unemployment rates and an indicator variable for the onset of the recession. Our findings indicate that the recession is associated with a decrease in the number of cigarettes smoked - which translated into a moderation in smoking intensity - and a reduction in alcohol intake. The recession indicator itself is associated with a decrease in fruit intake, a shift of the BMI distribution towards obesity, an increase in medicines consumption, and the likelihood of suffering from diabetes and mental health problems. These associations are often stronger for the less educated and for women. When they exist, the associations with the unemployment rate (UR) are nevertheless similar before and after 2008. Our results suggest that some of the health risks and intermediate health outcomes changes may be due to mechanisms not captured by worsened URs. We hypothesize that the uncertainty and the negative expectations generated by the recession may have influenced individual health outcomes and behaviours beyond the adjustments induced by the worsened macroeconomic conditions. The net effect translated into the erosion of the propensity to undertake several health risky behaviours but an exacerbation of some morbidity indicators. Overall, we find that the recession led to a moderation in risky behaviours but also to worsening of some risk factors and health outcomes. [ABSTRACT FROM AUTHOR]

This paper contributes to the international literature examining design of inpatient settings for mental health care. Theoretically, it elaborates the connections between conceptual frameworks from different strands of literature relating to therapeutic landscapes, social control and the social construction of risk. It does so through a discussion of the substantive example of research to evaluate the design of a purpose built inpatient psychiatric health care facility, opened in 2010 as part of the National Health Service (NHS) in England. Findings are reported from interviews or discussion groups with staff, patients and their family and friends. This paper demonstrates a strong, and often critical awareness among members of staff and other participants about how responsibilities for risk governance of ‘persons’ are exercised through ‘technical safety’ measures and the implications for therapeutic settings. Our participants often emphasised how responsibility for technical safety was being invested in the physical infrastructure of certain ‘places’ within the hospital where risks are seen to be ‘located’. This illuminates how the spatial dimensions of social constructions of risk are incorporated into understandings about therapeutic landscapes. There were also more subtle implications, partly relating to ‘Panopticist’ theories about how the institution uses technical safety to supervise its own mechanisms, through the observation of staff behaviour as well as patients and visitors. Furthermore, staff seemed to feel that in relying on technical safety measures they were, to a degree, divesting themselves of human responsibility for risks they are required to manage. However, their critical assessment showed their concerns about how this might conflict with a more therapeutic approach and they contemplated ways that they might be able to engage more effectively with patients without the imposition of technical safety measures. These findings advance our thinking about the construction of therapeutic landscapes in theory and in practice. [Copyright &y& Elsevier]

Different discourses that co-exist within the world of patient and public involvement in health and social care mirror a tangle of historical, social, political and theoretical roots. These range from the radical activism, born of civil rights movements, to a more passive model in which patients are the recipients of information. This paper explores the concept of ‘representation’ and the ways the concept is used by people serving as ‘patient’ or ‘lay’ representatives in a range of roles within research projects, funding bodies and academic institutions. We address the issue of why the representativeness of those involved is contestable. Drawing on qualitative research and engaged practice as well as on literature from social and political sciences we question how people conceptualise their own and their fellows' acts of representation. In doing this we identify nine different conceptualisations of what it is to represent and use these to explore how judgements are made about what can count as legitimate forms of representation. [ABSTRACT FROM AUTHOR]

Like other health care systems, the National Health Service (NHS) in England has looked to new staffing configurations faced with medical staff shortages and rising costs. One solution has been to employ physician associates (PAs). PAs are trained in the medical model to assess, diagnose and commence treatment under the supervision of a physician. This paper explores the perceived effects on professional boundaries and relationships of introducing this completely new professional group. It draws on data from a study, completed in 2014, which examined the contribution of PAs working in general practice. Data were gathered at macro, meso and micro levels of the health care system. At the macro and meso level data were from policy documents, interviews with civil servants, senior members of national medical and nursing organisations, as well as regional level NHS managers (n = 25). At the micro level data came from interviews with General Practitioners, nurse practitioners and practice staff (n = 30) as well as observation of clinical and professional meetings. Analysis was both inductive and also framed by the existing theories of a dynamic system of professions. It is argued that professional boundaries become malleable and subject to negotiation at the micro level of service delivery. Stratification within professional groups created differing responses between those working at macro, meso and micro levels of the system; from acceptance to hostility in the face of a new and potentially competing, occupational group. Overarching this state agency was the requirement to underpin legislatively the shifts in jurisdictional boundaries, such as prescribing required for vertical substitution for some of the work of doctors. [ABSTRACT FROM AUTHOR]

Abstract: Binge drinking has been linked to escalating costs of hospitalisation and to premature mortality, and implicated in a range of acute and chronic health problems as well as crime, violence and other negative aspects of the wider well-being agenda. Variously defined, it can be characterised as brief periods of heavy drinking (across one day or evening) within a longer time-frame of lower consumption or even abstinence (across a week or several weeks). In England the current binge drinking epidemic has become particularly salient in the past decade and has been seen largely in terms of excessive consumption by younger people, particularly women in urban centres. It has also been linked to the liberalisation of licencing laws and the promotion of 24 h club cultures. This paper presents an observational study of the regional development of binge drinking between 2001 and 2009 as evidenced in the Health Survey for England. We innovate by using two different definitions of binge drinking within a multivariate multilevel modelling framework, with a focus on the random effects attributable to the year of study and region. We control for age, sex, ethnicity, marital status and individual socio-economic status, and confounding by neighbourhood deprivation and urbanisation. The paper identifies pronounced regional geographies that persist in the face of controls and vary little over time, and strong spatio-temporal gender differences which reflect the definition of binge drinking. [Copyright &y& Elsevier]

