Unlike many other fields such as biomedical sciences, public health research has the potential to make an impact on a population in the very near future. With this comes the importance of having a clear focus within your research and ensuring it is practice orientated. After all, there is no point in doing research for research’s sake! The principle of research is undermined if the outcomes cannot be translated and implemented into action or policy. This is an important aspect for all areas of research in science and arts but is particularly pertinent for public health, which often deals with large populations.
The UK government has often commissioned independent reviews in response to a scandal or just to guide policy makers. Some of these have stood out over time as turning points in the history of public health in the UK, so I’ve compiled a select few in chronological order. I’d like to be able to summarise/analyse and contextualise them at some point, as I’ve noticed there aren’t any similar resources on the web aside from journal commentaries which only provide part of the picture. This is maybe a bit too ambitious though….!
1980: The Black Report (Inequalities in Health) link
In a nutshell: Commissioned by Labour and delayed and boycotted by Conservatives. Showed that health inequalities in Britain were increasing despite overall improvements.
1998: Acheson Report (Independent Inquiry into Inequalities in Health Report) link
In a nutshell: Again demonstrated health disparities along a socio-economic gradient.
2001: Bristol Enquiry (The report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984-1995: learning from Bristol) link
In a nutshell: A seminal report which revealed the importance of patient safety
2006: The Cooksey Review (A review of UK health research funding) link
In a nutshell: Realisation of the need for a better coordinated research scene in the UK, as well as the need for better translation into policy/action.
2008: Marmot Review (Fair Society, Healthy Lives) link
In a nutshell: Reiterated the importance of socio-economic factors as determinants of health and emphasised the need to tackle health inequalities
2010: The White Paper (Healthy Lives, Healthy People: Our strategy for Public Health in England) link
In a nutshell: Acknowledged the importance of public health and set out the beginnings of the Health and Social Care bill
2010: Francis Report (The Mid Staffordshire NHS Foundation Trust Public Enquiry) link
In a nutshell: Pointed out the current issues in the NHS of responsibility, accountability, institutionalised culture and system wide failure.
What is patient orientated research? Sounds like a bit of a well-intentioned phrase coined to make researchers feel like they are doing something useful, whilst making patients feel like they’re at the centre of the universe. If you take off the cynic goggles however, patient orientated describes research that is answering a much needed question, that will ultimately help improve patient experience or quality of care. Now this is true public health in action, and as corny as that sounds, I think it’s important to keep the individuals in sight when working in public health.
Thought I’d try to recap bits of the statistics module I learnt last year in an effort to retain it in my brain cells that much longer. I thought I’d start by comparing variance, standard deviation (SD) and the coefficient of variance (CV). They are nicely interlinked and come up frequently in quantitative analyses used in public health, making them useful to remember. Of the three, SD is definitely used the most, followed by variance. I’ve not seen the CV being used in a paper but that’s probably due to its function, which will be described later.
In a nutshell: Describes the extent of variety in a sample
Variance looks at the spread around the mean within the sample. It is calculated as the sum of squares divided by the degrees of freedom:
Standard Deviation (SD)
In a nutshell: A version of variance which is easier to work with
SD represents variance but it is in the same unit as the observations, which is useful. However the SD depends on the magnitude of the data which makes it a little less reliable when based on skewed data.
Coefficient of Variation (CV)
In a nutshell: A measure of variance used to compare different samples
CV represents the SD as a % of the mean. It is used to compare relative variability between data sets but it can only be used for positive variables.
Just because it needed to be done!
- Strength of association
- Temporal relationship
- Biological gradient (dose-response relationship)
- Plausibility (biological plausibility)
- Experiment (reversibility)
- Analogy (consideration of alternate explanations)
So (a little more than) a year has passed since I started my MPH course. I’ve been taught a lot of information, some of which will stay with me forever (and some of which I’ve already forgotten). I really enjoyed this year and I got a lot out of it, thanks to a lot of investment of time on my behalf but also a lot of excellent teaching and dedication on the course organisers’ part. Imperial postgraduates graduate in May for some reason so I won’t be donning a gown til then, but I hope to keep writing on this blog and keep up to date with the world of public health! Oh, and I got a job so the course can’t be that bad! 😛
Commissioning: what does that word mean to you? I had no idea when I first came across it but it sounded pretty dull. Turns out it’s not dull at all, in fact it’s possibly one of the most interesting aspects of a healthcare system if you’re interested in that kind of thing (as I am), particularly if you are in the UK. As to why that’s relevant, onwards we go…
So what is it?
