Neil McHugh

Social Innovation: Worklessness, Welfare and Well-being

The UK Government has recently implemented large-scale public-sector funding cuts and substantial welfare reform. Groups within civil society are being encouraged to fill gaps in service provision, and ‘social innovation’ has been championed as a means of addressing social exclusion, such as that caused by worklessness, a major impediment to citizens being able to access money, power and resources, which are key social determinants of health. The aim of this article is to make the case for innovative ‘upstream’ approaches to addressing health inequalities, and we discuss three prominent social innovations gaining traction: microcredit for enterprise; social enterprise in the form of Work Integration Social Enterprises (WISEs); and Self Reliant Groups (SRGs). We find that while certain social innovations may have the potential to address health inequalities, large-scale research programmes that will yield the quality and range of empirical evidence to demonstrate impact, and, in particular, an understanding of the causal pathways and mechanisms of action, simply do not yet exist.

RF23 Who knows best? perspectives of professional stakeholders and community participants on health in low-income communities

Background Health inequalities in the UK have proved to be stubborn, and health gaps between best and worst-off are widening. While we have an understanding of how the main causes of poor health are perceived among different stakeholders, similar insight is lacking regarding what solutions should be prioritised. Furthermore, we do not know the relationship between perceived causes and solutions to health inequalities, whether there is agreement between professional stakeholders and people living in low-income communities or agreement within these different societal groups. Methods Q methodology was used to identify and describe the shared perspectives (‘subjectivities’) that exist on i) why health is worse in low-income communities (’Causes’) and ii) the ways that health could be improved in these same communities (‘Solutions’). 53 purposively selected individuals from low-income communities (n=25) and professional stakeholder groups (n=28), for example, academics, policymakers, public health professionals, financial service practitioners, ranked ordered sets of 34 ‘Causes’ statements and 39 ‘Solutions’ statements onto quasi-normal shaped grids according to their point of view. These ‘Q’ sorts were followed by brief interviews. Factor analysis was used to identify shared points of view (patterns of similarity between individuals’ Q sorts). ‘Causes’ and ‘Solutions’ were analysed independently. Results Analysis produced three factor solutions for both the ‘Causes’ and ‘Solutions’. These rich, shared accounts can be broadly summarised as: ‘Causes’ i) ‘Unfair Society’, ii) ‘Individual Responsibility’, iii) ‘Hard Lives’ and for ‘Solutions’ i) ‘More than Money’, ii) ‘Guiding Choice’, iii) ‘Make Society Fair’. No professionals were among respondents who exemplified (had a significant association with) ‘Causes – Individual Responsibility’ or ‘Solutions – Guiding Choice’ and no community participants exemplified ‘Solutions – Make Society Fair’. There was an expected correlation between the ‘Causes’ and ‘Solutions’ factor solutions given the accounts identified. Conclusion While there was some disagreement among professional participants, there was more of a focus on material, social and environmental factors. Community participants recognised a range of causes of worse health but even among those identifying structural causes as the main problem, structural solutions were not recognised. Despite the plurality of views there was broad agreement across the accounts about issues relating to money. While no easy solutions exist, addressing basic needs and the unpredictability of finances are seen as important for good health.

Is “end of life” a special case? Connecting Q with survey methods to measure societal support for views on the value of life-extending treatments

Abstract Preference elicitation studies reporting societal views on the relative value of end‐of‐life treatments have produced equivocal results. This paper presents an alternative method, combining Q methodology and survey techniques (Q2S) to determine the distribution of 3 viewpoints on the relative value of end‐of‐life treatments identified in a previous, published, phase of this work. These were Viewpoint 1, “A population perspective: value for money, no special cases”; Viewpoint 2, “Life is precious: valuing life‐extension and patient choice”; and Viewpoint 3, “Valuing wider benefits and opportunity cost: the quality of life and death.” A Q2S survey of 4,902 respondents across the United Kingdom measured agreement with these viewpoints; 37% most agreed with Viewpoint 1, 49% with Viewpoint 2, and 9% with Viewpoint 3. Regression analysis showed associations of viewpoints with gender, level of education, religion, voting preferences, and satisfaction with the NHS. The Q2S approach provides a promising means to investigate how in‐depth views and opinions are represented in the wider population. As demonstrated in this study, there is often more than 1 viewpoint on a topic and methods that seek to estimate that averages may not provide the best guidance for societal decision‐making.

From wealth to health: Evaluating microfinance as a complex intervention

Innovative interventions that address the social determinants of health are required to help reduce persistent health inequalities. We argue that microcredit can act in this way and develop a conceptual framework from which to examine this. In seeking to evaluate microcredit this way we then examine how randomized controlled trials, currently considered as the ‘gold standard’ in impact evaluations of microcredit, compare with developments in thinking about study design in public health. This leads us to challenge the notion of trials as the apparent gold standard for microcredit evaluations and contend that the pursuit of trial-based evidence alone may be hampering the production of relevant evidence on microcredit’s public health (and other wider) impacts. In doing so, we introduce new insights into the global debate on microfinance impact evaluation, related to ethical issues in staging randomized controlled trials, and propose innovations on complementary methods for use in the evaluation of complex interventions.

Eliciting Societal Views on the Value of Life-Extending Treatments Using Q Methodology

Publicly funded healthcare systems operating with fixed budgets must incorporate rationing mechanisms of some sort in order to set priorities. Efficiency, which might be defined broadly in health terms as maximising health benefits with respect to cost, is a key consideration in setting priorities. However, efficiency is not the only consideration, and members of society may value other issues in relation to the distribution of resources to different groups of beneficiaries. Life-extending treatments for people with terminal illnesses, which are non-curative by definition and often produce relatively small health gains in relation to their costs, are a prime example of technologies that might not satisfy usual cost-effectiveness thresholds. It is generally accepted that the views and values of members of the public, as taxpayers and potential patients, are relevant in determining priorities in the provision of publicly funded healthcare. This chapter introduces Q methodology as a structured approach to eliciting and describing societal values, combining qualitative and quantitative techniques to study subjectivity, with reference to research carried out relating to people at the end of their lives.