Jonathan Mathers

Use of health impact assessment in incorporating health considerations in decision making

Study aim: The aim of this project is to identify from a range of sources the factors associated with the success of a health impact assessment (HIA) in integrating health considerations into the final decision and implementation of a planned policy, programme, or project. Design: Three methods were adopted: (a) a review of HIA case studies; (b) a review of commentaries, reviews and discussion papers relating to HIA and decision making; and (c) an email survey of a purposive sample of HIA academics, HIA practitioners, and policymakers. Information was captured on the following characteristics: information on the year undertaken; geopolitical level; setting; sector; HIA type; methods and techniques used; identification of assessors. Main results: Two groups of factors were identified relating to the decision making environment and to the technical conduct of the HIA. With regard to the environment, striking a balance between decision maker ownership and HIA credibility; organisational, statutory and policy commitment to HIA, and the provision of realistic, non-controversial recommendations were cited as enablers to the integration of HIA findings into the decision making process. Barriers included a lack of knowledge of the policymaking environment by those conducting HIA. Regarding factors relating to the conduct of the HIA: use of a consistent methodological approach; inclusion of empirical evidence on health impacts; timing of the HIA congruent with the decision making process; involvement of expert HIA assessors; and shaping of recommendations to reflect organisational priorities were cited as enablers while lack of a standardised methodology; lack of resources and use of jargon were cited as barriers. Conclusions: The findings emphasise the importance of considering the politico-administrative environment in which HIA operates. The extent to which HIA fits the requirements of organisations and decision makers may be as important as the technical methods adopted to undertake it.

Why are there so few working-class applicants to medical schools? Learning from the success stories

Objectives  Students from lower socio‐economic circumstances remain under‐represented in UK medical schools despite recent shifts in other demographic variables and specific policy emphasis on widening participation (WP). This study aimed to further understanding of the reasons for this.

Widening access to medical education for under-represented socioeconomic groups: population based cross sectional analysis of UK data, 2002-6

Objective To determine whether new programmes developed to widen access to medicine in the United Kingdom have produced more diverse student populations. Design Population based cross sectional analysis. Setting 31 UK universities that offer medical degrees. Participants 34 407 UK medical students admitted to university in 2002-6. Main outcome measures Age, sex, socioeconomic status, and ethnicity of students admitted to traditional courses and newer courses (graduate entry courses (GEC) and foundation) designed to widen access and increase diversity. Results The demographics of students admitted to foundation courses were markedly different from traditional, graduate entry, and pre-medical courses. They were less likely to be white and to define their background as higher managerial and professional. Students on the graduate entry programme were older than students on traditional courses (25.5 v 19.2 years) and more likely to be white (odds ratio 3.74, 95% confidence interval 3.27 to 4.28; P<0.001) than those on traditional courses, but there was no difference in the ratio of men. Students on traditional courses at newer schools were significantly older by an average of 2.53 (2.41 to 2.65; P<0.001) years, more likely to be white (1.55, 1.41 to 1.71; P<0.001), and significantly less likely to have higher managerial and professional backgrounds than those at established schools (0.67, 0.61 to 0.73; P<0.001). There were marked differences in demographics across individual established schools offering both graduate entry and traditional courses. Conclusions The graduate entry programmes do not seem to have led to significant changes to the socioeconomic profile of the UK medical student population. Foundation programmes have increased the proportion of students from under-represented groups but numbers entering these courses are small.

What impact will an increased number of teaching general practices have on patients, doctors and medical students?

Background  Recommendations for medical training have seen a growing drive for undergraduate teaching to take place within the community – primarily in the general practice surgery. In light of the ongoing expansion of medical student numbers, many more general practices will be required to participate in undergraduate teaching.

Hostile teaching hospitals and friendly district general hospitals: final year students' views on clinical attachment locations

Context  The NHS Plan has indicated the need to increase the number of doctors in the NHS. To accommodate the substantial increase in student numbers in Birmingham, clinical teaching will need to expand from its traditional base within established teaching hospitals (THs) to district general hospitals (DGHs). Previous studies elsewhere have suggested the experience of students who undertake clinical attachments in DGHs is different from that of students attached to THs. We sought to investigate whether such differences exist in the West Midlands region and to explore the opportunities and problems such differences may present to educators and students alike.

