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Previous studies of service reconfiguration in healthcare have explored the influence of power on processes and outcomes. However, in these accounts the moral agency of managers is often underemphasised. This paper draws on the theoretical tools provided by the sociology of morality to help deepen understanding of the interaction between power and moral agency in service reconfiguration in healthcare. It presents results from a qualitative study of a pan-organisational service reconfiguration in the NHS in England, involving nineteen in-depth interviews with those leading the change and the analysis of twelve programme documents. We combine concepts of the moral background and epistemic governance to interpret participants' conviction that the service change was 'the right thing to do'. The paper shows how epistemic work carried out by service change regulations shaped the moral background within which participants worked. This, in turn, channelled their moral agency – specifically their commitment to patient care – in a way that also reflected central priorities. The paper adds to sociological understandings of service reconfiguration through considering the interaction of structure, agency and power, while also developing the concept of the moral background to show how power relations can influence moral beliefs. • Managers can show strong faith in uncertain evidence for healthcare service change. • The moral background explains this in a way which considers power and moral agency. • Confidence in evidence depends on background assumption of future as predictable. • Confidence also depends on premise that finances are not open to moral evaluation. • Service change regulations carry out epistemic work on background assumptions. [ABSTRACT FROM AUTHOR]

Objective: To identify attitudes towards pharmacy characteristics and promotional methods for selected pharmacy public health services (lifestyle advice and screening for cardiovascular risk factors) among different sectors of the general public. Study design: Cross-sectional survey, using a previously validated questionnaire. Methods: Three survey methods were used, across 15 areas of England, to maximize diversity: face-to-face; telephone; and self-completion of paper questionnaires. Responses to closed questions regarding characteristics and promotion were quantified and differences among sub-groups explored by univariate and multivariate analysis. Results: In total, 2661 responses were available for analysis: 2047 face-to-face; 301 telephone; and 313 paper. There were strong preferences for a pharmacy near to home or doctor's surgery and for long opening hours, particularly among employed people and nonwhites. Fifty percent preferred not to use a pharmacy in a supermarket, particularly older people, the retired, those of lower education and frequent pharmacy users. Personal recommendation by health professionals or family/friends was reported as most likely to encourage uptake of pharmacy public health services, with older people and males being less likely and frequent pharmacy users more likely to perceive any promotional method as influential. Posters/leaflets were preferred over mass-media methods, with fewer than 30% perceiving the latter as potentially influential. Conclusion: Pharmacists, pharmacy companies and service commissioners should use promotional methods favoured by potential users of pharmacy public health services and be aware of differences in attitudes when trying to reach specific population sub-groups. For personal recommendation to be successful, good inter-professional working and a pro-active approach to existing customers are needed. [ABSTRACT FROM AUTHOR]

An endemic challenge facing healthcare systems around the world is how to spread innovation more widely and sustainably. A common response to this challenge involves conducting pilot implementation studies to generate evidence of the innovation's benefits. However, despite the key role that such studies play in the local adoption of innovation, their contribution to the wider spread and sustainability of innovation is relatively under-researched and under-theorized. In this paper we examine this contribution through an empirical examination of the experiences of an innovation intermediary organization in the English NHS (National Health Service). We find that their work in mobilizing pilot-based evidence involves three main strands; configuring to context; transitioning evidence; and managing the transition. Through this analysis we contribute to theory by showing how the agency afforded by intermediary roles can support the effective transitioning of pilot-based evidence across different phases in the innovation journey, and across different occupational groups, and can thus help to create a positive feedback loop from localized early implementers of an innovation to later more widespread adoption and sustainability. Based on these findings, we develop insights on the reasons for the unnecessary repetition of pilots – so-called 'pilotitis'- and offer policy recommendations on how to enhance the role of pilots in the wider spread and sustainability of innovation. • Innovation intermediaries mobilize evidence from pilot studies to spread innovation. • Pilot-based evidence can link early adoption to wider spread and sustainability. • Mobilizing involves co-creating multiple forms of evidence with different groups. • Intermediary roles allow transitioning of pilot-based evidence into wider adoption. • Pilotitis involves a failure to transition evidence along the innovation journey. [ABSTRACT FROM AUTHOR]

