Eleanor Winpenny

Exposure of children and adolescents to alcohol marketing on social media websites

Aims: In 2011, online marketing became the largest marketing channel in the UK, overtaking television for the first time. This study aimed to describe the exposure of children and young adults to alcohol marketing on social media websites in the UK. Methods: We used commercially available data on the three most used social media websites among young people in the UK, from December 2010 to May 2011. We analysed by age (6–14 years; 15–24 years) and gender the reach (proportion of internet users who used the site in each month) and impressions (number of individual pages viewed on the site in each month) for Facebook, YouTube and Twitter. We further analysed case studies of five alcohol brands to assess the marketer-generated brand content available on Facebook, YouTube and Twitter in February and March 2012. Results: Facebook was the social media site with the highest reach, with an average monthly reach of 89% of males and 91% of females aged 15–24. YouTube had a similar average monthly reach while Twitter had a considerably lower usage in the age groups studied. All five of the alcohol brands studied maintained a Facebook page, Twitter page and YouTube channel, with varying levels of user engagement. Facebook pages could not be accessed by an under-18 user, but in most cases YouTube content and Twitter content could be accessed by those of all ages. Conclusion: The rise in online marketing of alcohol and the high use of social media websites by young people suggests that this is an area requiring further monitoring and regulation.

For debate: a new wave in public health improvement

The rising burden of chronic disease poses a challenge for all public health systems and requires innovative approaches to effectively improve population health. Persisting inequalities in health are of particular concern. Disadvantage because of education, income, or social position is associated with a larger burden of disease and, in particular, multimorbidity. Although much has been achieved to enhance population health, challenges remain, and approaches need to be revisited. In this paper, we join the debate about how a new wave of public health improvement might look. We start from the premise that population health improvement is conditional on a health-promoting societal context. It is characterised by a culture in which healthy behaviours are the norm, and in which the institutional, social, and physical environment support this mindset. Achievement of this ambition will require a positive, holistic, eclectic, and collaborative effort, involving a broad range of stakeholders. We emphasise three mechanisms: maximisation of the value of health and incentives for healthy behaviour; promotion of healthy choices as default; and minimisation of factors that create a culture and environment which promote unhealthy behaviour. We give examples of how these mechanisms might be achieved.

Youth exposure to alcohol advertising on television in the UK, the Netherlands and Germany

BACKGROUND Exposure of young people to alcohol advertising is a risk factor for underage drinking. This study assessed youth exposure to television alcohol advertising in the UK, the Netherlands and Germany, from December 2010 to May 2011. METHODS A negative binomial regression model predicted number of alcohol advertisements from the proportion of the television viewership in each age group. This allowed comparison of alcohol advertisement incidence for each youth age category relative to an adult reference category. RESULTS In the UK, those aged 10-15 years were significantly more exposed to alcohol advertisements per viewing hour than adults aged ≥ 25 years [incidence rate ratio (IRR) = 1.11; 95% confidence interval (95% CI): 1.06, 1.18; P < 0.01]; in the Netherlands, those aged 13-19 years were more exposed per viewing hour than adults aged ≥ 20 years (IRR = 1.29; 95% CI: 1.19, 1.39; P < 0.01). Conversely, in Germany, those aged 10-15 years were less exposed to alcohol advertisements than adults aged ≥ 25 years (IRR = 0.79; 95% CI: 0.73, 0.85; P < 0.01). In each country, young children (aged 4-9 years in the UK and Germany, 6-12 years in the Netherlands) were less exposed than adults. CONCLUSION Adolescents in the UK and the Netherlands, but not Germany, had higher exposure to television alcohol advertising relative to adults than would be expected from their television viewing. Further work across a wider range of countries is needed to understand the relationship between national policies and youth exposure to alcohol advertising on television.