Abstract: This paper uses data from the Scottish Health Survey 2003 and the comparable Health Survey for England 2003 to look at whether Scotland''s poor health image and mortality profile is reflected in regional inequalities in prevalence of four risk factors for cardiovascular disease: fruit and vegetable consumption, smoking, obesity and diabetes. It also looks at the “Scottish effect” – how much of any difference between and within Scotland and England remains once socio-demographic factors have been taken in to account. The paper then uses regional analyses to determine the extent to which areas within England and Scotland contribute to their national health advantage and disadvantage. All 2003 strategic health authorities in England and Scottish health boards were compared with Greater Glasgow health board as the reference category. The results showed that significant geographic variation in the risk factors remained once individual economic status was taken into account, but the relationship was complex and varied in strength and direction depending upon risk factor involved and gender of respondent. A small number of areas had significantly lower odds of fruit and vegetable consumption of five portions or more a day in men, compared with Greater Glasgow. In contrast some areas had significantly higher odds of fruit and vegetable consumption for women compared with Greater Glasgow. There was greater geographic variation in the odds of smoking in women than in men. Respondents in the south west and southeast of England (areas which usually show health advantage) did not show significantly lower odds of smoking compared with Greater Glasgow once socio-economic variation, age and urban residence was taken into account. It was respondents from central England that had lower odds of smoking than might be expected. Obesity stood out as the single risk factor that had demonstrated a “Scottish effect” in women only. [Copyright &y& Elsevier]

Abstract: This paper is about the care of babies with confirmed or potential neurological problems in neonatal intensive care units. Drawing on recent ethnographic research, the paper considers parents’ experiences of sharing information and decisions with neonatal staff, and approaches that support or restrict parents’ involvement. There are growing medico-legal pressures on practitioners to inform parents and involve them in their babies’ care. Data are drawn from observations in four neonatal units in southern England, and interviews with the parents of 80 babies and with 40 senior staff. The paper compares standards set by recent guidance, with parents’ views about their share in decision-making, their first meetings with their babies, ‘minor’ decision-making, the different neonatal units, being a helpless observer and missed opportunities. Parents’ standards for informed decisions are summarised, with their reported views about two-way decision-making, and their practical need to know. Whereas doctors emphasise distancing aspects of the consent process, parents tend to value ‘drawing together’ aspects. [Copyright &y& Elsevier]

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. [Copyright &y& Elsevier]

This paper explores the links between lay knowledge, place and health related social action (or agency) at the individual and collective level. It is based on an analysis of in-depth interviews and neighbourhood survey data across four localities in two cities in the North West of England.The qualitative analysis has identified ‘guidelines’ that we argue provide socially shared understandings of the normative contours of ‘proper places’ which shape the way people respond to the everyday lived reality of places. The quantitative findings suggest that a substantial minority of people, particularly in disadvantaged areas, are exposed to significant dissonance between the normative dimensions and lived experience of place. The analysis points to potential interactions between individual and collective action which may affect the health of individuals and populations and ‘ontological fit’—people''s ability to (re) construct a positive identity despite living in what they and others perceive to be an ‘improper’ place. This is linked to their biographical connections with particular places and the extent to which they can localise problems and people in places at a distance from themselves. The paper contributes to understanding about the processes that generate inequalities in the health experience of people living in sharply contrasting socio-economic circumstances as well as finer-grained health inequalities between the ‘poor’ and the ‘poorest’. [Copyright &y& Elsevier]

This paper discusses changes occurring in the field of English forensic psychiatry which appear to be linked to feelings of discomfort amongst medical professionals who manage care in such settings. These changes are neither the result of a sudden ‘shock’ to the system, nor small improvisations at the margins, but instead appear to reflect a growing perception amongst psychiatrists of accepted field practice as inadequate for some types of patients. To understand how feelings and emotions are implicated in these changes we draw on and develop the work of Pierre Bourdieu to suggest that changes must be seen in the context of field tensions, which have implications for habitus. However, we do not view feelings of discomfort merely as a response to these tensions. Instead we suggest a more dynamic process. The habitus plays a key role in structuring what people pay attention to, how they perceive it and therefore, whether they experience particular feelings in the first place. [ABSTRACT FROM AUTHOR]

This paper investigates how the concepts of clinical specialisation and evidence influence the jurisdictional power of doctors, nurses and therapists involved in stroke care in Sweden, England and Poland. How stroke care has become a distinct specialism across Europe and the role that evidence has played in this development are critically analysed. Five qualitative case studies were undertaken across the three countries, consisting of 119 semi-structured interviews with a range of healthcare workers. The informants were purposively selected and their perspectives of evidence-based practice (EBP) within stroke care were explored. The data were analysed through thematic content analysis. The two key themes that emerged from the data were the health professionals' degrees of EBP and specialisation. The results illustrate how the two concepts of clinical specialisation and evidence are interrelated and work together to influence the different professions' degree of professional jurisdiction. It is concluded that doctors' professional dominance gives them full jurisdiction in stroke care and that nurses' and therapists' degrees of jurisdiction is dependent on their ability to specialise. [ABSTRACT FROM AUTHOR]

Sight impairment is experienced by approximately 253 million people worldwide, including people of all generations, at all life course stages. Caught between past and present embodiments of the world, people often express feelings of loss with the onset of sight impairment. This paper examines the role of nonhuman nature encounters as a contingent resource amongst individuals navigating these emotional transitions. It responds to recent calls to attend to the life course in both critical disability studies and the growing body of work linking nonhuman nature relations to human wellbeing. The paper draws on findings from a qualitative study that combined in-depth narrative interviews with in situ go-along interviews to explore how 31 people with sight impairment in England describe and experience a sense of wellbeing (or otherwise) with nature across their everyday lives and life trajectories. The data were analysed using inductive narrative thematic analysis. While nonhuman nature encounters were valued by many participants in promoting a sense of freedom, relatedness, pleasurable sensory immersion, opportunities for exploration and 'skilling up', this paper cautions against generalised or overly Romantic tropes of what nonhuman nature can 'do' through key sight loss junctures, and for whom. It highlights the value of providing timely and sensitive social scaffolding and nurturing creativity to open up meaningful opportunities to engage with nonhuman nature and to counter feelings of loss exacerbated by identity-limiting life course narratives and disability stereotypes. Informed by the stories shared by participants to chart and situate their experiences of sight loss, we call for a new identity politics within and beyond the growing movement to 'connect' people to nonhuman nature for wellbeing; a politics that affirms diverse forms of more-than-human embodiment, recognising how and why such relations may weave into – and indeed out of – people's varied, interdependent life course trajectories. • Disabling life course norms can exacerbate feelings of loss with sight impairment. • Care is needed in generalising benefits of nature through transitions of sight loss. • Social scaffolding and creativity can enable supportive nonhuman encounters. • A more inclusive identity politics is needed in nature-wellbeing policy & practice. [ABSTRACT FROM AUTHOR]