There is limited literature on the processes of choice-making in families of young people with learning disabilities. This paper examines the factors considered by parents of young people with learning disabilities when deciding their own and their child's role in a range of significant choices (health, social care and education) about their child's life. The paper reports data collected from a sub-sample of 14 parents recruited from 11 families participating in a longitudinal (2007–2010) qualitative study based in England. The parents all had children with learning disabilities and participated throughout the study. Data were collected over three semi-structured interviews. Parents' accounts demonstrated a continuum of parental involvement ranging from young people being unaware a choice was taking place to young people being fully involved in choice-making. Parents did not always adopt the same approach to choice-making; different approaches to their own and their son/daughter's level of involvement emerged when parents discussed different choices. Five choice-making factors are presented. These factors were used by parents to guide their own and their child's level of involvement. Although young people's level of understanding was considered, it was not always the most important factor. Other factors were important and, at times, could be considered more important by parents. The other factors were: parents' views on the nature of the choice, protecting their child, parents' personal attitudes/beliefs and confidence in practitioner knowledge. Insights from these factors highlight some important practice issues when practitioners work with families of young people with learning disabilities making significant life-choices. [Copyright &y& Elsevier]

Abstract: Operational Research (OR) analysts work alongside other specialists in providing policy analysis for the Department of Health in England. This paper outlines the roles played by OR analysis, taking three different areas of policy for illustration, with examples drawn from projects related to health service operation, health protection and health promotion. In addition to the provision of technical modelling skills, the contributions that OR analysts make to the processes of problem formulation and evidence synthesis are discussed. The paper concludes with some general reflections on what makes for successful OR in this context and on the challenges and opportunities faced by OR in informing health policy over the coming years. [Copyright &y& Elsevier]

A brief glance through the national papers and medical press shows the depth of concern with the cost of delivering high quality, free at the point of access healthcare to the population. However, at a time of increasingly greater demands being placed on public health systems across the globe, the question of how we can make health and healthcare both accessible to everyone and sustainable in the tong term is being posed. In this paper we provide an insight into how England is responding to these challenges. [ABSTRACT FROM AUTHOR]

This paper presents findings from a study of the context and processes of provider mergers in the NHS in England. Mergers are an example of organisational restructuring, a key lever for change in the UK health care sector and elsewhere, although it is only one strategy for organisational change. The framework for the study is key themes from the organisational change literature: the complexity of the effects of change; the importance of context; and the role of organisational culture. The drivers for health care mergers and the evidence for these are analysed.Using documentary analysis and in-depth qualitative interviews with internal and external stakeholders, the first part of the paper reports on stated and unstated drivers in nine mergers. This provides the context for four in-depth case studies of the process of merger in the second and third years post-merger.Our study shows that the contexts of mergers, including drivers of change, are important. Merger is a process without clear boundaries, and this study shows problems persisting into the third year post-merger. Loss of management control and focus led to delays in service developments. Difficulties in the merger process included perceived differences in organisational culture and perceptions of ‘takeover’ which limited sharing of ‘good practice’ across newly merged organisations. Merger policy was based on simplistic assumptions about processes of organisational change that do not take into account the dynamic relationship between the organisation and its context and between the organisation and individuals within it. Understanding the process of merger better should lead to a more cautious approach to the likely gains, provide understanding of the problems that are likely in the period of change, and anticipate and avoid harmful consequences. [Copyright &y& Elsevier]

Background The predicted demographic changes internationally have implications for the nature of care that older people receive and place of care as they age. Healthcare policy now promotes the implementation of end-of-life care interventions to improve care delivery within different settings. The Gold Standards Framework in Care Homes (GSFCH) programme is one end-of-life care initiative recommended by the English Department of Health. Only a small number of care homes that start the programme complete it, which raises questions about the implementation process. Aim To identify the type, role, impact and cost of facilitation when implementing the GSFCH programme into nursing care home practice. Design A mixed-methods study. Setting Nursing care homes in south-east England. Participants Staff from 38 nursing care homes undertaking the GSFCH programme. Staff in 24 nursing care homes received high facilitation. Of those, 12 also received action learning. The remaining 14 nursing care homes received usual local facilitation of the GSFCH programme. Methods Study data were collected from staff employed within nursing care homes (home managers and GSFCH coordinators) and external facilitators associated with the homes. Data collection included interviews, surveys and facilitator activity logs. Following separate quantitative (descriptive statistics) and qualitative (template) data analysis the data sets were integrated by ‘following a thread’. This paper reports study data in relation to facilitation. Results Three facilitation approaches were provided to nursing home staff when implementing the GSFCH programme: ‘fitting it in’ facilitation; ‘as requested’ facilitation; and ‘being present’ facilitation. ‘Being present’ facilitation most effectively enabled the completion of the programme, through to accreditation. However, it was not sufficient to just be present. Without mastery and commitment, from all participants, including the external facilitator, learning and initiation of change failed to occur. Implementation of the programme required an external facilitator who could mediate multi-layered learning at an individual, organisational and appreciative system level. The cost savings in the study outweighed the cost of providing a ‘being present’ approach to facilitation. Conclusions Different types of facilitation are offered to support the implementation of end-of-life care initiatives. However, in this study ‘being present’ facilitation, when supported by multi-layered learning, was the only approach that initiated the change required. [ABSTRACT FROM AUTHOR]