Improving the effectiveness and efficiency of outpatient services: a scoping review of interventions at the primary–secondary care interface:

Objectives Variation in patterns of referral from primary care can lead to inappropriate overuse or underuse of specialist resources. Our aim was to review the literature on strategies involving primary care that are designed to improve the effectiveness and efficiency of outpatient services. Methods A scoping review to update a review published in 2006. We conducted a systematic literature search and qualitative evidence synthesis of studies across five intervention domains: transfer of services from hospital to primary care; relocation of hospital services to primary care; joint working between primary care practitioners and specialists; interventions to change the referral behaviour of primary care practitioners and interventions to change patient behaviour. Results The 183 studies published since 2005, taken with the findings of the previous review, suggest that transfer of services from secondary to primary care and strategies aimed at changing referral behaviour of primary care clinicians can be effective in reducing outpatient referrals and in increasing the appropriateness of referrals. Availability of specialist advice to primary care practitioners by email or phone and use of store-and-forward telemedicine also show potential for reducing outpatient referrals and hence reducing costs. There was little evidence of a beneficial effect of relocation of specialists to primary care, or joint primary/secondary care management of patients on outpatient referrals. Across all intervention categories there was little evidence available on cost-effectiveness. Conclusions There are a number of promising interventions which may improve the effectiveness and efficiency of outpatient services, including making it easier for primary care clinicians and specialists to discuss patients by email or phone. There remain substantial gaps in the evidence, particularly on cost-effectiveness, and new interventions should continue to be evaluated as they are implemented more widely. A move for specialists to work in the community is unlikely to be cost-effective without enhancing primary care clinicians’ skills through education or joint consultations with complex patients.

Evaluation of telephone first approach to demand management in English general practice: observational study

Objective To evaluate a “telephone first” approach, in which all patients wanting to see a general practitioner (GP) are asked to speak to a GP on the phone before being given an appointment for a face to face consultation. Design Time series and cross sectional analysis of routine healthcare data, data from national surveys, and primary survey data. Participants 147 general practices adopting the telephone first approach compared with a 10% random sample of other practices in England. Intervention Management support for workload planning and introduction of the telephone first approach provided by two commercial companies. Main outcome measures Number of consultations, total time consulting (59 telephone first practices, no controls). Patient experience (GP Patient Survey, telephone first practices plus controls). Use and costs of secondary care (hospital episode statistics, telephone first practices plus controls). The main analysis was intention to treat, with sensitivity analyses restricted to practices thought to be closely following the companies’ protocols. Results After the introduction of the telephone first approach, face to face consultations decreased considerably (adjusted change within practices −38%, 95% confidence interval −45% to −29%; P<0.001). An average practice experienced a 12-fold increase in telephone consultations (1204%, 633% to 2290%; P<0.001). The average duration of both telephone and face to face consultations decreased, but there was an overall increase of 8% in the mean time spent consulting by GPs, albeit with large uncertainty on this estimate (95% confidence interval −1% to 17%; P=0.088). These average workload figures mask wide variation between practices, with some practices experiencing a substantial reduction in workload and others a large increase. Compared with other English practices in the national GP Patient Survey, in practices using the telephone first approach there was a large (20.0 percentage points, 95% confidence interval 18.2 to 21.9; P<0.001) improvement in length of time to be seen. In contrast, other scores on the GP Patient Survey were slightly more negative. Introduction of the telephone first approach was followed by a small (2.0%) increase in hospital admissions (95% confidence interval 1% to 3%; P=0.006), no initial change in emergency department attendance, but a small (2% per year) decrease in the subsequent rate of rise of emergency department attendance (1% to 3%; P=0.005). There was a small net increase in secondary care costs. Conclusions The telephone first approach shows that many problems in general practice can be dealt with over the phone. The approach does not suit all patients or practices and is not a panacea for meeting demand. There was no evidence to support claims that the approach would, on average, save costs or reduce use of secondary care.

Community Hospitals in Selected High Income Countries: A Scoping Review of Approaches and Models

Background: There is no single definition of a community hospital in the UK, despite its long history. We sought to understand the nature and scope of service provision in community hospitals, within the UK and other high-income countries. Methods: We undertook a scoping review of literature on community hospitals published from 2005 to 2014. Data were extracted on features of the hospital model and the services provided, with results presented as a narrative synthesis. Results: 75 studies were included from ten countries. Community hospitals provide a wide range of services, with wide diversity of provision appearing to reflect local needs. Community hospitals are staffed by a mixture of general practitioners (GPs), nurses, allied health professionals and healthcare assistants. We found many examples of collaborative working arrangements between community hospitals and other health care organisations, including colocation of services, shared workforce with primary care and close collaboration with acute specialists. Conclusions: Community hospitals are able to provide a diverse range of services, responding to geographical and health system contexts. Their collaborative nature may be particularly important in the design of future models of care delivery, where emphasis is placed on integration of care with a key focus on patient-centred care.