Evidence on provider payment systems that incorporate patient outcomes is limited for mental health care. In England, funding for mental health care services is changing to a prospective payment system with a future objective of linking some part of provider payment to outcomes. This research examines performance of mental health providers offering hospital and community services, in order to investigate if some are delivering better outcomes. Outcomes are measured using the Health of the Nation Outcome Scales (HoNOS) – a clinician-rated routine outcome measure (CROM) mandated for national use. We use data from the Mental Health Minimum Data Set (MHMDS) – a dataset on specialist mental health care with national coverage – for the years 2011/12 and 2012/13 with a final estimation sample of 305,960 observations with follow-up HoNOS scores. A hierarchical ordered probit model is used and outcomes are risk adjusted with independent variables reflecting demographic, need, severity and social indicators. A hierarchical linear model is also estimated with the follow-up total HoNOS score as the dependent variable and the baseline total HoNOS score included as a risk-adjuster. Provider performance is captured by a random effect that is quantified using Empirical Bayes methods. We find that worse outcomes are associated with severity and better outcomes with older age and social support. After adjusting outcomes for various risk factors, variations in performance are still evident across providers. This suggests that if the intention to link some element of provider payment to outcomes becomes a reality, some providers may gain financially whilst others may lose. The paper contributes to the limited literature on risk adjustment of outcomes and performance assessment of providers in mental health in the context of prospective activity-based payment systems. [ABSTRACT FROM AUTHOR]

This paper examines potential explanations for recent declines in teenage pregnancy in England. We estimate panel data models of teenage conception, birth and abortion rates from regions in England. Although point estimates are consistent with the promotion of long acting reversible contraception (LARC) having a negative impact on teenage pregnancy rates, the effects are generally small and statistically insignificant. In contrast, improvements in educational achievement and, to a lesser extent, increases in the non-white proportion of the population are associated with large and statistically significant reductions in teenage pregnancy. [ABSTRACT FROM AUTHOR]

Governments world-wide have attempted to use market mechanisms and privatisation to increase the quality and/or reduce the cost of healthcare. England's Health and Social Care Act 2012 is an attempt to promote privatisation through marketisation in the National Health Service (NHS). While the health policy literature tends to assume that privatisation follows from private-sector entry points, we argue that this is more likely if firms expect to make a profit. This paper examines the link between privatisation and marketisation in England drawing on 32 semi-structured interviews with private-sector and public-sector respondents, campaigners, and other experts conducted 6–10 months after the implementation of the 2012 Act. By generating a theoretical framework on the conditions of profitability we seek a better understanding of the conditions under which marketisation leads to privatisation. We find that significant barriers to profit-making remain after the reforms, including a top-down squeeze on prices, uncertainty in market rules, state dominance of funding and provision, and failures to depoliticise the market. These factors restrict private-sector involvement by frustrating profit-making. Where profits are made they are through reduced unit costs and high volumes by a longstanding incumbent in a particular market segment. This, however, restricts marketisation by reinforcing entry barriers. [ABSTRACT FROM AUTHOR]

Understanding the socioeconomic gradient in physical inactivity is essential for effective health promotion. This paper exploits data on over one million individuals (1,002,216 people aged 16 and over) in England drawn from the Active People Survey (2004–11). We identify the separate associations between a variety of measures of physical inactivity with education and household income. We find high levels of physical inactivity. Further, both education and household income are strongly associated with inactivity even when controlling for local area deprivation, the availability of physical recreation and sporting facilities, the local weather and regional geography. Moreover, the gap in inactivity between those living in high and low income households is already evident in early adult life and increases up until about age 85. Overall, these results suggest that England is building up a large future health problem and one that is heavily socially graded. [ABSTRACT FROM AUTHOR]

This paper investigates the link between cannabis depenalisation and crime using individual-level panel data for England and Wales from 2003 to 2006. We exploit the declassification of cannabis in the UK in 2004 as a natural experiment. Specifically, we use the fact that the declassification changed expected punishments differently in various age groups due to thresholds in British criminal law and employ a difference-in-differences type design using data from the longitudinal version of the Offending, Crime and Justice Survey. Our findings suggest essentially no increases in either cannabis consumption, consumption of other drugs, crime and other forms of risky behaviour. [ABSTRACT FROM AUTHOR]

Abstract: There has much debate about the extent to which professional discretion has been challenged by recent organisational changes such as through the new forms of governance associated with the introduction of the principles of the New Public Management (NPM) into health systems and other public sector services. What appears to be missing from these debates is a detailed analysis of the concept of professional discretion itself. This paper attempts to fill this gap by delineating the key concepts of professional discretion evident in the literature and exploring their significance in an empirical study of the influence of the 2004 new general medical services contract (nGMS) and the introduction of the Quality and Outcomes Framework (QOF), a prescriptive pay-for-performance system designed to standardise the quality of care provision in general medical practice in the United Kingdom. The study adopted a longitudinal design using semi-structured interviews with general practitioners (GPs, N = 62) working in the English National Health Service (NHS) between 2007 and 2009. A multi-dimensional conception of discretion was used to explore how GP discretion might have been influenced by contractual changes and in particular, QOF. The findings suggest that through a complex interplay of factors, a post-QOF reduction in GP discretion was identifiable, highlighting different potential sources of constraint such as in the social, organisational and economic dimensions of discretion. The evidence also suggested the emergence of a new form of organisational medical professionalism within general practice characterised by standardisation, bureaucracy and performance management. [Copyright &y& Elsevier]