This paper interrogates the legitimacy of formal ethical regulation regarding people with dementia under the Mental Capacity Act, 2005 in England and Wales. Under the Act, research among people diagnosed with dementia must be approved by Health Research Authority committees, irrespective of whether that research engages with health organisations or service users. As examples, I discuss two ethnographic dementia studies that do not engage with healthcare services, but which nonetheless require HRA approval. These instances raise questions regarding legitimacy and reciprocity in the governance of dementia. Through capacity legislation, the state exerts control over people with dementia, automatically delineating them as healthcare subjects because of their diagnoses. This diagnosis functions as a form of administrative medicalisation, rendering dementia a medical entity and those diagnosed with it the property of formal healthcare. However, many people with dementia in England and Wales do not receive related health or care services beyond diagnosis. This institutional imbalance of high governance and low support undermines the contractual citizenship of people with dementia, wherein state-citizen rights and responsibilities should be reciprocal. In response, I consider resistance to this system in ethnographic research. "Resistance" here is not necessarily deliberate, hostile, difficult or perceived, but rather encompasses micropolitical effects that are contrary to power or control, sometimes emerging from systems themselves rather than individual resistive actors. Resistance can be unintentional, through mundane failures to satisfy specific aspects of governance bureaucracies. It can also be deliberate, through refusals to comply with restrictions that seem cumbersome, inapplicable or unethical, potentially raising questions of malpractice and misconduct. I suggest that resistance is made more probable due to the expansion of governance bureaucracies. On the one hand, the potential for both unintentional and intentional transgression increases, while on the other hand, the capacity for those transgressions to be discovered and rectified decreases, because the maintenance of control over such a system requires vast resources. Behind this ethico-bureaucratic tumult, people with dementia themselves are largely invisible. People with dementia often have no interaction with committees that determine their research participation. This further renders ethical governance a particularly disenfranchising facet of the dementia research economy. The state stipulates that people with dementia must be treated differently because of their diagnoses, without consulting those people. In response, resistance to unethical governance could be intuitively deemed ethical per se, but I suggest that such a simplistic binary is somewhat misleading. • Capacity law extends state control over people receiving little state support. • High control and low support weakens contractualist citizenship in dementia. • Hence ethical governance of dementia ethnography can have inherently unethical facets. • Raises ethical dilemmas regarding researcher relationships with procedural ethics. • Ambiguous (un)ethical resistance is embedded in procedural dementia research ethics. [ABSTRACT FROM AUTHOR]

Abstract: Change efforts in healthcare sometimes have an ambitious, whole-system remit and seek to achieve fundamental changes in norms and organisational culture rather than (or as well as) restructuring the service. Long-term evaluation of such initiatives is rarely undertaken. We report a secondary analysis of data from an evaluation of a profound institutional change effort in London, England, using a mixed-method longitudinal case study design. The service had received £15 million modernisation funding in 2004, covering multiple organisations and sectors and overseen by a bespoke management and governance infrastructure that was dismantled in 2008. In 2010–11, we gathered data (activity statistics, documents, interviews, questionnaires, site visits) and compared these with data from 2003 to 2008. Data analysis was informed by neo-institutional theory, which considers organisational change as resulting from the material-resource environment and three ‘institutional pillars’ (regulative, normative and cultural-cognitive), enacted and reproduced via the identities, values and activities of human actors. Explaining the long-term fortunes of the different components of the original programme and their continuing adaptation to a changing context required attention to all three of Scott''s pillars and to the interplay between macro institutional structures and embedded human agency. The paper illustrates how neo-institutional theory (which is typically used by academics to theorise macro-level changes in institutional structures over time) can also be applied at a more meso level to inform an empirical analysis of how healthcare organisations achieve change and what helps or hinders efforts to sustain those changes. [Copyright &y& Elsevier]

