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Purpose: Recovery Colleges (RCs) have been implemented across England with wide variation in organisational characteristics. The purpose of this study is to describe RCs across England in terms of organisational and student characteristics, fidelity and annual spending, to generate a RC typology based on characteristics and to explore the relationship between characteristics and fidelity. Methods: All RC in England meeting criteria on recovery orientation, coproduction and adult learning were included. Managers completed a survey capturing characteristics, fidelity and budget. Hierarchical cluster analysis was conducted to identify common groupings and generate an RC typology. Results: Participants comprised 63 (72%) of 88 RC in England. Fidelity scores were high (median 11, IQR 9–13). Both NHS and strengths-focussed RCs were associated with higher fidelity. The median annual budget was £200,000 (IQR £127,000–£300,000) per RC. The median cost per student was £518 (IQR £275–£840), cost per course designed was £5,556 (IQR £3,000–£9,416) and per course run was £1,510 (IQR £682–£3,030). The total annual budget across England for RCs is an estimated £17.6 m including £13.4 m from NHS budgets, with 11,000 courses delivered to 45,500 students. Conclusion: Although the majority of RCs had high levels of fidelity, there were sufficiently pronounced differences in other key characteristics to generate a typology of RCs. This typology might prove important for understanding student outcomes and how they are achieved and for commissioning decisions. Staffing and co-producing new courses are key drivers of spending. The estimated budget for RCs was less than 1% of NHS mental health spending. [ABSTRACT FROM AUTHOR]

This paper draws on coupling and systems frameworks to investigate the relationships between two English Multi-Academy Trusts (MATs) and their member schools in how decisions are made around budgeting, recruitment processes, and curriculum and assessment. Findings demonstrate when and under what conditions executive leaders and specifically CEOs, as primary agents of coupling, created greater consistency across schools either through centralization or deliberate alignment of school improvement planning, while operating within their complex institutional environments. Implications for practice, policy, and research on system-wide reform are discussed. [ABSTRACT FROM AUTHOR]

In 2003, the Department for Education in England commissioned research which supported the policy drive to reduce the reliance on statements for special educational needs (SEN). Twenty years on and the government's emphasis has now switched from reducing workload to creating financially sustainable systems. There continues to be wide variations in local authority (LA) statutory assessment practice, with considerable differences in the proportion of pupils with education, health and care plans (EHCPs), even when benchmarked across demographically comparable authorities. LAs with low EHCPs have smaller high needs block (HNB) budgets but typical rates of special needs and disability (SEND) Tribunal appeals. A comparison is also made of the statutory assessment process within the four nations of the UK. The discussion considers the implications of the findings for sustainable high needs systems and for appropriately managing the demand for EHCPs. The current 25-year trendline is projecting towards 10% EHCPs by 2042, a remarkable increase from 2.5% in 2017. [ABSTRACT FROM AUTHOR]

Background: Understanding the health care activity and associated hospital costs of caring for people living with HIV is an important component of assessing the cost effectiveness of new technologies and for budget planning. Methods: Data collected between 2010 and 2017 from an English HIV treatment centre were combined with national reference costs to estimate the rate of hospital attendances and costs per quarter year, according to demographic and clinical factors. The final dataset included records for 1763 people living with HIV, which was analysed using negative binomial regression models and general estimating equations. Results: People living with HIV experienced an unadjusted average of 0.028 (standard deviation [SD] 0.20) inpatient episodes per quarter, equivalent to one every 9 years, and 1.85 (SD 2.30) outpatient visits per quarter. The unadjusted mean quarterly cost per person with HIV (excluding antiretroviral drug costs) was £439 (SD 604). Outpatient appointments and inpatient episodes accounted for 88% and 6% of total costs, respectively. In adjusted models, low CD4 count was the strongest predictor of inpatient stays and outpatient visits. Low CD4 count and new patient status (having a first visit at the Trust in the last 6 months) were the factors that most increased estimated costs. Associations were weaker or less consistent for demographic factors (age, sex/sexual orientation/ethnicity). Sensitivity analyses suggest that the findings were generally robust to alternative parameter and modelling assumptions. Conclusion: A number of factors predicted hospital activity and costs, but CD4 cell count and new patient status were the strongest. The study results can be incorporated into future economic evaluations and budget impact assessments of HIV‐related technologies. [ABSTRACT FROM AUTHOR]

This study aimed to test (official) evaluation criteria including the potential role of budget impact (BI) on health technology assessment (HTA) outcomes published by the Federal Joint Committee (Gemeinsamer Bundesausschuss [GBA]) and the Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen [IQWiG]) in Germany as well as the National Institute for Health and Care Excellence (NICE) in England. Data were extracted from all publicly available GBA decisions and IQWiG assessments as well as NICE single technology appraisals between January 2011 and June 2018, and information with regard to evaluation criteria used by these agencies was collected. Data were analyzed using logistic regression to estimate the effect of the BI on the HTA outcomes while controlling for criteria used by GBA/IQWiG and NICE. NICE recommendations are largely driven by the incremental cost-effectiveness ratio and, if applicable, by end-of-life criteria (P <.01). While IQWiG assessments are significantly affected by the availability of randomized controlled trials and patient-relevant endpoints (P <.01), GBA appraisals primarily focus on endpoints (P <.01). The BI correlated with NICE single technology appraisals (inverted-U relationship, P <.1) and IQWiG recommendations (increasing linear relationship, P <.05), but not with GBA decisions (P >.1). Nevertheless, given that IQWiG assessments seem to be more rigorous than GBA appraisals regarding the consideration of evidence-based evaluation criteria, decisions by GBA might be negatively associated with the BI. Results reveal that GBA/IQWiG and NICE follow their official evaluation criteria consistently. After controlling for all significant variables, the BI seems to have an (independent) effect on HTA outcomes as well. • Empirical studies usually focus on the effect of evaluation criteria on recommendations by health technology assessment (HTA) agencies or compare assessment outcomes and underlying regulations. • Findings add to the existing evidence that both the Federal Joint Committee (Gemeinsamer Bundesausschuss [GBA])/Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen [IQWiG]) and the National Institute for Health and Care Excellence (NICE) follow their evaluation criteria consistently, as also reflected in the frequent occurrence of variation in recommendations. Furthermore, budget impact seems to have an effect on HTAs by GBA/IQWiG and NICE. • This article will contribute to health policy making in Europe, in particular to the debate whether and, if so, to what extent budget impact analyses shall be included in HTA to inform decision makers in England and Germany. [ABSTRACT FROM AUTHOR]