Recent reforms, which change incentive and accountability structures in the English National Health Service, can be conceptualised as trying to shift the dominant institutional logic in the field of primary medical care (general medical practice) away from medical professionalism towards a logic of "population based medicine". This paper draws on interviews with primary care doctors, conducted during 2007–2009 and 2011–2012. It contrasts the approach of active management of populations, in line with recent reforms with responses to patients with medically unexplained symptoms. Our data suggest that rather than one logic becoming dominant, different dimensions of organisational activity reflect different logics. Although some aspects of organisational life are relatively untouched by the reforms, this is not due to ‘resistance’ on the part of staff within these organisations to attempts to ‘control’ them. We suggest that a more helpful way of understanding the data is to see these different aspects of work as governed by different institutional logics. [ABSTRACT FROM AUTHOR]

Abstract: In a context of ever increasing demand, the recent economic downturn has placed further pressure on decision-makers to effectively target healthcare resources. Over recent years there has been a push to develop more explicit evidence-based priority-setting processes, which aim to be transparent and inclusive in their approach and a number of analytical tools and sources of evidence have been developed and utilised at national and local levels. This paper reports findings from a qualitative research study which investigated local priority-setting activity across five English Primary Care Trusts, between March and November 2012. Findings demonstrate the dual aims of local decision-making processes: to improve the overall effectiveness of priority-setting (i.e. reaching ‘correct’ resource allocation decisions); and to increase the acceptability of priority-setting processes for those involved in both decision-making and implementation. Respondents considered priority-setting processes to be compartmentalised and peripheral to resource planning and allocation. Further progress was required with regard to disinvestment and service redesign with respondents noting difficulty in implementing decisions. While local priority-setters had begun to develop more explicit processes, public awareness and input remained limited. The leadership behaviours required to navigate the political complexities of working within and across organisations with differing incentives systems and cultures remained similarly underdeveloped. [Copyright &y& Elsevier]

Abstract: This study is situated within the international literature on geographic health inequalities between urban and rural areas. Using data from the Office for National Statistics Longitudinal Study (ONS LS), this paper assesses the role of residential mobility within England between 1981 and 2001 in explaining geographic inequalities in all-cause mortality between urban and rural Local Authority Districts at the end of the period (deaths occurring between 2001 and 2005). First, the pattern of directly age-standardised death rates (2001–2005) in urban and rural areas of residence in 2001 is examined and compared with the pattern that would have been seen if the observed death/survival of individuals had occurred in their original place of residence in 1981, or in 1991. Secondly, logistic regression is applied to examine whether individuals'' residential mobility between urban and rural areas predict the risk of mortality, adjusting for people''s socio-demographic characteristics. Findings show that, for this sample, residential mobility 1981–2001 accounts for about 30% of the urban–rural inequalities in mortality observed at the end of the period. LS members who were residentially mobile between urban and rural areas were relatively healthier than long-term urban residents, with better mortality outcomes among rural in-migrants. In age-stratified analysis, LS members of working age (20–64 years) moving out of rural areas, and LS members of retirement age (65 years and older) moving into rural areas, were shown to be healthier. Processes of selective migration in and out of rural areas in England are complex and may partly explain urban–rural health inequalities. In terms of varying mortality risk, findings also highlight the possible marginalisation and disadvantage of sub-groups of the rural population. [Copyright &y& Elsevier]

Abstract: The use of contracts is vital to market transactions. The introduction of market reforms in health care in the UK and other developed countries twenty years ago meant greater use of contracts. In the UK, health care contracting was widely researched in the 1990s. Yet, despite the changing policy context, the subject has attracted less interest in recent years. This paper seeks to fill a gap by reporting findings from a study of contracting in the English National Health Service (NHS) after the introduction of the national standard contract in 2007. By using economic and socio-legal theories and two case studies we examine the way in which the new contract was implemented in practice and the extent to which implementation conformed to policy intentions and to our theoretical predictions. Data were collected using non-participant observation of 36 contracting meetings, 24 semi-structured interviews, and analysis of documents. We found that despite efforts to introduce a more detailed (‘complete’) contract, in practice, purchasers and providers often reverted to a more relational style of contracting. Frequently reliance on the NHS hierarchy proved to be indispensable; in particular, formal dispute resolution was avoided and financial risk was re-allocated in compromises that sometimes ignored contractual provisions. Serious data deficiencies and shortages of skilled personnel still caused major difficulties. We conclude that contracting for health care continues to raise serious problems, which may be exacerbated by the impending transfer of responsibility to groups of general practitioners (GPs) who generally lack experience and expertise in large-scale, secondary care contracting. [Copyright &y& Elsevier]

Abstract: This paper seeks to make sense of the sleeping practices of people who are recovering from heroin use. It brings together two hitherto unrelated literatures: the sociology of sleep and studies on heroin use and recovery. Conceptual resources developed within the sociology of sleep are deployed to facilitate the analysis of interview data generated as part of a qualitative investigation into the everyday lives of recovering heroin users living in England. Twenty one men and 19 women were interviewed with 37 of the 40 being interviewed twice, giving a corpus of 77 interviews. Without exception all the participants in the research experienced extensive sleeping problems that were not only exacerbated by the pharmacological effects of heroin, but were made worse by the way of life that accompanied their using. Irregular and anarchic sleeping practices mirrored the study participants’ disrupted and difficult lives. Attempts to establish sleep routines, and normative sleeping patterns, constitutes an important marker of recovery, but after years, and for some decades, of chaotic, intermittent and irregular sleeping, cultivating sleep presents a series of difficult challenges. Their embodied biographies of heroin use constrain the promotion of sleep, and attempts to develop rituals and routines to restore sleeping patterns are confounded by the involuntary aspects of sleep and their recalcitrant bodies. These findings are significant because not only is the quality of sleep critical to health outcomes but it also forms an important but hitherto relatively overlooked aspect of recovery from heroin use. [Copyright &y& Elsevier]

