Jonathan Wistow

A Qualitative Comparative Analysis of factors associated with trends in narrowing health inequalities in England

This study explores why progress with tackling health inequalities has varied among a group of local authority areas in England that were set targets to narrow important health outcomes compared to national averages. It focuses on premature deaths from cancers and cardiovascular disease (CVD) and whether the local authority gap for these outcomes narrowed. Survey and secondary data were used to create dichotomised conditions describing each area. For cancers, ten conditions were found to be associated with whether or not narrowing occurred: presence/absence of a working culture of individual commitment and champions; spending on cancer programmes; aspirational or comfortable/complacent organisational cultures; deprivation; crime; assessments of strategic partnership working, commissioning and the public health workforce; frequency of progress reviews; and performance rating of the local Primary Care Trust (PCT). For CVD, six conditions were associated with whether or not narrowing occurred: a PCT budget closer or further away from target; assessments of primary care services, smoking cessation services and local leadership; presence/absence of a few major programmes; and population turnover. The method of Qualitative Comparative Analysis was used to find configurations of these conditions with either the narrowing or not narrowing outcomes. Narrowing cancer gaps were associated with three configurations in which individual commitment and champions was a necessary condition, and not narrowing was associated with a group of conditions that had in common a high level of bureaucratic-type work. Narrowing CVD gaps were associated with three configurations in which a high assessment of either primary care or smoking cessation services was a necessary condition, and not narrowing was associated with two configurations that both included an absence of major programmes. The article considers substantive and theoretical arguments for these configurations being causal and as pointing to ways of improving progress with tackling health inequalities.

Using Qualitative Comparative Analysis to understand complex policy problems

This article shows how Qualitative Comparative Analysis (QCA) can be used to understand what works to address complex policy problems at a local level, using the example of tackling high rates of teenage conceptions in England’s most deprived local authority areas. QCA is a promising method for providing evidence in situations where interventions interact with contexts, enabling causal pathways to be discerned from how sets of conditions combine with particular outcomes: in this instance, whether inequalities in conception rates do or do not narrow, compared with the England average. A wide range of survey and secondary data, sourced in collaboration with practitioners, was explored to identify conditions that might show a relationship with the outcome. Applying QCA’s process of logical reduction enabled identification of sets of cases. Two narrowing sets and three not-narrowing sets are presented, showing how there are different pathways to narrowing and not-narrowing outcomes, and how conditions often combine to have causal effect. Although based on systematic cross-case comparison, the article also demonstrates the importance of judgement and interpretation in QCA.

Applying Qualitative Comparative Analysis (QCA) to evaluate a public health policy initiative in the North East of England

Abstract This paper presents a Qualitative Comparative Analysis (QCA) analysis of data produced as part of the evaluation a Nation Health Service commissioned intervention in the North East of England. QCA is a case-oriented method that allows systematic comparison of cases as configurations of set memberships based on their attributes and the relationship of these to particular outcomes. QCA provides an alternative to conventional quantitative approaches which are generally concerned with isolating the independent effect of one variable whilst controlling the influence of others. Instead, QCA allows for interactions between multiple attributes and recognises that the same outcomes may be generated by different configurations of attributes. The intervention evaluated provided case management for individuals who were out of work due to ill health, and had been for three years or more. It aimed to improve the health of individuals and move them closer to the labour market. The intervention and a comparison group were assessed at base line (T1), after 3 months — (T2) after 6 months (end of the intervention — T3) and after 9 months (three months post intervention — T4). The size of the respective populations at each time point were, Intervention group at T1, N = 131, T2, N = 44, T3, N = 79, T4, N = 95. Comparison group at T1, N = 229, T2, N = 188, T3, N = 166, T4, N = 154. General health was measured using EQ5-D (a standardised instrument for use as a measure of general health outcome) and SF-8. Two condition specific measures were included: the Hospital Anxiety and Depression Scale (HADS) and the Nordic Musculoskeletal questionnaire. Data was also collected on socio demographics (gender, age, housing tenure), social capital (contact with family and friends and participation with the wider community), and work history (previous jobs, time spent in the job, time spent on sickness absence). The aim of the QCA analysis was to identify whether individuals with certain characteristics or combinations of characteristics benefited from the intervention. In order to do this the cases were sorted according to whether their EQ-5D VAS (Visual Analogue Scale) scores (a self rated measure of general health) narrowed or did not narrow towards the population norm for the measure between baseline (T1) and (T4) 9 months (three months post intervention — T4). Cases which narrowed towards the UK population norm of 82.48 were judged to be experiencing a health improvement whilst those whose scores did not narrow towards the norm were judged to not have experienced a health improvement. A crisp set (cs) QCA analysis was then performed. The paper assesses the benefits of using QCA, and asks whether it can provide a viable and practical tool for social policy evaluations.