This study investigated the impact of local government spending on mental health in England between 2013 and 2019. Guided by the "Health in All Policies" vision, which encourages the integration of health in all decision-making areas, we explored how healthcare and multiple nonmedical budgeting decisions related to population mental health. We used random curve general cross-lagged modelling to dynamically partition effects into the short-run (from t to t + 1) and long-run (from t to t + 2) impacts, account for unobserved area-level heterogeneity and reverse causality from health outcomes to financial investments, and comprehensive modelling of budget items as an interconnected system. Our findings revealed that spending in adult social care, healthcare, and law & order predicted long-term mental health gains (0.004–0.081 SDs increase for each additional 10% in expenditure). However, these sectors exhibited negative short-term impulses (0.012–0.077 SDs decrease for each additional 10% in expenditure), markedly offsetting the long-term gains. In turn, infrastructural and environmental spending related to short-run mental health gains (0.005–0.031 SDs increase for each additional 10% in expenditure), while the long-run effects were predominantly negative (0.005–0.028 SDs decrease for each additional 10% in expenditure). The frequent occurrence of short-run and long-run negative links suggested that government resources may not be effectively reaching the areas that are most in need. In the short-term, negative effects could also imply temporary disruptions to service delivery largely uncompensated by later mental health improvements. Nonetheless, some non-health spending policies, such as law & order and infrastructure, can be related to long-lasting positive mental health impacts. • Dynamic impacts of local spendings on mental health vary in magnitude and sign. • Health-related and law & order spendings relate to improved long-run mental health. • These spendings are however associated with substantial short-run disruptions. • Some nonmedical expenditures relate to better mental health only in the short run. • Policymakers may need to review how financial resources are allocated and utilised. [ABSTRACT FROM AUTHOR]

In April 2013 the local public health function in England was returned from the National Health Service (NHS) to local government, reversing the transfer to the NHS made in 1974 with the abolition of the medical officer of health. Although many in the field had long felt that local government was the appropriate home for public health given its wide-ranging responsibilities for the social determinants of health, the timing was poor. Local government was in the third year of what continued to be an unprecedented ten-year period of austerity imposed by central government with cumulative cuts of the order of 40% for many local authorities. And despite an initial commitment to a ring-fenced public health grant, this grant has been cut each year since 2015–2016 in addition to the wider local authority funding cuts which have had inevitable knock-on effects on the public health function. Crucial public health services such as early years, smoking cessation and sexual health services have all been cut. Despite these cuts the UK government continues to claim a commitment to improving public health and tackling inequalities in health. This study examines the government's discourse on funding local public health services, and the ways in which it has responded to critics through a detailed documentary analysis of key government white papers, ministerial statements and its responses to criticisms, particularly from parliamentary select committees and professional bodies. The paper concludes by considering the implications for effective local public health action in a national regime of austerity. [ABSTRACT FROM AUTHOR]

Drawing on a 2010 analysis of the reform and costs of adult social care commissioned by Downing Street and the UK Department of Health, this paper sets out projected future costs under different reform scenarios, reviews what happened in practice from 2010-19, explores the impact of the growing gap between need and funding, and explores the relationship between future spending and economic growth. In the process, it identifies a 'lost decade' in which policy makers failed to act on the warnings which they received in 2010, draws attention to the disproportionate impact of cuts on older people (compared to services for people of working age) and calls for urgent action before the current system becomes unsustainable. [ABSTRACT FROM AUTHOR]

Background: Local Healthwatch have been operating since 2013 as 'consumer champions' in health and social care in England. There is little evidence about how they operate and the daily practices through which they seek to represent citizen views and influence others. Objective: To explore (a) the current organizational arrangements, relationships and impact of local Healthwatch in England, and (b) to what extent do these vary across local Healthwatch organizations. Design: An online survey of all 150 local Healthwatch in England between December 2018 and January 2019. The survey comprised 47 questions and used a combination of closed‐ and open‐response questions. Results: We received responses from 96 local Healthwatch (68% response rate). Most local Healthwatch reported that they are 'independent' organizations that only do Healthwatch‐related work (58.3%) and are funded through a contract (79.2%). Budget cuts have affected four‐fifths of local Healthwatch (79.3%) since 2013. Three‐quarters (74%) of local Healthwatch currently receive funding external to that provided by their local authority for their Healthwatch functions. Most Healthwatch engage with only one CCG (56.3%), one mental health trust (82.3%) and one community health trust (62.5%), though 59.4% engage with more than one hospital trust. Healthwatch respondents overwhelmingly reported impacts that were local in nature. Conclusions: Geographical and historical factors, the quality and quantity of their relationships with stakeholders, and different funding arrangements all contribute to high variability in the structure and activities of local Healthwatch and to shaping the nature of their work and impact across England. [ABSTRACT FROM AUTHOR]

