'It's a small world': mental health policy under welfare capitalism since 1945

Much sociological theorising about community care in mental health universalises from Anglo-American contexts. So do assessments of policy shifts towards deinstitutionalisation, whose tendency towards negativity largely reflects the downsized mental health care systems that have emerged in welfare regimes, strongly influenced by neoliberal political ideology. Drawing on the framework of Esping-Anderson (1990), the article seeks to theorise from a wider range of welfare regimes, including Sweden and Italy, where political influences on policy provide more support for a degree of optimism. It also seeks to demonstrate in outline the advantages of analysing global influences on mental health policy under welfare capitalism, as key factors shaping policy throughout the whole post-1945 period.     

Innovation in primary care: Community health services in Mexico and the United States

Providing adequate health care to a nation's citizens is a challenge in every country. Despite large differences in wealth, health care organization, and health politics, both Mexico and the United States undertook similar efforts to expand primary care to previously underserved populations during the past 30 years. This study analyzes common antecedents, contexts of change, elements of the innovations, problems with entrenched interests, and resources that have allowed both programs to survive in difficult environments. We show that new forms of primary health care can face similar problems and prospects in very different countries because of similar political, bureaucratic, and economic limitations.     

Welfare benefits’ screening and referral: a new direction for community nurses?

The White Paper, Towards a Healthier Scotland considerably widens the community nursing scope for health promotion, as it recognises that disadvantaged life circumstances as well as unhealthy lifestyles contribute to poor health. It has been shown that income and health are interrelated. This evidence has demonstrated that it is not how rich a nation is that determines the overall health of its inhabitants; it is how equitably its wealth is distributed that counts: countries that have narrow income differentials tend to have better health. Both the income and health divide in Britain widened considerably between 1980 and 1992. It is argued that increasing income inequality leads to social isolation and chronic stress, which can impact on psycho-social pathways and damages life expectancy. This paper suggests that community nurses can address adverse life circumstances by finding ways of improving the economic status of their most vulnerable clients, and that one way of doing this would be to ensure that clients claim their full quota of welfare entitlement, given that there is several billion pounds of social security benefits that remain unclaimed in Britain every year.     

积极开展农村社区卫生服务不断提高初级卫生保健水平

实施“农民健康工程”,紧紧围绕为人民健康和经济建设、服务这一中心,以初级卫生保健为目标,以卫生机构改革、管理一体化为基础,以合作医疗为保障,大力开展农村社区卫生服务,有效缓解农民群众看病贵、看病难的问题。     

Welfare benefits advice in primary care: evidence of improvements in health

It is not uncommon for welfare benefits advice organisations to offer services in primary care settings. Given the link between deprivation and poor health, the maximising of individual income in this way may also be expected to improve health. However, such improvement has hitherto not been successfully measured. This paper reports on a small study of such a service, provided by the local Citizens Advice Bureau. Statistically significant increases in SF-36 scores were measured for those whose income increased as a result of receiving advice, despite the prevalence in the group (average age 56 y) of chronic disabling conditions such as arthritis and sensory impairment. These findings suggest that 'prescribing advice' is a health intervention which is appropriately situated in primary care.     

Defining “Rural” for Veterans’ Health Care Planning

Purpose: The Veterans Health Administration (VHA) devised an algorithm to classify veterans as Urban, Rural, or Highly Rural residents. To understand the policy implications of the VHA scheme, we compared its categories to 3 Office of Management and Budget (OMB) and 4 Rural-Urban Commuting Area (RUCA) geographical categories. Method: Using residence information for VHA health care enrollees, we compared urban-rural classifications under the VHA, OMB, and RUCA schemes; the distributions of rural enrollees across VHA health care networks (Veterans Integrated Service Networks [VISNs]); and how each scheme indicates whether VHA standards for travel time to care are met for the most rural veterans. Results: VHA's Highly Rural and Urban categories are much smaller than the most rural or most urban categories in the other schemes, while its Rural category is much larger than their intermediate categories. Most Highly Rural veterans live in VISNs serving the Rocky Mountains and Alaska. Veterans defined as the most rural by RUCA or OMB are distributed more evenly across most VISNs. Nearly all urban enrollees live within VHA standards for travel time to access VHA care; so do most enrollees defined by RUCA or OMB as the most rural. Only half of Highly Rural enrollees, however, live within an hour of primary care, and 70% must travel more than 2 hours to acute care or 4 hours to tertiary care. Conclusions: VHA's Rural category is very large and broadly dispersed; policy makers should supplement analyses of Rural veterans’ health care needs with more detailed breakdowns. Most of VHA's Highly Rural enrollees live in the western United States where distances to care are great and alternative delivery systems may be needed.     