Abstract: Reducing avoidable inequalities in health is a priority in many health care systems, including the NHS in Great Britain. Evidence suggests that lifestyle factors may play a role in explaining socioeconomic inequalities in health. In this paper we measure the contribution of smoking and obesity to income-related inequality in health. We use the corrected concentration index to measure inequality across time and areas of England, and decomposition methods to quantify directly the contribution of smoking and obesity to income-related inequality. Instrumental variables regression is used to test the endogeneity of smoking and obesity. We use data from nine rounds of the Health Survey for England (1998–2006). The results show that there are significant income-related health inequalities in England, that the extent of the inequality varies by area, and that in some areas it has increased over time. Nationally, smoking and obesity make a significant but modest contribution to income-related inequality in health (2.3% and 1.2%, respectively). Despite the reduction in smoking prevalence, the contribution of smoking has slightly increased over time, due to its increasing concentration among the poor and its negative effect on health. While the prevalence of obesity is increasing, it is more equally distributed across society. The prevalence of these problems varies between areas, and so does the contribution they make to income-related inequalities in health. [ABSTRACT FROM AUTHOR]

This paper reports the impact on nurses working in primary health care settings of changes to the general practitioner (GP) contract in England implemented in 2004. Previous changes to the GP contract in 1990, which gave financial rewards for health promotion activities, were seen as enabling nurses to take on work that GPs did not want and providing an impetus for the development of a professional project (Broadbent, J. (1998). Practice nurses and the effects of the new general practitioner contract in the British NHS: the advent of a professional project? Social Science & Medicine, 47(4), 497–506). Our study, which involved interviews with nurses from 20 practices, finds that nurses are taking on work which has previously been the exclusive preserve of medical professionals. An increasing emphasis in nurses'' accounts on technical skills and knowledge may help decouple nursing from a narrative of caring, which has been seen as detracting from professional advancement. Our research suggests that practice nurse work is changing to reflect a more medical (and masculine) orientation to service delivery. At the same time, nursing work is described as routine and template driven, which may limit claims to ‘professional’ status. The reaction of some practice nurses to Health Care Assistants encroaching on what was previously practice nurse territory suggests a policing of boundaries, rather than an inclusive approach to colleagues within the nursing team. This resonates with Davies'' (Davies, C. (1995). Gender and the professional predicament in nursing. Bucks: Open University Press) suggestion that professionalisation as a process involves compliance with a masculine notion of professionalism (autonomous, elite, individual, divisive, detached) which marginalises feminine attributes and devalues the work done by women. The study also raises questions about the role of caring in general practice settings where nurses choose to prioritise other concerns. [Copyright &y& Elsevier]

Efforts to ‘modernize’ the clinical workforce of the English National Health Service have sought to reconfigure the responsibilities of professional groups in pursuit of more effective, joined-up service provision. Such efforts have met resistance from professions eager to protect their jurisdictions, deploying legitimacy claims familiar from the insights of the sociology of professions. Yet to date few studies of professional boundaries have grounded these insights in the specific context of policy challenges to the inter- and intra-professional division of labour, in relation to the medical profession and other health-related occupations. In this paper we address this gap by considering the experience of newly instituted general practitioners with a special interest (GPSIs) in genetics, introduced to improve genetics knowledge and practice in primary care. Using qualitative data from four comparative case studies, we discuss how an established intra-professional division of labour within medicine—between clinical geneticists and general practitioners—was opened, negotiated and reclosed in these sites. We discuss the contrasting attitudes towards the nature of genetics knowledge and its application of GPSIs and geneticists, and how these were used to advance conflicting visions of what the nascent GPSI role should involve. In particular, we show how the claims to knowledge of geneticists and GPSIs interacted with wider policy pressures to produce a rather more conservative redistribution of power and responsibility across the intra-professional boundary than the rhetoric of modernization might suggest. [Copyright &y& Elsevier]

For Freidson [(1985). The reorganisation of the medical profession. Medical Care Review, 42(1), 11–35], collegiality, or ostensible equal status amongst members of the medical profession, serves a dual purpose. It socialises members into an attitude of loyalty to colleagues and presents an image to those outside the profession that all its members are competent and trustworthy. However, Freidson saw the use of formal standards developed by one (knowledge) elite within medicine and enforced by another (administrative) elite as threatening collegiality and professional unity. Drawing on two studies in English primary medical care this paper reports the emergence of new strata or elites, with groups of doctors involved in surveillance of others and action to improve compliance in deficient individuals and organizations. Early indications are that these developments have not led to the consequences which Freidson predicted. The increasing acceptance of the legitimacy of professional scrutiny and accountability that we identify suggests that new norms are emerging in English primary medical care, the possibility of which Freidson''s analysis fails to take account. [Copyright &y& Elsevier]

Abstract: Smoking prevalence in England continues to reduce but further reduction is increasingly difficult. Cessation policy has successfully targeted those who want to quit but further reduction will need to shift attention to more difficult ‘core smoker’ populations. Following the established ‘stages of change’ perspective, this paper considers the characteristics of people who do not intend to quit smoking, anticipate difficulties in quitting and have not received advice about quitting. We deploy multilevel models of data drawn from the Health Survey for England years 2002–2004, and the NHS Primary Care Trust Patient Surveys for 2004 and 2005. It was found that variations in intentionality and anticipated ease of quitting are associated with individual factors such as smoking intensity, parental smoking, age/length of time as a smoker and the nature of the advice-giving consultation. Household composition and household income are also implicated in the intention to quit and anticipated difficulties in quitting. Once individual and household factors are taken into account the only identifiable area-level variation is reduced intentionality towards quitting in rural areas. We conclude by arguing that further gains in smoking cessation must focus on understanding the characteristics of ‘hard-to-engage’ populations. [Copyright &y& Elsevier]

Primary care management of patients with multimorbidity in the UK is underpinned by clinical guidelines, quality standards and measurable targets which govern practices of risk management and disease control. There is concern that standardised approaches may not always be appropriate for older patients living with multimorbidity. Using a narrative approach, we elicited the voices of older people living with multiple conditions in order to rethink chronicity, and consider what their accounts might mean for reconfiguring care practices. Within an ethnographic study of multimorbidity and polypharmacy, we conducted in-depth interviews, based on the Biographical Narrative Interpretive Method, with 24 participants aged 65 to 94. Participants were recruited from three general practices in England. All had two or more chronic conditions and were prescribed ten or more medicines. Our analysis draws on Bakhtinian theory, tracing the multiple ways in which participants voiced living with multimorbidity. In this paper, we focus on 'keeping in balance' which emerged as a key meta-conceptualisation across our dataset. Adopting the metaphor of the 'multimorbidity tightrope' we explore the precarity of patients' experiences and show their struggle to create coherence from within a deeply ambiguous living situation. We consider how and to what extent participants' narrative constructions co-opt or resist normative biomedical framings of multimorbidity. Our analysis foregrounds the complex ways in which patients' voices and values may sometimes be at odds with those promoted within professional guidelines. Narrative approaches may offer significant potential for reorienting healthcare towards enabling patients to live a flourishing life, even when facing significant adversity. • A voice-centred analytical method illuminates participants' multivocal narratives. • The 'multimorbidity tightrope' illustrates the precarity of patients' experiences. • Managing multimorbidity requires careful balance in order to flourish. • Participants both co-opted and resisted biomedical framings of multimorbidity. • I-poems present the contradictory nature of participants' narratives. [ABSTRACT FROM AUTHOR]