Personal health budgets (PHBs) are being promoted in England as expanding the benefits of choice and control to individuals with healthcare needs. National Health Service (NHS) money is provided to eligible people to use as set out in approved care plans, including direct employment of personal assistants (PAs). The government plans to increase NHS‐funded PHBs and to further introduce integrated personal budgets (IPBs). This potentially creates more demand for directly employed or self‐employed PAs with health‐related skills. The objective of this paper is to report findings from interviews with PAs (n = 105) and key informants (n = 26) from across England, undertaken between October 2016 and August 2017, about the potential for the PA workforce to undertake 'health‐related' tasks as facilitated by the introduction of PHBs. PAs were purposefully recruited to ensure the sample included participants from different geographical locations. Key informants were purposefully selected based on their knowledge of policy and community services. Data were analysed quantitatively and qualitatively. This paper focuses on reporting qualitative findings, which are set within the theoretical framework of normalisation process theory to explore implementation challenges of PHBs. The majority (64%) of PAs confirmed that they saw their current roles as congruent with PHBs, were willing to engage with PHBs and undertake health‐related tasks. However, 74% of PAs said they would need additional training if enacting such roles. Key informant interviews appraised the development of PHBs as complex, noting incongruences arising from NHS and social care‐funded PAs carrying out similar roles within different organisational systems. We conclude the current PA workforce is willing to take on PHB work and is likely to interweave this with work funded by PBs and self‐funding care users. Implications include the need for careful consideration of training requirements and delivery for PHB‐funded PAs. [ABSTRACT FROM AUTHOR]

Predicting the future behavior of beach and nearshore systems requires an accurate delineation and understanding of coastal cell boundaries, sediment transport pathways, and sediment sources and sinks. Unfortunately, there is a paucity of field datasets on beach and nearshore morphological change that extend fully from the top of the dunes to beyond the depth of closure to enable quantification of the sediment budget. Here, for the first time, we employ a total sediment budget approach, examining a sandy and embayed beach located in the north coast of SW England, to investigate inter- and multi-annual embayment scale sediment dynamics over a 10-year period that includes extreme storm erosion and post-storm recovery. We demonstrate that, despite the deeply embayed nature of the beach, the shoreline orientation roughly parallel to the dominant wave direction and the overwhelmingly cross-shore forcing of the inter-tidal beach volume, the system is neither closed, nor balanced. The very significant net changes in the recorded sediment volume from dune top to depth of closure (−14.5 m ODN), representing a loss of c. 100 m3 m−1 during the extreme storm period and a gain of c. 200 m3 m−1 during the recovery period, indicate that significant sediment transport occurs seaward of the base of the terminating headlands and beyond the morphological depth of closure. The results further indicate that the inter-tidal region is partly uncoupled from the sub-tidal region, with the former region dominated by cross-shore sediment fluxes, whereas the subtidal region is also significantly affected by longshore sediment fluxes. A conceptual model is presented that balances the observed volume changes with inferred fluxes, forced by variations in total and alongshore wave power. This study contradicts the general assumption that when sediment exits the inter-tidal, it rests undisturbed in the sub-tidal, waiting for a period of low-moderate energy to bring it onshore. The large sediment volumetric variations across the lower shoreface (depth of 5–20 m), which are of the same order of magnitude as, but uncorrelated with, those occurring in the inter-tidal region, are suggestive of an energetic longshore transport system across this deeper region. It is possible that this transport system extends along the whole north coast of SW England and this finding may lead to a shift in understanding of sediment budgets along exposed and macrotidal embayments globally. Unlabelled Image • Full sediment budget was produced along an exposed macrotidal embayment and linked to wave forcing. • Inter- and sub-tidal volumes are not inversely correlated, indicating decoupling. • Sediment budget suggests significant exchange around headlands and/or across depth of closure. • Beaches on this coast type can be considered part of an extended coastal cell. [ABSTRACT FROM AUTHOR]

Aim: To estimate the healthcare costs of diabetic foot disease in England. Methods: Patient‐level data sets at a national and local level, and evidence from clinical studies, were used to estimate the annual cost of health care for foot ulceration and amputation in people with diabetes in England in 2014–2015. Results: The cost of health care for ulceration and amputation in diabetes in 2014–2015 is estimated at between £837 million and £962 million; 0.8% to 0.9% of the National Health Service (NHS) budget for England. More than 90% of expenditure was related to ulceration, and 60% was for care in community, outpatient and primary settings. For inpatients, multiple regression analysis suggested that ulceration was associated with a length of stay 8.04 days longer (95% confidence interval 7.65 to 8.42) than that for diabetes admissions without ulceration. Conclusions: Diabetic foot care accounts for a substantial proportion of healthcare expenditure in England, more than the combined cost of breast, prostate and lung cancers. Much of this expenditure arises through prolonged and severe ulceration. If the NHS were to reduce the prevalence of diabetic foot ulcers in England by one‐third, the gross annual saving would be more than £250 million. Diabetic foot ulceration is a large and growing problem globally, and it is likely that there is potential to improve outcomes and reduce expenditure in many countries. What's new?: At least 2% of people with diabetes experience new foot ulcers annually, and one in 400 undergoes amputation.The cost of diabetic foot disease in England is almost 1% of the health service budget.More than 90% of these costs are for ulcer care.It is hoped that knowledge of human and financial costs will increase research effort, clinical attention and compliance with national guidance, to improve ulcer healing rates and reduce amputations. [ABSTRACT FROM AUTHOR]

Devolution of health systems from national to local levels is a common focus of policymakers across the world. The overarching aim is to improve population health by better meeting the specific needs of local citizens. We examine the case of a coordinated devolution across several public service sectors in Greater Manchester, England, in 2016. We estimate the impact on experienced health and well-being using Short-Form 12 scores from 13,938 adult respondents to the UK Household Longitudinal Survey between 2012 and 2020. We use difference-in-differences and lagged-dependent variable regressions to compare Greater Manchester to the rest of England. We find no statistically significant changes in experienced health and well-being over the four years following the start of devolution. Our findings suggest that devolving population health management alone without budgetary powers and local accountability mechanisms may not be effective in improving experienced health and well-being in the relatively short-term. • We estimate difference-in-differences and lagged-dependent variable regressions. • Greater Manchester devolution had little impact on health-related life quality. • Decentralizing health management alone in England did not improve health outcomes. • Non-fiscal devolution may not improve experienced health and well-being in short-term. [ABSTRACT FROM AUTHOR]

The article discusses how the Royal College of Nursing (RCN) is urging general practice nurses to claim their 6 percent pay increase backdated to April 2023, focusing on distress as a result of the delay between the announcement in July 2023 and the incoming funding in November 2023. It highlights the RCN demands that all general practitioner employers honor the salary increase, claiming increasing prices as a factor.