Abstract: Today in the England there are around 60,000 children and young people in public care, more than one in 200 of the child population. Over the last 12 months about 100,000 children and young people spent some time in public care, almost one in 100 of the child population and the best estimates are that around 3.4% of adults spent some time in public care during their childhood; this is a relatively common experience. So what are the health and other issues for these children and young people during public care and on into adulthood? This paper uses the Every Child Matters outcomes; being healthy, staying safe, enjoying and achieving, making a positive contribution and achieving economic well-being to organize the evidence from the UK and abroad to answer this question. [Copyright &y& Elsevier]

Abstract: This paper describes the application of the principles of evidence based medicine to public health. It recounts the experience of the National Institute for Health and Clinical Excellence in England (NICE) which acquired a remit to develop public health guidance in 2005. Some of the history of the origins of the evidence based approach is described in the writings of Cochrane and others, and the way that this came to be a critical part of the NICE approach to developing clinical cost effectiveness is outlined. The challenge of applying these methods to an evidence base which is social and psychological as well as biomedical is considered. Key problems are identified: the breadth of the evidence base, different analytic levels of explanation, and the length of the causal chain between interventions and outcomes in public health. [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]

This paper proposes that an individual''s self-assessed health (SAH) does not only suffer from systematic reporting bias and adaptation bias but is also biased owing to confounding health norm effects. Using 13 waves of the British Household Panel Survey covering the period 1991–2005, I show that, while there is a negative and statistically significant correlation between SAH and individuals'' own health problem index, this negative effect reduces with the average number of health problems per (other) family member. The relative health bias is small, however, which implies that measures of SAH may not suffer seriously from systematic health norm bias. This is an important finding for researchers working with SAH data as it indicates that we do not have to worry too much about controlling for confounding influences from the health of other household members when estimating SAH regression equations. [Copyright &y& Elsevier]

Abstract: In line with the increasing emphasis on informed choice, women invited for cervical cancer screening in England receive a leaflet containing information on the risk factors and causation of the condition. However, data from a qualitative interview study with 35 women suggest that the ways in which women make sense of this information can vary and frequently do not correspond to the causal pathways and explanations which characterise contemporary professional medical explanations. This paper examines the complex interplay between lay and professional understandings that takes place as women attempt to weave the information they receive, their prior understandings and contextual factors together into some kind of coherent framework, in which each piece of information makes sense in relation to everything else. We conclude by arguing that, while presenting full and accurate information about orthodox medical understandings of cervical cancer causation in an accessible way maybe challenging, partial presentation of ‘the facts’ is likely to be ineffective. [Copyright &y& Elsevier]

Abstract: This paper considers the spatial characteristics of the relationship between deprivation and mortality rates in Scotland. Scotland not only has higher average mortality rates than England and Wales but the greatest spatial concentrations of the poorest health areas in Britain. Recent analysis has suggested that degree of deprivation alone cannot explain the majority of Scotland''s ‘excess’ poor health relative to England and Wales, a finding referred to as the ‘Scottish effect’. This analysis considers if the spatial patterning of deprivation could be significant to understanding of high mortality in Scotland. Exploratory spatial data analysis methods are implemented to study the spatial relationships between deprivation and standardised mortality ratios (SMRs) in post-code sectors in Scotland. Deprivation was measured using the 2001 Carstairs score, and the total number of deaths during a 3-year period around the 2001 census was used to calculate SMRs. A strong spatial relationship is observed between deprivation and mortality. Deprivation impacts mortality levels not only within the same areas but also in spatially proximate areas. It is concluded that, further research on the ‘Scottish effect’ can benefit from new methodological approaches which assess the variation in both the extent and spatial arrangement of deprivation and mortality in small areas. [Copyright &y& Elsevier]