The Quality and Outcomes Framework (QOF) is a UK system for monitoring general practitioner (GP) activity and performance, introduced in 2004. The objective of this paper is to explore the potential of QOF datasets as a basis for better understanding geographical variations in disease prevalence in England. In an ecological study, prevalence estimates for four common disease domains (coronary heart disease (CHD), asthma, hypertension and diabetes) were derived from the 2004–2005 QOF primary care disease registers for 354 English Local Authority Districts (LADs). These were compared with synthetic estimates from four prevalence models and with self-reported measures of general health from the 2001 census. Prevalence models were recalculated for LADs using demographic and deprivation data from the census. Results were mapped spatially and cross-tabulated against a national classification of local authorities. The four disease domains display different spatial distributions and different spatial relationships with the corresponding prevalence model. For example, the prevalence model for CHD under-estimated QOF cases in northern England, but this north-south pattern was not evident for the other disease domains. The census-derived health measures were strongly correlated with CHD, but not with the other disease domains. The relationship between modelled prevalence and QOF disease registers differs by disease domain, implying that there is no simple cross-domain effect of the QOF process on prevalence figures. Given reliable synthetic estimates of small area prevalence for the QOF disease domains, one potential application of the QOF dataset may be in assessing the geographical extent of under-diagnosis for each domain. [Copyright &y& Elsevier]

Public participation in health-service management is an increasingly prominent policy internationally. Frequently, though, academic studies have found it marginalized by health professionals who, keen to retain control over decision-making, undermine the legitimacy of involved members of the public, in particular by questioning their representativeness. This paper examines this negotiation of representative legitimacy between staff and involved users by drawing on a qualitative study of service-user involvement in pilot cancer-genetics services recently introduced in England, using interviews, participant observation and documentary analysis. In contrast to the findings of much of the literature, health professionals identified some degree of representative legitimacy in the contributions made by users. However, the ways in which staff and users constructed representativeness diverged significantly. Where staff valued the identities of users as biomedical and lay subjects, users themselves described the legitimacy of their contribution in more expansive terms of knowledge and citizenship. My analysis seeks to show how disputes over representativeness relate not just to a struggle for power according to contrasting group interests, but also to a substantive divergence in understanding of the nature of representativeness in the context of state-orchestrated efforts to increase public participation. This divergence might suggest problems with the enactment of such aspirations in practice; alternatively, however, contestation of representative legitimacy might be understood as reflecting ambiguities in policy-level objectives for participation, which secure implementation by accommodating the divergent constructions of those charged with putting initiatives into practice. [Copyright &y& Elsevier]

This paper aims to understand the relationship between area level deprivation and monthly COVID-19 cases in England in response to government policy throughout 2020. The response variable is monthly reported COVID-19 cases at the Middle Super Output Area (MSOA) level by Public Health England, with Index of Multiple Deprivation (IMD), ethnicity (percentage of the population across 5 ethnicity categories) and the percentage of the population older than 70 years old and time as predictors. A GEE population-averaged panel-data model was employed to model trends in monthly COVID-19 cases with the population of each MSOA included as the exposure variable. Area level deprivation is significantly associated with COVID-19 cases from March 2020; however, this relationship is reversed in December 2020. Follow up analysis found that this reversal was maintained when controlling for the novel COVID-19 variant outbreak in the South East of England. This analysis indicates that changes in the role of deprivation and monthly reported COVID-19 over time cases may be linked to two government policies: (1) the premature easing of national restrictions in July 2020 when cases were still high in the most deprived areas in England and (2) the introduction of a regional tiered system in October predominantly in the North of England. The analysis adds to the evidence showing that deprivation is a key driver of COVID-19 outcomes and highlights the unintended negative impact of government policy. • Area level deprivation is significantly associated with monthly COVID-19 cases. • Initially, areas with higher levels of deprivation had higher reported cases. • Government policy played a role in reversing this relationship. [ABSTRACT FROM AUTHOR]

Abstract: This paper uses national survey data for young adults in England to explore empirically the relationships between social fragmentation in communities (measured for geographical areas), social support experienced by individuals from their immediate social circle, and psychosocial health of young adults. After reviewing previous research about these associations, we adopted an empirical approach to these questions, which was innovative in using data on area social fragmentation from a different source to the survey data on individuals. Also, we have examined the relevance for mental health of interactions between individual social support and area social fragmentation, as well as their independent associations with health. To test these ideas empirically, we present a statistical analysis, using survey data from the national Health Survey for England on young people aged 16–24 years, linked to a geographical indicator of social fragmentation, derived from the population census and with a measure of material poverty. The outcome variable was distress measured by the General Health Questionnaire (GHQ). In a logistic regression model that controls for grouping of individuals within areas we included data on individuals’ sex, ethnic group, employment status, social class and educational level. Controlling for these indicators, we demonstrate that risk of individual distress (indicated by GHQ score of 3+) was significantly and positively associated with area social fragmentation and there was a significant association with social support received within the individual''s immediate social circle, which was negative (‘protective’). An index of material poverty in one''s area of residence did not predict individual distress. There was no evidence that social support was more ‘protective’ in areas of greatest social fragmentation. We also note that while being in employment was associated with better mental health in this sample, higher educational level was associated with worse average levels of distress (controlling for age). We consider some of the policy implications of the findings. [Copyright &y& Elsevier]