An increasing burden of chronic disease and multimorbidity has prompted experimentation with new models of care delivery that aim to improve integration across sectors and reduce overall costs through decreased use of secondary care. One approach to stimulate this change is to pool health and social care budgets to incentivise care delivery in the most efficient location. The Better Care Fund is a large pooled funding initiative gradually taken up by local areas in England between 2014 and 2015. We exploit this variation in timing of uptake to examine the short- (1 year) and intermediate-term (up to 2 years) effects of the Better Care Fund on seven measures of hospital use and costs from a cohort of 14.4 million patients constructed using national Hospital Episode Statistics. We test for differential effects on people with multimorbidity. We find no effects of budget pooling on secondary care use for the whole population. For multimorbid patients the use of bed days increased in the short-term by 0.164 (4.9%) per patient per year. In the short-to intermediate-term, pooling health and social care budgets does not reduce hospital use nor costs. However, pooling funds does appear to stimulate additional integration activity. • Pooled budgets can theoretically provide an added incentive to integrate care. • There appears to be a small additional effect of pooling on outcomes. • Effect is not in intended direction, but fits with integrated care literature. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this paper is to present findings from one element of a study exploring the relationship between personalisation, in the form of personal budgets (PBs) for publicly funded social care and safeguarding. Design/methodology/approach: Semi-structured interviews were conducted with 12 people receiving PBs who had recently been the focus of a safeguarding investigation. Participants were recruited from two English local authority areas and data were subject to thematic analysis. Findings: The analysis identified three main themes: levels of information and awareness; safeguarding concerns and processes; and choice and control. Many of the participants in this small study described having experienced multiple forms of abuse or neglect concurrently or repeatedly over time. Research limitations/implications: This was a small scale, qualitative study, taking place in two local authorities. The small number of participants may have had strong opinions which may or may not have been typical. However, the study provides some rich data on people's experiences. Practical implications: The findings suggest that adults receiving PBs may need information on an ongoing and repeated basis together with advice on how to identify and address poor quality care that they are arranging for themselves. Practitioners need to be aware of the influence of the level of information received and the interaction of organisational or legal requirements when responding to safeguarding concerns when care being supplied tries to reflect the benefits of choice and control. Originality/value: This paper reports original research asking adults with care and support needs about the interaction between two key policies of safeguarding and personalisation. [ABSTRACT FROM AUTHOR]

Abstract Health systems around the world face financial pressures that can affect sustainability and patient outcomes, and there is a vast literature devoted to the allocation of scarce health care resources. Capital spending - for example on estates, equipment and information technology - is an important but often neglected area of this literature. This study explores the constraints on the allocation of capital budgets in health care, before addressing the question: what is the role of priority setting and rationing in responses to these constraints? The paper presents findings from interviews conducted with senior finance professionals in 30 National Health Service local provider organisations across England. Findings suggest a pervasive sense of impending crisis, with capital restrictions limiting investment in buildings, infrastructure and equipment. The paper applies a conceptual classification scheme from the classic rationing literature (the forms of rationing framework) and identifies widespread practices of 'selection', 'dilution' and 'delay', with 'denial' and 'termination' comparatively rare. Practices of 'deflection' and 'deterrence' are ascribed to national actors as a means of restricting the flow of capital resources to the system. The study suggests that there is little by way of tailored support for priority setting in capital spending, and a perception that decisions are often reactive and short term. It also suggests that wider system features and dynamics can preclude or constrain priority setting at the organisational level. The authors use these findings to suggest future conceptual development of the forms of rationing framework and make recommendations for research and practice in this area. Highlights • Respondents described capital budget deficits affecting quality and safety of care. • Most had adopted rationing and/or priority setting to help deal with this. • Service dilution, delay and selection were the most cited forms adopted. • Lack of tools and the system context impeded local decision-making. [ABSTRACT FROM AUTHOR]

Personalised budgets are promoted as the person-centred alternative to generically provided services. Nine parents/carers of disabled children (aged 18 years or younger) who accessed at least two rehabilitation therapy services (physiotherapy, occupational therapy, and speech and language therapy) were recruited from one region in England. Focus group/interviews explored their views on the proposed introduction of personalised budgets. Parents and carers viewed a personal health budget with caution and perceived benefits were tempered by their experiences of current provision. Concerns were raised about entitlement and how a personal budget would work in practice. [ABSTRACT FROM PUBLISHER]

Abstract: The role that area deprivation, family poverty, and austerity policies play in the demand for and supply of children's services has been a contested issue in England in recent years. These relationships have begun to be explored through the concept of inequalities in child welfare, in parallel to the established fields of inequalities in education and health. This article focuses on the relationship between economic inequality and out‐of‐home care and child protection interventions. The work scales up a pilot study in the West Midlands to an all‐England sample, representative of English regions and different levels of deprivation at a local authority (LA) level. The analysis evidences a strong relationship between deprivation and intervention rates and large inequalities between ethnic categories. There is further evidence of the inverse intervention law (Bywaters et al., 2015): For any given level of neighbourhood deprivation, higher rates of child welfare interventions are found in LAs that are less deprived overall. These patterns are taking place in the context of cuts in spending on English children's services between 2010–2011 and 2014–2015 that have been greatest in more deprived LAs. Implications for policy and practice to reduce such inequalities are suggested. [ABSTRACT FROM AUTHOR]