Tele-First. Evaluation of a ‘telephone first’ approach to demand management in English general practice: observational study

The study was funded by the National Institute for Health Research (HS&DR Project 13/59/40).

Future evaluation of the Integrated Personal Commissioning programme: Mapping the logic and assessing evaluability

The Integrated Personal Commissioning (IPC) Programme is a new programme that joins up health and social care funding for individuals with complex needs and gives them greater control over how their combined health and social care budget is used. The programme specifically aims to enable people and communities to take a more active role in their health and care needs. It is a new approach to joining up health, social care and education at the level of each individual for children and adults with complex needs. IPC incorporates a range of personalised approaches: support to build people’s knowledge, skills and confidence to manage their own health; the offer of greater choice and control through personal budgets; and changes in the design and commissioning of services to put people in the driving seat of decisions around their own care. Nine demonstrator sites have been selected for the first wave of roll-out, which began on 1 April 2015. RAND Europe was invited by NHS England to provide support for the sites, and at the national level, in collaboration with the NHS England team at this early stage of roll-out. RAND Europe carried out a workshop with each site to support the development of the logic model behind their local plans, and to identify suitable metrics to measure local progress against these logic models. With the national team, RAND Europe used this learning from the workshops to help define how to evaluate the IPC programme with a common logic model, and provide advice for evaluation going forward. It should be recognised that such early evaluation work is formative and is not describing a finalised IPC model. It is likely that as sites develop, further core streams will emerge. We found that there are differences in how well prepared each site is for an evaluation. All are in a position to draw upon and adapt the generic theory of change model and therefore have a model that can be evaluated. However, each site has recognised that they are unlikely to get it right the first time and that they will want to adapt and improve their activities. Ongoing evaluation could help produce site-level data to support local decision-makers and also support future decision-making nationally. Both of these aims would be supported by common measurements collected across the sites, and by a comparative evaluation. The IPC demonstrator sites do not exist in isolation; integrated personal commissioning is one of several complementary programmes and new models of care being introduced or piloted across the country. The learning from IPC and the future IPC evaluation should be outward looking and contribute to these programmes as well, and so contribute more broadly than to IPC alone.

PS29 Youth Exposure to Online Alcohol Advertising in The UK: An Analysis of Social Media Websites

Background There is increasing evidence that youth exposure to alcohol marketing is a risk factor for underage drinking. In 2011, online marketing became the largest channel for marketing for the first time, overtaking television. However, there is little understanding of the level of exposure of young people to online alcohol marketing. Methods We obtained data on the top 3 social media sites in the UK for each month from December 2010 to May 2011, based on unique user figures, by gender and age (6–14, 15–24). We analysed the reach (the proportion of available internet users who used the site in each month) and impressions (the number of individual pages viewed on the site in each month) of the overall top three social media sites, Facebook, YouTube and Twitter in each demographic. Using data from the top 10 TV channels in the UK we identified 5 drinks brands, which had the highest TV advertising exposure to children (4–15) during this 6 month period. During February and March 2012, we examined each of these brands across the 3 social media sites. We analysed the brand presence and page content on each site and assessed the use and effectiveness of age restrictions. Results Facebook was the most-used social media site, with an average reach across the observation period ranging from 39% in males aged 6–14 to 91% among females aged 15–24. The average impressions per month varied between 697 million and 2,717 million. YouTube had a similar average reach (41–81%) while Twitter had a considerably lower usage in the age groups studied. All 5 of the alcohol brands studied maintained a brand website, facebook page and twitter page, while 3 of the 5 also hosted a YouTube channel. Features such as the ‘like’ button on facebook and the use of competitions and games enable spread of brand engagement through the network. Age restrictions to alcohol brand content varied across the sites. Facebook users under the age of 18 years were not able to access ‘official’ alcohol brand pages, although most user-generated content and some brand-generated applications were still accessible. By contrast, YouTube and Twitter did not maintain age-restriction with users of all ages able to view and interact with brand content. Conclusion Social media sites are heavily used by children and young adults. Their exposure through these sites to alcohol marketing warrants intervention.