Commissioning is all about buying the right healthcare services for your population. In addition to purchasing responsibilities, the use of the word “commissioning” as done in the UK indicates that the role also involves extensive strategic planning and setting priorities etc.
It is obviously massively important in any healthcare system but in the UK this concept of commissioning has undergone multiple costume changes in the last two decades, making it a rather “hot” topic.
What’s happened in the UK?
A lot actually. The following is mostly based on the chapter of Commissioning written by Judith Smith and Natasha Curry, at the Kings Fund.
The first most important reform affecting commissioning was Thatcher’s New Public Management reforms in the early 1990s. It was the birth of commissioning if you will, as it was formally split from healthcare provision. It was supposed to overcome the information asymmetry that favoured providers.
Then in the early 2000s, new Labour came in and made PCTs in charge of commissioning. As Smith and Curry have written:
“The PCT model was predicated on a belief that strong local commissioners would be able to assume financial risk for a defined geographic population, providing community health services, and buying other services”.
In essence, this regional level of commissioning meant that the financial risk of making sure that the population’s needs were being met appropriately was divided up between 303 statutory bodies, making it less risky for central government, which was paying all these PCTs out. Having relatively decentralised regional level services meant that there was also the opportunity for individual PCTs to shape their commissioning on grounds of their particular population’s needs.
The Labour government also brought in practice based commissioning, a voluntary scheme whereby a GP practice or a group of practices could ask their PCT to delegate a budget to them. This meant that the GPs themselves could plan and commission a defined set of services for their patients, either from themselves or other providers. The GPs were allowed to keep the financial savings that were made for other services, which acted as an incentive to prevent overspending. As it was voluntary however, some argue that it led to a “two tier service” for patients, depending on whether their GP practice had chosen to get involved in commissioning or not. There is also limited evidence that PCTs and PBC has improved health inequalities and efficient use of resources. Also, no-one in the public knew about commissioning; this low profile and lack of legitimacy meant that there was weak downwards accountabiltiy and little PPI, an important aspect in all strands of healthcare.
Now fast forward to 2013: the Conservative government are again in power, and both PCTs and practice based commissioning has been abolished. So what remains? New bodies called clinical commissioning groups (CCGs) have been set up to take over the responsibility of around 60% of all commissioning done in the NHS. The NHS Commissioning Board (NHS CB) remains responsible for commissioning specialised services. It is hoped that as CCGs have lots of clinical representation (nurses, clinical directors, doctors, GPs), they will know best to align financial risks and incentives and keep a control on service provision.
There are several major challenges that face CCGs once they get their acts together. Alongside coping with system-wide changes to public health, the HPA, social care etc., they must focus on maintaining and improving population health in the face of budget freezes and further economic challenges. That’s the most obvious issue I guess.
Secondly, as GPs now have a major role in where resources go, there could be a shift in patient doctor relationships. GPs who sit on CCGs may not have the time and/or skills for effective commissioning. Also, for example if you’re a GP whose CCG has just made a decision on shaving off the budget for COPD clinics or something, talking to all your COPD patients could get a little awkward knowing that you’ve contributed to that decision. In all honesty I’m not sure to what extent this could be a problem as I would have thought that the majority of patients wouldn’t know what their GP did outside of their office.
Thirdly, the key word of the Coalition government’s approach to Healthcare (and everything else) has been “COMPETITION”. Simultaneously however, there is an increasing movement towards integration of services, which has a strong and growing evidence base. How these two ideas (which seem at odds to one another) will be balanced is something I’m sure a lot of CCGs are still worried about 7 months down the line.
It’s not all bad news however, and CCGs have great potential to do good. Merging PCTs may make it easier to influence large providers. They also offer a new face of commissioning which could be more accessible to the general public. With patient and public involvement (PPI) being so important, this has great potential. Also the shift in focus from process led frameworks to an outcomes framework may be beneficial.