Summary This paper reports on part of a research study carried out in three local authority adult social care departments in England, which explored links between adult safeguarding and personalisation. The study included statistical analysis of data on safeguarding referrals and the take up of personal budgets and qualitative interviews with managers, social workers, other staff working on safeguarding and with service users. The paper reports the findings from 16 interviews with managers and social workers, highlighting their perspectives and experiences. Findings Five main themes emerged from our analysis: contexts and risk factors; views about risks associated with Direct Payments, approaches to minimising risk; balancing risk and choice; and weaving safeguarding and personalisation practice. Social workers identified similar ranges and kinds of risks to those identified in the national evaluation of Individual Budgets. They described a tension between policy objectives and their exercise of discretion to assess and manage risks. For example, some described how they would discourage certain people from taking their personal budget as a Direct Payment or suggest they take only part of a personal budget as a Direct Payment. Application This exploratory study supports the continued need for skilled social workers to deliver outcomes related to both safeguarding and personalisation policies. Implementing these policies may entail a new form of ‘care and control’, which may require specific approaches in supervision in order to ensure good practice is fostered and positive outcomes attained. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this paper is to present a case study describing the progress that is being made in one city in England to increase access to Care Act 2014 assessments and personal budgets among people with experiences of homelessness and multiple exclusion.Design/methodology/approach A case study employing a “study group” to describe and reflect on local development work.Findings The authors focus on the “systems change” activity that was undertaken by one voluntary sector partnership project to address issues of referral and access to adult social care. This included the development of a “Multiple Needs Toolkit” designed to support voluntary sector workers to communicate more effectively with adult social care around the application of the new Care Act 2014 eligibility thresholds. The authors discuss the role of “persistent advocacy” in increasing access to assessments and also the limitations of this as regard the potential for poorer joint working.Originality/value Throughout, the authors draw on the “ambiguity-conflict” model of policy implementation to assess if the learning from this single case study might be applied elsewhere. [ABSTRACT FROM AUTHOR]

NICE's budget impact test - in which new drugs that will have a net impact of £20 million or more in any one of their first three years of use will trigger commercial negotiations between NHS England and the drug company - was introduced in April, amid much controversy. Many argue the threshold is too low and will have an unacceptable impact on the availability of new medicines. [ABSTRACT FROM AUTHOR]

Action to address biodiversity declines and climate change must be taken on farmland which covers half of all habitable land on Earth. European governments have predominantly invested in agri-environment schemes (AES) which pay farmers to change their management to the benefit of the environment. We conducted the first UK-based comparison of the cost-effectiveness of this approach with an alternative strategy of land purchase where organisations are contracted to manage government-owned land for nature. We took a novel approach to estimating the costs of paying farmers in an AES to create and manage habitat using results from a choice experiment conducted amongst 118 arable farmers in England. We estimated the costs of land purchase, and its subsequent management, based on the literature. Given equal annual spend, we estimated the benefit delivered by each strategy for a suite of environmental outcomes (bullfinches, lapwings, yellowhammers and climate mitigation) and explored how relative cost-effectiveness varied with budget, discount rate and timescale. We found AES were more cost-effective if budgets for environmental policies do not increase and where the environmental outcome is expected to decline rapidly without action in the next 50 years. However, if budgets were to increase considerably to reflect the scale of the biodiversity and climate crises, land purchase would deliver more biodiversity and climate mitigation in the longer term. The cost-effectiveness of the land-purchase strategy was sensitive to fluctuations in land prices which presents a challenge to policymaking which also must consider the impacts on farming communities of large-scale changes in land ownership. [ABSTRACT FROM AUTHOR]

The limited research that considers people from black and minority ethnic communities' experiences of personalisation tends to focus on personal budgets rather than personalisation per se. This article provides an opportunity to hear the voices of people from Chinese backgrounds and their experiences of personalisation. The study used individual semi-structured interviews and focus groups to collect data from physically disabled people from Chinese backgrounds who lived in England, were aged between 18 and 70, and received social care. Data were analysed using an iterative and thematic approach, with early analysis informing the subsequent analytical rounds. The findings reveal that personalisation has the potential to transform the lives of people from Chinese backgrounds, especially when tailored support is available for people to understand and access personal budgets and put them to creative use. However, the impact of personalisation is barely evident because few eligible individuals access personal budgets or participate in co-production. This is related to a lack of encouragement for service users to become genuine partners in understanding, designing, commissioning and accessing a diverse range of social care services to meet their cultural and social care needs. [ABSTRACT FROM AUTHOR]

Summary The policy of personalisation in English adult social care prioritises choice and control by service users over the support they receive. Carers also have rights to assessments and support, but these rights have developed separately, so interdependencies between carers and service users may be overlooked. Moreover, it may be difficult to reconcile these divergent policies in routine practice. This article reports findings from a study examining the roles played by carers in England in the processes of assessment, support planning and management of personal budgets for disabled and older people. The study was conducted between January 2011 and February 2013. It involved a survey of 16 adult social care departments across 2 English regions, and interviews with personalisation and carers lead officers in three local authorities. The Framework approach was used to manage the data, and analysis was done thematically. Findings Practice was fragmented and inconsistent. Carers were reported to be involved in service users' assessments, and also asked about their willingness and ability to continue caring, but not necessarily about their own needs. Separate carers' assessments were reported to be usually offered, but take-up was low and lead officers' opinions about their value varied. Any help given by carers reduced the level of service users' personal budgets, but there was no evidence that carers' own needs (as identified in carers' assessments) were taken into account. Applications Greater clarity and consistency is needed, especially the linking of service users' and carers' assessments and finding appropriate ways to meet both. These changes will become increasingly urgent with the implementation of the 2014 Care Act. [ABSTRACT FROM AUTHOR]