‘Health and well-being’: questioning the use of health concepts in public health policy and practice

In recent years, health and well-being have been ‘mainstreamed’ as a policy issue and have become the concern of a widening range of agencies. Simultaneously, increasing weight has been placed on the measurement of population health status, the implementation of evidence-based practice in public health and the more effective evaluation of policy interventions targeted at health gain and health inequalities. Thus, at a time when greater conceptual clarity is crucial, there are more stakeholders in ‘health’, each with a potentially different perspective and understanding of what ‘health’ is. In this study, we explore the need for greater conceptual clarity in relation to health, using the term ‘well-being’ as an exemplar. We draw on findings from a research project undertaken with community and professional groups in the Black Country and Shropshire that explored shared ways to measure aspects, and determinants, of health. We suggest a lack of attention to health concepts and their clarification, as indicated by the use of ‘well-being’ as an ill-defined tag to health, is having a negative impact on public healths ability to deliver health gain, and that commitment to clarifying concepts would lead to a range of benefits. At present, however, the term ‘well-being’ muddies the waters, acting more as an open-ended catch-all category than a clearly considered component of ‘health’.

The use of qualitative methods to inform Delphi surveys in core outcome set development

BackgroundCore outcome sets (COS) help to minimise bias in trials and facilitate evidence synthesis. Delphi surveys are increasingly being used as part of a wider process to reach consensus about what outcomes should be included in a COS. Qualitative research can be used to inform the development of Delphi surveys. This is an advance in the field of COS development and one which is potentially valuable; however, little guidance exists for COS developers on how best to use qualitative methods and what the challenges are. This paper aims to provide early guidance on the potential role and contribution of qualitative research in this area. We hope the ideas we present will be challenged, critiqued and built upon by others exploring the role of qualitative research in COS development.This paper draws upon the experiences of using qualitative methods in the pre-Delphi stage of the development of three different COS. Using these studies as examples, we identify some of the ways that qualitative research might contribute to COS development, the challenges in using such methods and areas where future research is required.ResultsQualitative research can help to identify what outcomes are important to stakeholders; facilitate understanding of why some outcomes may be more important than others, determine the scope of outcomes; identify appropriate language for use in the Delphi survey and inform comparisons between stakeholder data and other sources, such as systematic reviews. Developers need to consider a number of methodological points when using qualitative research: specifically, which stakeholders to involve, how to sample participants, which data collection methods are most appropriate, how to consider outcomes with stakeholders and how to analyse these data. A number of areas for future research are identified.ConclusionsQualitative research has the potential to increase the research community’s confidence in COS, although this will be dependent upon using rigorous and appropriate methodology. We have begun to identify some issues for COS developers to consider in using qualitative methods to inform the development of Delphi surveys in this article.

Consultant attitudes to undertaking undergraduate teaching duties: perspectives from hospitals serving a large medical school

Objective  To explore attitudes among National Health Service consultants responsible for delivering basic clinical teaching to medical students.

What are the challenges to the Big Society in maintaining lay involvement in health improvement, and how can they be met?

The UK Coalition Governments Big Society policy has highlighted the value of the contribution that local people can make to well-being in their own communities, and plans to increase the contribution of community groups and third sector organizations in delivering services. This paper attempts to unpick some of the challenges to delivering health improvement interventions within the Big Society framework, and offers suggestions to reduce risk and preserve the value of the unique contribution that local people can make. The challenges identified are: supporting and developing skills in social enterprise; demonstrating effectiveness to commissioners; supporting local enterprise while mindful of inequality; guarding against the third sector losing its dynamism; using volunteers to replace or complement existing services. We conclude that the drive to increase community sustainability through the involvement of individuals is laudable, and responds to potential flaws in the welfare state. In order to protect the most vulnerable, and ensure equity, any change will take time and resources. More efficient ways of meeting societys needs must be sought, but we recommend that a stepwise, supported and appropriately evaluated approach is essential, and equity of provision across communities and organizations must be a primary concern.

Improving health in deprived communities: What can residents teach us?

The purpose of this paper is to illustrate how residents of disadvantaged communities believe where they live influences their health. The authors describe focus group work they have undertaken with older and younger adults resident in three neighbourhoods in the West Midlands region of England, which are participating in the New Deal for Communities initiative. Drawing on the narratives of residents, examples are given of specific ‘pathways’ they described linking place to health experiences. Resident discussions highlight a number of key points. First, health was conceived in physical and non-physical terms: participants spoke of health not only in terms of physical disease or illness, but also as ‘being happy’, ‘having confidence’, ‘contentment’ and ‘peace of mind’. Second, place was seen by residents to impact on health through three core levers—physical structures (for example housing quality, visual amenity), social structures (for example, friendliness of neighbours, community norms) and service provision (for example, public transport, local police). Although the influence of each lever was described separately in certain instances, their interplay with health was often complex and intertwined. Third, although groups were not prompted to compare themselves with others, discussions frequently included comparison with other areas, and also consideration of what ‘others’ must think of them. Finally, it was noted that ‘fear’ was a common node in many of the pathways that residents described linking aspects of place with their health.