"Developing good taste in evidence": facilitators of and hindrances to evidence-informed health policymaking in state government

CONTEXT: Policymaking is a highly complex process that is often difficult to predict or influence. Most of the scholarship examining the role of research evidence in policymaking has focused narrowly on characteristics of the evidence and the interactions between scientists and government officials. The real-life context in which policymakers are situated and make decisions also is crucial to the development of evidence-informed policy. METHODS: This qualitative study expands on other studies of research utilization at the state level through interviews with twenty-eight state legislators and administrators about their real-life experiences incorporating evidence into policymaking. The interviews were coded inductively into the following categories: (1) the important or controversial issue or problem being addressed, (2) the information that was used, (3) facilitators, and (4) hindrances. FINDINGS: Hindrances to evidence-informed policymaking included institutional features; characteristics of the evidence supply, such as research quantity, quality, accessibility, and usability; and competing sources of influence, such as interest groups. The policymakers identified a number of facilitators to the use of evidence, including linking research to concrete impacts, costs, and benefits; reframing policy issues to fit the research; training to use evidence-based skills; and developing research venues and collaborative relationships in order to generate relevant evidence. CONCLUSIONS: Certain hindrances to the incorporation of research into policy, like limited budgets, are systemic and not readily altered. However, some of the barriers and facilitators of evidence-informed health policymaking are amenable to change. Policymakers could benefit from evidence-based skills training to help them identify and evaluate high-quality information. Researchers and policymakers thus could collaborate to develop networks for generating and sharing relevant evidence for policy.     

Elderly people's perspectives on health and well-being in rural communities in England: findings from the evaluation of the National Service Framework for Older People

Addressing the problems of meeting the needs of ageing populations in rural areas is recognised as a political and service delivery challenge. The National Service Framework (NSF) for Older People (NSFOP) set out a series of service standards to raise quality, to redress variations in service use and to enhance the effectiveness of services across health and social care in England and alluded to the challenges of meeting such standards in rural communities. This paper reports findings from the consultations undertaken with 713 elderly people as part of the midpoint review of the NSFOP in 2006, presenting and analysing the views and experiences of elderly people from rural areas. The consultations to engage with elderly people employed a mixed methodology that included public events, focus groups and individual interviews. The data reveal participants' views of how different patterns of social change in diverse country areas in England influence health and well-being in later life. The costs and benefits of centralization of services, and the pivotal issue of transport are important themes. The findings raise questions about the unclear and contradictory usages of the term 'rural' in England and the portrayal of rural ageing as a homogeneous experience.     

REFLECTIONS ON NATIONAL RURAL HEALTH POLICY: THE 'BIG PICTURE' FRAMEWORK

ABSTRACT: A major concern of many rural and remote communities, as they struggle to cope with the impacts of social, economic and demographic changes, is the effect of government policies on health services. The National Rural Health Strategy has evolved as the key framework guiding action for improving health services for people in rural and remote Australia. The importance of maintaining an awareness of the 'big picture' of rural health remains paramount if interventions designed to bring about improved health status are to tackle the underlying causes of the problems, minimise problems associated with lack of co-ordination between health authorities, and avoid duplication of activity. Given the communality of rural health problems across Australia, close co-operation and collaboration among rural health groups is vital in developing appropriate national rural health policy. At the same time rural communities must continue to participate actively in the policy formulation and implementation process.     

Who uses welfare benefits advice services in primary care?

There is considerable interest among organisations such as primary care trusts and health action zones in commissioning welfare benefits advice services in primary healthcare settings as part of local strategies to reduce health inequalities. However, very little is known about the contribution to health of such services or about the health status of those who use them. The present study reports on a longitudinal study of the contribution to individual health of welfare benefits advice in primary care that has gathered baseline demographic and health data on 345 research subjects. The average age of the subjects was 54 years, and they were likely to be unemployed or retired. Over 85% were advised to apply for welfare benefits or to appeal against the loss of a benefit, the most common benefit being Disability Living Allowance (over 50% of all subjects). Three-quarters reported a physical disability or long-term illness that limited their daily activity, and over half reported arthritis or rheumatism. Scores on the short form 36 (SF-36) which quantify self-reported physical and psychosocial aspects of health, were much lower than population norms, indicating poorer health. The burden of illness borne by users of these services is not surprising. However, reliable data has not previously been available. It appears that primary care provides good access to advice services for people in middle and old age, but not to other groups (e.g. families with young children, substance misusers or those with mental health problems). Better data collection by advice services, wherever located, would strengthen their understanding of the needs of those whom they serve, and help them to identify under-served groups. These data could be used to support requests for continued or extended funding.     