Solutions to support older people to live independently and reduce the cost of an ageing population are high on the political agenda of most developed countries. Help-at-home schemes offer a mix of community support with the aim to address a range of well-being needs. However, not much is currently known about the costs, outcomes and economic consequences of such schemes. Understanding their impact on individuals' well-being and the economic consequences for local and central government can contribute to decisions about sustainable long-term care financing. This article presents results from a mixed-methods study of a voluntary sector-provided help-at-home scheme in England for people of 55 years and older. The study followed a participatory approach, which involved staff and volunteers. Data were collected during 2012 and 2013. Social care-related quality of life was measured with the Adult Social Care Outcomes Toolkit for 24 service users (59% response rate) when they started using the scheme and 4-6 months later. A customised questionnaire that captured resource use and well-being information was sent to 1064 service users (63% response rate). The same tool was used in assessment with service users who started using the scheme between November 2012 and April 2013 (100% response rate). Costs of the scheme were established from local budget and activity data. The scheme was likely to achieve a mean net benefit of £1568 per person from a local government and National Health Service (NHS) perspective and £3766 from the perspective of the individual. An expenditure of £2851 per person accrued to central government for the additional redistribution of benefit payments to older people. This article highlights the potential contribution of voluntary sector-run help-at-home schemes to an affordable welfare system for ageing societies. [ABSTRACT FROM AUTHOR]

This paper reports findings from a study that aimed to explore how practitioners were bringing together the demands of the personalisation agenda, in particular the offer of direct payments (DPs), with the Mental Capacity Act, and to investigate current practices of offering and administering indirect payments for people who lack capacity to consent to them, including the use of 'suitable person' proxies under the new regulations ( DH, 2009). The study adopted a qualitative interview-based design; participants were social work practitioners (67) and recipients of 'indirect' payments (18) in six local authorities in England in 2011-2012. The paper reports on five key decision-making points in the indirect payments process: the decision to take on an indirect payment, the assessment of mental capacity, the identification of a suitable person, the establishment of the care recipient's best interests and the decisions about how to execute the indirect payment. We found that practitioners and suitable people had different experiences of the system, although in both cases, there was overarching support for the benefits of enabling people who lack capacity to consent to a DP to receive their social care funding in the form of an 'indirect' payment via a proxy suitable person. [ABSTRACT FROM AUTHOR]

• Mining records are used to reconstruct a depositional chronology. • Zinc concentrations strongly correlated with ore extraction records. • Peaks in Zinc concentration were used to date post 1845 deposits. • Mine-worker population statistics were used to simulate pre-1845 lead extraction. • Sediment delivery was strongly linked to periods of mining intensification. Chronological markers in fluvial sediments can provide useful information on geomorphic response to historic catchment disturbance, and help explain historic channel morphodynamics. We concentrate on the River Nent catchment in Northern England, which was heavily impacted by lead and zinc mining in the 18th and 19th centuries. We date a 2 m deep profile of fine (<2mm) floodplain sediments using ore extraction records, covering the period 1845 to 1913, based on a significant correlation between zinc concentrations and zinc-ore extraction (r = 0.78, n = 27; p < 0.01). These dates were constrained with a basal OSL date of 2.7 ± 0.3 ka (Age min to Age mean 1.4–3.0 ka) and existing lichenometric dates for surface gravels. Earliest lead contaminated sediments at the base of the profile most likely resulted from Roman mining operations within the catchment. Local mine-worker population statistics were used to simulate pre-1845 lead ore extraction; where above-average peaks in lead concentration, recorded at the 125–130 cm, 105–110 cm and 95–100 cm horizons, were linked to respective peaks in lead ore extraction in 1825, 1850 and 1866. Estimates of historic sediment delivery volumes at a 0.062 km2 sink site at Blagill, approximately 6.5 km downstream of the headwaters to the Nent, were estimated through coupling the chronological markers with accumulated sediment thickness and reach area. Sediment delivery was seen to be strongly enhanced by phases of metal mining, with peaks between 1800 and 1825 reflecting the final stages of lead mining, and later between 1892 and 1895, reflecting the peak extraction of zinc. Although lag times between ore extraction peaks and sediment delivery to the Blagill site introduce uncertainty to the proposed chronology, we conclude that where good local mining statistics are available, our approach provides a useful alternative or may be used in conjunction with other commonly used methodologies. [ABSTRACT FROM AUTHOR]

• The top 5% of car users travel nearly 27,500 miles (4.8 times the average) and emit 5742 kg CO 2 annually (5.7 times the average). • The top 20% of car users in England travel 16,740 miles and emit 3200 kg CO 2 annually. • Male, high-income professionals and large car owners are more likely to record higher mileage. • Rationing the top 5% of car users would reduce emissions by 6.9% whilst rationing the top 20% would lead to reductions of 26%. • Rationing high CO2 emitters directly is more effective than rationing car mileage. This paper measures 'excess' car travel for its role in decarbonisation. On average, each English adult travels around 5,680 miles a year and emits 1,006 kg of CO 2. However, the top 5% 'excess' car users travel 4.8 times and emit 5.7 times the national average. Four binary logistic regression analyses were used to model the probability that people with specified characteristics belong to the 'excess' mileage and emitter groups. Results indicated that gender, employment and socio-economic status, household income (higher quintiles), company car availability, residential location and local population density were highly significant correlates of this 'excess' travel mileage. Multiple car ownership, business travel by car, multiple international flight frequencies and ownership of larger and diesel cars were positively associated with excess travel and emissions. A mileage rationing scheme targeting the top 20% users can cut emissions substantially (by 26%) compared to targeting 'excess' (top 5%) users only. [ABSTRACT FROM AUTHOR]

Personalisation of social care for adults is a key policy objective in the United Kingdom (UK), as in many other welfare states, having gained wide acceptance as essential for the empowerment of service users and as a means of managing increasing population demand. The system of personal budgets being established in the UK pursues twin objectives: aiming to ‘empower’ individuals to achieve ‘more for less’. However, there is mixed evidence that either objective is being achieved in practice. This is especially so in respect of older people who are less likely to accept a personal budget and more likely to be dissatisfied with their experience of using one. A qualitative study of eight cases in two local authority areas in England explored older people's experience of using a personal budget taken in the form of a direct payment. Data were elicited through a series of three in-depth interviews with each participant. The study was concerned with understanding the relationship between participants' experience of ‘Self’ and personalised services. Participants experienced personalisation when paid carers perceived and accommodated their ‘special requirements of Self’. In most cases this was achieved despite the consumerist aspects of personalisation rather than because of them, and often gave rise to risk and dilemma. The findings emphasise the importance of holistic assessment, and commissioning for quality over maximising choice. [ABSTRACT FROM PUBLISHER]

The article presents a study which aims to compare discrete choice experiment (DCE) and constant- sum paired comparison (CSPC) methods for eliciting societal preferences. The researchers detail the methodology and procedures in data gathering to compare outcomes. It implies that CSPC may offer advantages over DCE in eliciting societal preferences over the distribution of resources and/or outcomes.