The role of formal and informal networks in supporting older people’s care during extreme weather events.

We use theories of formal and informal networks of care, within a local governance system, to interpret networks supporting older people during extreme weather events. Drawing on international literatures about network governance and emergency management this paper outlines an approach which considers the views of older people and service providers to explore resilience of infrastructures and service agencies. During emergencies, links between different networks of care are important to avoid discontinuities that could endanger older peoples health and well-being. This paper explores the scope to draw on local knowledge and local caring networks to inform preparedness for extreme weather.

Adaptation to extreme weather events in complex health and social care systems: The example of older people’s services in England

Our findings contribute to a growing international literature on how conceptual models from complexity theory may be relevant to inform planning in health and social care systems, helping to adapt and improve preparedness and resilience to extreme weather events. We focus on findings from two case studies in England and their relationship to national policy for adaptation. Complexity theory helped to frame strategies for planning for events that are emergent and unpredictable. We find from our case studies that, in spite of the uncertainty involved, some ‘principles’ derived from parts of the literature on complexity theory may provide a helpful framework for the development of more robust preparedness strategies in the health and social care sector. By viewing health and social care as a ‘system of systems’, adaptation planning recognises the interrelationships of built, institutional and social infrastructures. The idea of local systems, with variable, path-dependent attributes, which are partially closed, but permeable to other parts of the wider network, leads to an actionable model of adaptation which emphasises the potential value of local self-organisation, but also underlines the importance of co-evolution across the wider system and the vital role of national initiatives and support for adaptation strategies. The value of sharing experience from local case studies across the national system, as well as among local partners, is very apparent in the experience reported here.

Impact of extreme weather events and climate change for health and social care systems

This review, commissioned by the Research Councils UK Living With Environmental Change (LWEC) programme, concerns research on the impacts on health and social care systems in the United Kingdom of extreme weather events, under conditions of climate change. Extreme weather events considered include heatwaves, coldwaves and flooding. Using a structured review method, we consider evidence regarding the currently observed and anticipated future impacts of extreme weather on health and social care systems and the potential of preparedness and adaptation measures that may enhance resilience. We highlight a number of general conclusions which are likely to be of international relevance, although the review focussed on the situation in the UK. Extreme weather events impact the operation of health services through the effects on built, social and institutional infrastructures which support health and health care, and also because of changes in service demand as extreme weather impacts on human health. Strategic planning for extreme weather and impacts on the care system should be sensitive to within country variations. Adaptation will require changes to built infrastructure systems (including transport and utilities as well as individual care facilities) and also to institutional and social infrastructure supporting the health care system. Care sector organisations, communities and individuals need to adapt their practices to improve resilience of health and health care to extreme weather. Preparedness and emergency response strategies call for action extending beyond the emergency response services, to include health and social care providers more generally.

Implementing Health Scrutiny: Meeting the Challenge in one Local Authority

This article provides insights into how the health scrutiny function has performed in its first year of operation in a unitary authority in the North of England, through a case study of an inquiry into health inequalities.