Is Obesity Policy in England Fit for Purpose? Analysis of Government Strategies and Policies, 1992–2020

Policy Points

• This analysis finds that government obesity policies in England have largely been proposed in a way that does not readily lead to implementation; that governments rarely commission evaluations of previous government strategies or learn from policy failures; that governments have tended to adopt less interventionist policy approaches; and that policies largely make high demands on individual agency, meaning they rely on individuals to make behavior changes rather than shaping external influences and are thus less likely to be effective or equitable.
• These findings may help explain why after 30 years of proposed government obesity policies, obesity prevalence and health inequities still have not been successfully reduced.
• If policymakers address the issues identified in this analysis, population obesity could be tackled more successfully, which has added urgency given the COVID‐19 pandemic.

ContextIn England, the majority of adults, and more than a quarter of children aged 2 to 15 years live with obesity or excess weight. From 1992 to 2020, even though the government published 14 obesity strategies in England, the prevalence of obesity has not been reduced. We aimed to determine whether such government strategies and policies have been fit for purpose regarding their strategic focus, nature, basis in theory and evidence, and implementation viability.MethodWe undertook a mixed‐methods study, involving a document review and analysis of government strategies either wholly or partially dedicated to tackling obesity in England. We developed a theory‐based analytical framework, using content analysis and applied thematic analysis (ATA) to code all policies. Our interpretation drew on quantitative findings and thematic analysis.FindingsWe identified and analyzed 14 government strategies published from 1992 to 2020 containing 689 wide‐ranging policies. Policies were largely proposed in a way that would be unlikely to lead to implementation; the majority were not interventionist and made high demands on individual agency, meaning that they relied on individuals to make behavior changes rather than shaping external influences, and are thus less likely to be effective or to reduce health inequalities.ConclusionsThe government obesity strategies’ failure to reduce the prevalence of obesity in England for almost 30 years may be due to weaknesses in the policies’ design, leading to a lack of effectiveness, but they may also be due to failures of implementation and evaluation. These failures appear to have led to insufficient or no policy learning and governments proposing similar or identical policies repeatedly over many years. Governments should learn from their earlier policy failures. They should prioritize policies that make minimal demands on individuals and have the potential for population‐wide reach so as to maximize their potential for equitable impacts. Policies should be proposed in ways that readily lead to implementation and evaluation.     

Assessing the health benefits of advice services: using research evidence and logic model methods to explore complex pathways

Poverty is positively associated with poor health; thus, some healthcare commissioners in the UK have pioneered the introduction of advice services in health service locations. Previous systematic reviews have found little direct evidence for a causal relationship between the provision of advice and physical health and limited evidence for mental health improvement. This paper reports a study using a broader range of types of research evidence to construct a conceptual (logic) model of the wider evidence underpinning potential (rather than only proven) causal pathways between the provision of advice services and improvements in health. Data and discussion from 87 documents were used to construct a model describing interventions, primary outcomes, secondary and tertiary outcomes following advice interventions. The model portrays complex causal pathways between the intervention and various health outcomes; it also indicates the level of evidence for each pathway. It can be used to inform the development of research designed to evaluate the pathways between interventions and health outcomes, which will determine the impact on health outcomes and may explain inconsistencies in previous research findings. It may also be useful to commissioners and practitioners in making decisions regarding development and commissioning of advice services.     

经济欠发达地区农村社区卫生服务模式探索

目的:介绍经济欠发达地区农村社区卫生服务模式并评价该模式对促进农村卫生工作和初级卫生保健的有效性。方法:通过开发领导、培训卫生人员、制定标准及完善制度、开发激励政策等方面对试点进行干预。选取江西省崇义县作为干预组,江西省芦溪县作为对照组。2009年6月和2010年6月分别对两地进行基线调查和追踪调查,评价其实施效果。结果:通过开展社区卫生服务,崇义县卫生机构公共卫生服务数量增加,村卫生机构在3岁以下儿童系统管理、孕产妇产后访视、慢性病人管理等方面开展比例分别由53.1%、51.2%、46.9%上升到77.8%,73.3%、71.1%,居民对医疗服务(就诊、住院)满意度提高;芦溪县没有明显变化。结论:建立了一种通过服务理念、服务模式的改变和激励政策的开发促进农村初级卫生保健工作的工作模式,这种模式适合于经济欠发达地区,政府投入不会太大,也不需涉及机构的转型和太多的体制问题,给欠发达地区农村卫生改革提供了启示和借鉴。