This article explores how role boundaries and professional priorities in integrated mental health teams have impacted on the implementation of personalised approaches to social care support. We focus on the use of personal budgets to meet mental health-related social care needs as a key mechanism for personalised care. Drawing on 28 qualitative interviews with mental health practitioners from three local authorities in England undertaken in 2013, we report nurses’, social workers’, and occupational therapists’ attitudes towards, and engagement with, personal budgets. Professional boundaries and competing priorities heavily influenced the extent to which personal budgets were perceived as a legitimate part of their roles. Across different professional groups, a sense emerged that personal budgets should be somebody else’s job. A focus on attention to treatment, stability, and risk management often resulted in low prioritisation of personal budgets and led practitioners to avoid recommending them or to exclude service users from the process as a way to save time. Implications of the dominant medical model and the protection of traditional professional roles for the implementation of new, person-centred models of practice are discussed. [ABSTRACT FROM PUBLISHER]

Background: In England, personal budgets are offered to eligible people with severe mental health problems to enable them to purchase what is helpful for their quality of life or recovery. However, in-depth insight into people's own perceptions of the outcomes is lacking. Aims: To investigate people's own reporting of outcomes from using personal budgets in relation to social care needs arising from severe mental health problems. Method: A convenience sample of 47 individuals receiving personal budgets was recruited from three English local authorities. In-depth semi-structured interviews were subject to thematic framework analysis. Results: Most participants identified positive outcomes across domains interconnected through individual life circumstances, with mental health and wellbeing, social participation and relationships, and confidence and skills most commonly reported. Some needed more support than others to identify goals and make use of the personal budget to take a more active part in the society. Conclusions: Personal budgets can enable people to achieve outcomes that are relevant to them in the context of their lives, particularly through enhancing their wellbeing and social participation. Consideration should be given to distinguishing those individuals potentially requiring more support for engagement from those who can engage more independently to identify and pursue their goals. [ABSTRACT FROM AUTHOR]

Purpose – The purpose of this paper is to provide a synthesis of current and previous government policies and strategies, in relation to people with learning disabilities and employment, to facilitate a better understanding of the current situation and future challenges. Design/methodology/approach – A search was completed to identify government policies relating to the employment of people with learning disabilities. Key policies were identified and their impact was discussed in the paper. Findings – It appears there is a necessity to identify how successful pilot projects can be replicated on a national scale, with clear targets and measures and initial financial support to set up these services. Alongside this there is a need for interventions targeting not just employers, but the general population, educating people about the importance of including and valuing people with learning disabilities in the workforce. Originality/value – It is important that policy is analysed and the impact of it is assessed to determine whether more action is necessary. This paper adds updates to some of the issues discussed in Melling et al.’s (2011) paper about “Supported employment for people with learning disabilities”. [ABSTRACT FROM AUTHOR]

Accessible Summary This study goes back to look at some research which was about gay, lesbian, bisexual and transgender ( LGBT) people with learning disabilities., Have things got better or worse for LGBT people as this research was performed?, It is hard to say whether things have changed because we still do not know very much about the experiences of LGBT people with learning disabilities themselves., Summary 'Secret Loves, Hidden Lives?' was a piece of research which explored the lives and loves of gay, lesbian and bisexual people with learning disabilities. The research arguably influenced the development of policy in that same sex relationships were subsequently mentioned in English government policy on learning disability. The research had an extensive programme of dissemination, and whilst no systematic attempt was made to measure the impact of the dissemination or the research, this study suggests ways in which the research might (or might not) have made a difference in relation to: telling untold stories, supporting front line workers with practical resources, challenging negative assumptions held by staff in services and putting LGBT people with learning disabilities in touch with each other. The study also considers work which was left undone and reflects on the opportunities to support LGBT people with learning disabilities in the current context of financial austerity. [ABSTRACT FROM AUTHOR]

The pressure to contain health expenditures is unprecedented. In England a flattening of the health budget but increasing demand led the National Health Service (NHS) to seek reductions in health expenditures of 17 percent over four years. The spending cuts were to be achieved through improvements in service quality and efficiency, including reducing the use of ineffective, overused, or inappropriate procedures. However, the NHS left it to the local commissioning (or funding) organizations, known as primary care trusts, to determine what steps to take to reduce spending. To assess whether the initiative had an impact, we examined six low-value procedures: spinal surgery for lower back pain, myringotomy to relieve eardrum pressure, inguinal hernia repair, cataract removal, primary hip replacement, and hysterectomy for heavy menstrual bleeding. We found significant reductions in three of the six procedures—cataract removal, hysterectomy, and myringotomy—in the program's first year, compared to prior years' trends. However, changes in the rates of all examined procedures varied widely across commissioning organizations. Our findings highlight some of the challenges of making major budget cuts in health care. Reducing ineffective spending remains a significant opportunity for the US health care system, and the English experience may hold valuable lessons. [ABSTRACT FROM AUTHOR]