Abstract: In a context of rapid technological advances in health care and increasing demand for expensive treatments, local formulary committees are key players in the management of scarce resources. However, little is known about the information and processes used when making decisions on the inclusion of new treatments. This paper reports research on the use of economic evaluations in technology coverage decisions in England, although the findings have a relevance to other health care systems with devolved responsibility for resource allocation. It reports a study of four local formulary committees in which both qualitative and quantitative data were collected. Our main research finding is that it is an exception for cost-effectiveness analysis to inform technology coverage decisions. Barriers to use include access and expertise levels, concerns relating to the independence of analyses and problems with implementation of study recommendations. Further barriers derive from the constraints on decision makers, a lack of clarity over functions and aims of local committees, and the challenge of disinvestment in medical technologies. The relative weakness of the research-practice dynamics in this context suggests the need for a rethinking of the role of both analysts and decision makers. Our research supports the view that in order to be useful, analysis needs to better reflect the constraints of the local decision-making environment. We also recommend that local decision-making committees and bodies in the National Health Service more clearly identify the ‘problems’ which they are charged with solving and how their outputs contribute to broader finance and commissioning functions. This would help to establish the ways in which the routine use of cost-effectiveness analysis might become a reality. [Copyright &y& Elsevier]

Abstract: Changes in health socio-economic inequalities are currently measured by comparing the mortality gradient across aggregates of small administrative areas at two points in time. However, this methodology may be flawed as it ignores population movement, which previous research has shown to be selective, with a net loss of the more affluent (and possibly healthier) residents from deprived to more affluent areas. This paper investigates whether selective migration contributed sufficiently to the observed socio-economic gradients in mortality in England and Wales throughout the 1990s so as to invalidate the current method of monitoring health inequalities. The ONS Longitudinal Study for England and Wales was used to calculate directly standardised mortality rates (DSR) by decile of deprivation in 1991 and 2001. The DSRs for 2001 were calculated twice, once according to decile of residence in 2001, and also according to the original decile in 1991. Selective migration was found to make an important contribution in explaining increases in inequalities between areas, accounting for about 50% of the increase for those aged less than 75. At the older age groups, however, selective migration was responsible for a narrowing of mortality differentials over time. These results indicate that caution should be exercised when using repeated ecological studies in assessing the extent of changes in inequalities over time. [Copyright &y& Elsevier]

Abstract: The increased appreciation of the effects socio-ecological factors have on health, witnessed over the last few decades, has given rise to many international, national, and local Health For All (HFA) initiatives tasked with addressing them. However, such initiatives have had to operate within environments which were not specifically designed for them or for the new social (rather than medical) perspective on health they were based upon. As a result, they have been facing significant barriers and constraints to fulfilling their mission. This paper explores the constraints which are imposed on such initiatives by the various environments within which they are nested. Drawing upon our experience in evaluating European Healthy City (HC) projects and English Health Action Zones (HAZs), we develop a dynamic conceptual model which shows how the national, governmental policy, interorganisational, organisational, and initiative environments relate with each other and their cumulative effects on initiatives. We argue that this model, and the principles on which it is based, can be used constructively to identify constraints facing HFA-type initiatives in many countries. We use our case study of English HCs and HAZs to illustrate the applicability of the model in a particular national context. We, first, interpret the model to reflect differences and similarities between their respective environments and trace the sources of the different constraints they encountered. We, then, show how an alternative structural configuration could enable some of these constraints to be eliminated. We argue that what is needed for HFA initiatives to be able to fulfill their brief in full is for governments to rethink existing organisational structures and update them to match the evolution of ideas on health which have emerged over the last decades. [Copyright &y& Elsevier]

Abstract: The paper explores the phenomenon of early parenthood in minority ethnic communities in England. The data were collected using focus group interviews, in-depth semi-structured interviews and a telephone survey. The sample consisted of 139 participants (41 service providers, 10 grandmothers, 88 young parents). The findings map out the complexity and diversity of experience of early parenthood amongst young people of minority ethnic origin, not least the multiple attachments many experience in relation to their social groups, religious affiliations and the traditional patterns of parenting within their immediate and extended family. Both the young parents and professionals in this study constructed early parenthood in more positive terms than is currently portrayed in the contemporary policy. The findings are analysed and discussed in relation to ethnic identity, social inclusion and exclusion. We explore participants’ attempts to counter negative ‘deficit’ models of early parenthood with reference to perspectives on youth, parenthood and contemporary strategic policy. In conclusion, we suggest an unambiguous focus on the reduction of pregnancy is not a credible message when teenage pregnancy is a social norm for a particular ethnic or cultural group. For young parents of Muslim faith in particular, teenage parenting within marriage is not necessarily considered a ‘problem’ or seen as a distinctive event. Most participants did not view early parenthood as a barrier to re-establishing career and educational aspirations. A wide diversity of experience amongst young parents is evidenced in the communities studied; this needs to be reflected more comprehensively both in UK policy and in support services. [Copyright &y& Elsevier]

Abstract: Hirschman contrasts exit and voice as ‘recuperation’ mechanisms for making organisations responsive to users. However, the emergence of health-care quasi-markets and of network governance structures since Hirschman necessitate revising his theory, for they complicate the relationships between governance structures and recuperation mechanisms. Using a case study of nine primary care trusts (PCTs), this paper analyses the recuperation mechanisms, governance structures and relations between them in primary care in England. User voice can be exercised through dedicated networks besides hierarchies. As well as the ‘user exit’ described by Hirschman, two new ‘exit’ mechanisms now exist in quasi-markets. Commissioner exit occurs when a third-party payer stops using a given provider. Professional proxy exit occurs when a general practitioner (GP) fund-holder (or analogous budget-holder) behaves similarly. Neither exit mechanism requires the existence of mechanisms for user exit from healthcare purchasers, provided strong voice mechanisms exist instead to make commissioners responsive to users’ demands. Establishing such voice mechanisms is not straightforward, however, as the experience of English PCTs illustrates. [Copyright &y& Elsevier]