Abstract: Encouraging self-management has been viewed as one means of reducing health service utilisation and contributing to improved demand management. However, the processes and imputed relationship between self-management education skills and health service contact are poorly understood. This paper reports on data from an embedded qualitative study which ran alongside a randomised controlled trial in England designed to test the clinical and cost effectiveness of a self-care support policy which found no statistically significant reductions in health service utilisation. Drawing on concepts from the sociology of chronic illness, analyses suggest that the biographical and social context relevant to individuals’ experience of living with a long-term condition, history of health service utilisation, and relationships with health professionals are relevant to understanding the impact of self-management education and related policies aimed at bringing about changes in service use. Our study suggests that future health policy assumptions about utilisation in the context of chronic disease management and self-care support polices may benefit by acknowledging the complex, contextual and recursive nature of health service utilisation operating in the life worlds of patients’ experience of living with a long-term condition. [Copyright &y& Elsevier]

Abstract: Contingent valuation (CV) studies in health care have used the willingness to pay (WTP) approach, to the virtual exclusion of willingness to accept (WTA). Outside the health care field, disparities between WTP and WTA values have been observed. Were such disparities to be demonstrated for health care technologies, the conventional assumption of a linear cost-effectiveness plane would be invalidated. This paper employs data derived from interviews with users of the UK''s paediatric cochlear implantation (PCI) programme based in Nottingham (i) to assess the feasibility of estimating WTA for the potential discontinuation of an existing technology, and (ii) to investigate any WTA–WTP disparity which might be revealed. Only one-third of subjects providing WTP values were willing and able to offer a corresponding WTA value. Our qualitative data revealed that modes of response differed between the two valuation approaches. In particular, the presumption of fungibility of the health care intervention was a far more serious obstacle to completing the WTA task than it was for WTP. Among those prepared to offer values under both approaches, mean WTA was approximately four times mean WTP. Until more health studies are conducted, it remains unclear whether or not the findings are specific both to the intervention and to the elicitation format. [Copyright &y& Elsevier]

Abstract: This paper describes general practitioners’ (GPs) experiences of detecting and managing alcohol and alcohol-related problems in consultations. We undertook qualitative research in two phases in the North-East of England. Initially, qualitative interviews with 29 GPs explored their everyday work with patients with alcohol-related issues. We then undertook group interviews—two with GPs and one with a primary care team—where they discussed and challenged findings of the interviews. The GPs reported routinely discussing alcohol with patients with a range of alcohol-related problems. GPs believed that this work is important, but felt that until patients were willing to accept that their alcohol consumption was problematic they could achieve very little. They tentatively introduced alcohol as a potential problem, re-introduced the topic periodically, and then waited until the patient decided to change their behaviour. They were aware that they could identify and manage more patients. A lack of time and having to work with the multiple problems that patients brought to consultations were the main factors that stopped GPs managing more risky drinkers. Centrally, we compared the results of our study with [Thom, B., & Tellez, C. (1986). A difficult business—Detecting and managing alcohol-problems in general-practice. British Journal of Addiction, 81, 405–418] seminal study that was undertaken 20 years ago. We show how the intellectual, moral, emotional and practical difficulties that GPs currently face are quite similar to those faced by GPs from 20 years ago. As the definition of what could constitute abnormal alcohol consumption has expanded, so the range of consultations that they may have to negotiate these difficulties in has also expanded. [Copyright &y& Elsevier]