Background Personalization - most often understood in terms of granting patients greater opportunity to participate in, and make choices about, the services they receive - has become a key principle guiding reform of the English NHS. Objective This study sets out to explore the relationship between two senses of the term 'personal' within the context of personalization. Firstly, much of the policy literature equates a 'personal' service with one that is responsive to the choices of individual patients. Secondly, the term 'personal' can be thought to refer to the intimate relationships between patients and medical professionals that have typified traditional models of good practice. Methodology and Discussion I combine a review of the relevant academic and policy literature on personalization with a process of conceptual analysis to uncover three arguments, which suggest that personalization based on choice may adversely affect standards of care by eroding the qualities of intimacy at the heart of the care process. Thus, an unintended consequence of the drive for personalization may be the creation of an NHS that is, in an important sense, less personal than it once was. Conclusion Whilst personalization may deliver many potential benefits, the tension between promoting patient choice and retaining intimate professional-patient relationships ought to be taken seriously. Thus, the task of promoting choice whilst retaining intimacy represents a key policy challenge for advocates of personalization. [ABSTRACT FROM AUTHOR]

Carers play an ambiguous role within the personalisation paradigm currently shaping adult social care practice in England. Although carers have rights to assessments and support in their own right, these rights sit uneasily alongside the practices of assessment, support planning and personal budget ( PB) allocation for older and disabled people. This paper reports how 14 dyads of older and learning disabled people with cognitive and/or communication impairments and their carers viewed the roles - desired and actual - played by carers in PBs. Interviews with carers and with older and disabled people were conducted during 2012 as part of a wider study into carers' roles in assessment, support planning and managing PBs. The interviews complemented a survey of reported practice in two English regions - interviews with adult social care services senior managers and focus groups with front-line care managers. Talking Mats© were used to support interviews with some service users. Interviews were transcribed and data analysed using the Framework approach. The interviews indicated that carers played important roles in service users' assessments and support planning, but were less likely to report receiving assessments or support of their own. While carers had the potential to benefit from PBs and support arrangements for service users, this did not reflect practice that aimed to enhance choice and control for carers. The paper draws on Twigg's typology of service conceptualisations of family carers and concludes that, despite the important social rights won by carers in England, current practice continues to regard carers primarily as a resource or a co-worker, rather than a co-client. [ABSTRACT FROM AUTHOR]

This paper reports findings drawn from a study of good practice in English social care for adults with disability and older people with severe and complex needs. People with severe and complex needs are a relatively small proportion of adult social care service users, but they are growing in numbers and have resource-intensive needs. The study involved qualitative research with adults with disability and older people with severe and complex needs, family carers and members of specialist organisations (n = 67), focusing on the features of social care services they considered to be good practice. Data were collected between August 2010 and June 2011. The approach to data collection was flexible, to accommodate participants' communication needs and preferences, including face-to-face and telephone interviews, Talking Mats© sessions and a focus group. Data were managed using Framework and analysed thematically. Features of good practice were considered at three levels: (i) everyday support; (ii) service organisation; and (iii) commissioning. Findings relating to the first two of these are presented here. Participants emphasised the importance of person-centred ways of working at all levels. Personalisation, as currently implemented in English social care, aims to shift power from professionals to service users through the allocation of personal budgets. This approach focuses very much on the role of the individual in directing his/her own support arrangements. However, participants in this study also stressed the importance of ongoing professional support, for example, from a specialist key worker or case manager to co-ordinate diverse services and ensure good practice at an organisational level. The paper argues that, despite the recent move to shift power from professionals to service users, people with the most complex needs still value support from professionals and appropriate organisational support. Without these, they risk being excluded from the benefits that personalisation, properly supported, could yield. [ABSTRACT FROM AUTHOR]

Cuts to essential grant funding for disabled students in England will put disabled students’ studies at risk. Proposed cuts to Disabled Students’ Allowances (DSAs) in 2015 will redefine disability and damage the validity of equality indicators. As a result, the needs of many disabled students may be systematically overlooked, leading to unequal outcomes for students, academia and wider society. [ABSTRACT FROM PUBLISHER]

The Government has introduced personal health budgets in England's National Health Service (NHS). A three-year programme of pilots has shown that personal health budgets have improved outcomes and are generally cost-effective. They are seen as a key step toward creating a personalized service. However, the Government is attributing the success of the pilots to entirely the wrong factors. It believes that a process similar to the one introduced in social care – where it is called self-directed support – based on the person being given a sum of money ‘up-front’ with which to plan their own care – is responsible for the better outcomes. However, this is not supported by the evidence from the pilots which points to quite different factors being at play. The consequences are potentially very serious. The success of the pilots will not be repeated in roll out. Further, there is the potential to greatly weaken the service by creating confused process and practice, and additional dysfunctional bureaucracy. The practice and process implications from a correct reading of the reasons for success within the pilots centre on replacing the consumerist concepts underpinning self-directed support with what we have called ‘flexibility through partnership’. This will require freeing up the resource base as cash and creating a policy framework to enable decisions about how much resource each person should get within a cash-limited budget that will almost certainly be less than would be required to meet all assessed need. [ABSTRACT FROM PUBLISHER]

The introduction of cash-for-care schemes such as individual or personal budgets in England has been seen as central to the personalisation agenda for reforming the delivery of adult social care. However, despite there being 5.2 million carers in England and Wales, the initiative concentrates predominantly on the needs of the service user. The implementation of individual budgets (IBs) was piloted within 13 local authorities during 2005–2007 and the Department of Health commissioned an independent evaluation of this pilot (IBSEN). The focus was only on the service user in the evaluation and therefore a separate but linked study was set up to evaluate the impact and outcomes of IBs on carers. Carers of service users who had consented to take part in the main IBSEN study were identified and invited to participate in a follow-up study aimed at exploring how IBs impacted on carers and the caring role. The study found that the receipt of the budget was significantly associated with positive impacts on carers' reported quality of life and, when other factors were taken into account, with social care outcomes. These outcome gains were achieved despite no higher costs being incurred to the public purse, thus suggesting that IBs for service users are cost-effective for carers. [ABSTRACT FROM PUBLISHER]