Abstract: The last two decades have witnessed an upsurge in the development and implementation of ‘Health For All-type’ initiatives in many parts of the world. However, despite the popularity of the approach, barriers and constraints to the fulfillment of their remit still persist, making it difficult for them to achieve the potential originally envisaged. Drawing upon considerable empirical work while evaluating the European Healthy City projects and English Health Action Zones, this paper explores the differences between barriers and constraints and then focuses on barriers as they manifest themselves in England. It distinguishes between cultural barriers, stemming from different philosophical, organisational, and professional/experiential cultures, and political barriers, stemming from both party political and realpolitik concerns. It discusses how these barriers often operate together, compounding their individual impacts, with detrimental effects for Health For All initiatives. Consequently, while the prevailing rhetoric appears to promote an alternative, and more appropriate, vision of how health can be maintained and enhanced, these barriers effectively function to sustain the hegemony of the status quo which was, and is, based on a different and outdated vision. We argue that acknowledging the continuous persistence of these barriers is an essential first step towards turning the prevailing health-related rhetoric into reality. [Copyright &y& Elsevier]

Abstract: This examination of how Chinese migrant women resident in England engage with Western and Chinese healthcare systems when seeking treatment considers whether medical pluralism can enhance the cultural appropriateness of health care. The paper identifies the extent to which women''s pathways to healthcare can be seen as ‘Chinese’ or as a reflection of the Western culture in which they live. It is based on an analysis of in-depth interviews with 42 women of Chinese origin living in the South East of England. Their use of Western and Chinese medicine is related to explanatory models underpinning health beliefs, treatment barriers encountered and resources drawn upon when seeking treatment. Variation is described, with some women using only Western medicine and others returning to their place of origin for indigenous Chinese medical treatment. Most, however, draw upon both medical systems. Women who are more connected with majority English culture are more successful in their consultations with Western health service practitioners but do not necessarily discontinue using Chinese medicine. We find that recourse to two different systems helps to overcome barriers when accessing health care. The health policy implications of the findings would suggest that a system that acknowledges and embraces medical pluralism would assist the development of culturally appropriate health care provision. [Copyright &y& Elsevier]

In the UK, a small private health care sector has always existed alongside the national health service (NHS). The conventional assumption is that doctors who work as salaried employees of the NHS are guided in their clinical practice by professional values which encourage them to put their patients’ interests first. A common suspicion is that doctors undertaking fee-for-service practice in the private sector are motivated by self-interest, with commitment to their patients compromised by consideration for their purse. The great majority of hospital consultants are salaried employees of the NHS, but most also undertake some private practice. This paper uses findings from an interview study of 60 surgeons and physicians engaged in dual practice of this kind to investigate their reasons for working in this way and look at how they reconcile their personal, professional and public sector values and responsibilities with the temptations of the market. The existence of the private sector and their own engagement in it was regarded by almost all respondents as a net benefit, not only to themselves and their private patients, but also to the NHS, so long as they handled it properly. The interviews revealed a complex range of beliefs and assumptions through which these doctors justify their activities and a variety of informal principles for dealing with such conflicts of interest as they acknowledge. Neither their values nor their actions can be adequately explained using generic concepts of professional self-interest or public service values without consideration of what such concepts represented in the specific social, economic, professional and policy context of health care in south-east England at the time of the study. [Copyright &y& Elsevier]

Attempts to control hospital expenditure by managing down General Practitioner (GP) referrals are reoccurring features of UK health policy. However, despite the best efforts of GPs to benchmark referral criteria, patient health may be damaged and other costs created by constraining referrals to targets. This paper adopts an indirect method to indicate whether rationing practice referrals may damage population health by distorting the use of health resources away from patients' interests. We utilise a comprehensive database at practice level that allows us to explore the relationship between referrals and emergency admissions, using a panel fixed effects model of admissions that allows for the endogeneity of referrals. We find that practice referrals are positively and partially correlated with emergency admissions, which is consistent with time-varying practice-level sickness shocks driving the relationship between referrals and emergency care, rather than shocks to the practice willingness to refer, or to system reforms. In this environment, government policy to constrain referrals may make the elective care less responsive to practice-level variations in illness, and thereby lower health. • We find evidence that emergency admissions and referrals are positively correlated. • Variations in patient health drive both referrals and emergency admissions. • Relationship is more disparate in deprived areas. • Trying to cut costs in the NHS by simply reducing referrals is likely flawed. [ABSTRACT FROM AUTHOR]

This paper examines trends in mental health among adults in England during the period of economic recovery and austerity following the 2008 'great recession'. We report analysis of data on 17,212 individuals living in England, from the longitudinal Understanding Society Survey (USS). We examined how individual's self-reported mental health over time (2011–2017), related to their changing socio-geographical status. Self-reported mental health is reported in the USS using version 2 of the SF12 Mental Component Summary. Trends in this score (across 5 observations per subject) were categorised into Mental Health Trajectory Groups (MHTGs) using Group Based Trajectory Modelling. We used maximum-likelihood multinomial logit models to estimate for individuals the relative likelihood of belonging to different Mental Health Trajectory categories as compared with a 'base' category, for whom mental health was good and stable throughout the period. We focus on likelihood of belonging to a group showing 'declining' mental health. Predictor variables included individuals' attributes and area conditions in their places of residence (including Office of National Statistics indicators of local employment deprivation and data on average income loss within districts due to welfare benefit reforms, published by the Centre of Regional Economic and Social Research at Sheffield Hallam University, UK). Our results emphasise the multiple socio-geographical 'determinants' likely to be operating on individual mental health. Declining mental health was associated both with conditions at the start of the study period and with social and socio-geographical mobility by the end of the study period. Risks of declining mental health were significantly greater for more deprived individuals and also (controlling for individual attributes) among those living in English neighbourhoods that were already economically disadvantaged at the beginning of the 'great recession' and located in districts where average incomes were most severely impacted by the effects of governmental austerity programmes on welfare benefits. • Study of trends in adult mental health following the 2008 'great recession'. • Data on 17,212 individuals in England, from the Understanding Society Survey. • Individual data linked to information on places of residence. • Risk of declining mental health (compared with stable good health) is analysed. • Area deprivation, welfare reforms, socio-economic mobility are important risk factors. [ABSTRACT FROM AUTHOR]