Abstract: Through the lens of the ‘welfare of the child’ assessment, this paper explores how staff working in the area of in vitro fertilisation and preimplantation genetic diagnosis (IVF/PGD) balance reflexive relations of legitimacy and accountability between the public and private spheres, and between medicine, the citizen and the state. The wider research of which this analysis is a part uses multiple methods to study two National Health Service Assisted Conception Units in England. Research methods used included observation clinics and interviews with staff from a range of disciplines. We illustrate how the staff reveal tensions between their views that the welfare of the child assessment can be seen as intrusive and discriminatory, and on the other hand that medical intervention in reproduction should be socially and professionally accountable. These tensions can be understood sociologically in terms of a gradual movement from socially based solutions to fertility problems and disabilities, towards a biomedical, and arguably genetically oriented worldview of such problems. Rather than being viewed as discrete, these two orientations should be seen as indicating an emergent direction of travel along a continuum, with elements of both being present in the accounts. We argue that consideration of the welfare of the child involves staff in ethical boundary-work across the two orientations and between the accountabilities and responsibilities of healthcare professionals, individuals and the state. [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: Medicine finds human blood infinitely useful. It is a source of important and sometimes controversial information about individuals, their relatives and the general public. Blood also has economic value, carries a heavy cultural freight, and can transmit dangerous diseases. Yet there is precious little sociological analysis of how these radically different applications, potentials and significations are managed in health care settings where, it is no exaggeration to claim, everyday a vast quantity of blood is produced by venepuncture. This paper focuses on blood produced in hospitals for tests. The data were derived from 19 focus groups of patients, health care professionals, and members of the public, held between 2002 and 2003, in and around the obstetrics and gynaecology department of a large London teaching hospital. Not surprisingly, all the participants had had a blood test at some time or other. Yet their responses suggest no template exists for talking about them. No-one—lay or professional—had a full picture of how blood produced for tests circulates around the hospital. Lay people tended to envisage it as remaining in a liquid form whereas health care professionals saw it as materially and substantially transformed. Participants deployed a variety of ritual and rhetorical devices that devalue blood produced for tests. Nonetheless, blood left over from tests emerged as a significant anomoly, simultaneously an excess (waste), a challenge (to use wisely), or a potential crime (illegitimate research). [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]

During recent years, health geography has focused increasingly on how people's experiences of health and places are interrelated. This has included historical research on a variety of well-known places and remarkable events. In contrast, relatively little attention has been paid to how health and health care can be influential historically to the development, image and identity of `everyday' and ordinary places. We focus on the case of a small town in Southern England to demonstrate the long and diverse historical connections that exist between health and such places. Using both historical documents and local literature, the paper reviews early invasions and incursions, epidemics of infectious disease, the development of a therapeutic seaside resort, the impacts of the Second World War, and more recent social and economic developments associated with an ageing population. Complex and diverse health-related histories are shown to be interwoven with local and extra-local histories including those of national or international significance. We argue that health histories can be integral to shaping the past and present of places and our broader understandings and interpretations of them. From a disciplinary perspective, we contend that by adopting theoretical perspectives from cultural geography, an enhanced historical geography of health could disentangle these historical strands, tell these important stories and put everyday health histories in their place. [ABSTRACT FROM AUTHOR]

This paper discusses the perceived benefits to a local health authority and a district council environmental services department of a joint approach to a health impact assessment (HIA) of a proposed container port development in North Essex, England. The main perceived benefits were: the opening up of contacts within each organisation; the development of local working relationships between the agencies involved; the exchange of knowledge; the sharing of expertise; the opportunity to address a wide range of health impacts; greater credibility of the assessment during discussion with the decision-makers; the pooling of resources; and greater ownership of the assessment. [Copyright &y& Elsevier]

The article presents some of the highlights of the 14th United Kingdom Public Health Association annual forum held in West Midlands, England. The event addressed issues relating to overcoming health inequalities, promoting sustainable development and dealing with anti-health forces. Papers presented during the conference focus on public health issues and social marketing interventions. Attendees include Health State Secretary Patricia Hewitt and speakers Derek Wanless and Melvyn Hillsdon.

Local authorities in England are required to routinely collect administrative data on children in care and cross-sectional analyses of national data are published by central government. This paper explores the usefulness of undertaking a longitudinal analysis of these data at local authority level to determine the care pathways for children entering care, differentiating by age at entry. The sample consisted of 2208 children who entered care in one English local authority over a six-year period, and who were followed up for at least 2 years. A logistic regression model was fitted to explore factors associated with children staying long term in care. Age at entry was a key determinant of where children ended up (return to a parent, special guardianship or residence order, adoption or staying long term in care). Only a minority of entrants (mainly those entering care in their middle years) remained in longer term care. For the vast majority of children, the 'pre-care family context' remains important as children will either return to parents or relatives or stay in touch with them. The findings are used to urge service planners to make full use of data on care entrants, especially age at entry, when deciding on the balance between the different placement options needed, and the social work service delivery models. • After two years in care over one third of children (37%) had returned to their parents. • Just under one third of children (31%) stayed at least two years in care. • Age at entry was a very strong predictor of where children ended up. • Children age 0–2 were more likely to be adopted than any other outcome. • More than half (51%) of children entering care age 7–11 stayed long term in care. [ABSTRACT FROM AUTHOR]