Health Policy

Health for All by the year 2000: a retrospective look at the ambitious public health initiative

by Hope Corbin

The Intersectional Determinants of Systematic Global Health Inequality: The Effects of International Policy

by Laura Robinson

Paper for intro Social Health class - 2011

"I Don't Think This is Theoretical; This is Our Lives.” How Erasure Impacts Health Care for Transgender People

by Greta Bauer

Practice size and quality attainment under the new GMS contract: a cross-sectional analysis

by Kate O'Donnell

Authored by Yingying Wang, Catherine O'Donnell, Danny Mackay and Graham Watt and published in British Journal of General Practice

Background The Quality and Outcomes Framework (QOF) of the new General Medical Services contract, for the first time,... more Background The Quality and Outcomes Framework (QOF) of the new General Medical Services contract, for the first time, incentivises certain areas of general practice workload over others. The ability of practices to deliver high quality care may be related to the size of the practice itself. Aim: To explore the relationship between practice size and points attained in the QOF. Design of study: Cross-sectional analyses of routinely available data. Setting: Urban general practice in mainland Scotland. Method: QOF points and disease prevalence were obtained for all urban general practices in Scotland (n = 638) and linked to data on the practice, GP and patient population. The relationship between QOF point attainment, disease prevalence and practice size was examined using univariate statistical analyses. Results: Smaller practices were more likely to be located in areas of socioeconomic deprivation; had patients with poorer health; and were less likely to participate in voluntary practice-based quality schemes. Overall, smaller practices received fewer QOF points compared to larger practices (P = 0.003), due to lower point attainment in the organisational domain (P = 0.002). There were no differences across practice size in the other domains of the QOF, including clinical care. Smaller practices reported higher levels of chronic obstructive pulmonary disease (COPD) and mental health conditions and lower levels of asthma, epilepsy and hypothyroidism. There was no difference in the reported prevalence of hypertension or coronary heart disease (CHD) across practices, in contrast to CHD mortality for patients aged under 70 years, where the mortality rate was 40% greater for single-handed practices compared with large practices. Conclusions: Although smaller practices obtained fewer points than larger practices under the QOF, this was due to lower scores in the organisational domain of the contract rather than to lower scores for clinical care. Single-handed practices, in common with larger practices serving more deprived populations, reported lower than expected CHD prevalence in their practice populations. Our results suggest that smaller practices continue to provide clinical care of comparable quality to larger practices but that they may need increased resources or support, particularly in the organisational domain, to address unmet need or more demanding QOF criteria.

Impact of the 2004 GMS contract on practice nurses: a qualitative study

by Kate O'Donnell

Authored by Wendy McGregor, Hussein Jabareen, Catherine O'Donnell, Stewart Mercer and Graham Watt and published in British Journal of General Practice

BackgroundThe new GMS contract has led to practice nurses playing an important role in the delivery of the Quality and... more BackgroundThe new GMS contract has led to practice nurses playing an important role in the delivery of the Quality and Outcomes Framework (QOF). AimThis study investigated how practice nurses perceive the changes in their work since the contract's inception. Design of study A qualitative approach, sampling practice nurses from practices in areas of high and low deprivation, with a range of QOF scores. Setting Glasgow, UK. MethodIndividual interviews were conducted, audiotaped, transcribed, and analysed using a thematic approach. Results Three themes emerged: roles and incentives, workload, and patient care. Practice nurses were positive about the development of their professional role since the introduction of the new GMS contract but had mixed views about whether their status had changed. Views on incentives (largely related to financial rewards) also varied, but most felt under-rewarded, irrespective of practice QOF achievement. All reported a substantial increase in workload, related to incentivised QOF domains with greater 'box ticking' and data entry, and less time to spend with patients. Although the structure created by the new contract was generally welcomed, many were unconvinced that it improved patient care and felt other important areas of care were neglected. Concern was also expressed about a negative effect of the QOF on holistic care, including ethical concerns and detrimental effects on the patient–nurse relationship, which were regarded as a core value. ConclusionsThe new GMS contract has given practice nurses increased responsibility. However, discontent about how financial gains are distributed and negative impacts on core values may lead to detrimental long-term effects on motivation and morale.

Practice postcode versus patient population: a comparison of data sources in England and Scotland

by Kate O'Donnell

Authored by Gary McLean, Bruce Guthrie, Graham Watt, Mark Gabbay and Catherine O'Donnell and published in International Journal of Health Geographics

BACKGROUND:Health professionals, policy-makers and researchers need to be able to explore potential associations... more BACKGROUND:Health professionals, policy-makers and researchers need to be able to explore potential associations between prevalence rates and quality of care with a range of possible determinants including socio-economic deprivation and morbidity levels to determine the impact of commissioning and service delivery. In the UK, data in England are only available nationally at practice postcode level. In Scotland, such data are available based on an aggregate of the practices population's postcodes. The use of data assigned to the practice postcode may underestimate the association between ill health and income deprivation. Here, we report on the impact of using data assigned to the practice population by comparing analyses using English and Scottish data.RESULTS:Income deprivation based on data assigned to the practice postcode under-estimated deprivation compared to using income deprivation data assigned to the practice population for the five least deprived deciles, and over-estimated deprivation for the five most deprived deciles. The biggest differences were found for the most deprived decile. A similar trend was found for limiting long-term illness (LLTI). Differences between the QOF prevalence rates of the least and most deprived deciles using practice postcode data were similar (0.2% points or less) in England and Scotland for 8 out of 10 clinical domains. Using practice population assigned deprivation, differences in the prevalence rate between the least and most deprived deciles increase for all clinical domains. A similar trend was again found for LLTI. Using practice population assigned deprivation, differences for population achievement increase for all CHD quality indicators with the exception of beta-blockers (CHD10). With practice postcode assigned deprivation, significant differences between the least and most deprived deciles were found for 2 out 8 indicators, compared to 5 using practice population assigned deprivation. For LLTI differences between the lowest and most deprived deciles increased for all indicators when ill health assigned to the practice population was used.CONCLUSION:We have found, through comparing deprivation and ill health data assigned to either the practice postcode or the practice population postcode in Scotland, that analyses based on practice postcode assigned data under-estimated the relationship between deprivation and ill health for both prevalence and quality care. Given the importance of understanding the effect of deprivation and ill health on a range of determinants related to health care, policy makers should ensure that practice population data are available and used at national level in England and elsewhere where possible

Practice nurses' workload, career intentions and the impact of professional isolation: A cross-sectional survey

by Kate O'Donnell

Authored by Catherine O'Donnell, Hussein Jabareen and Graham Watt and published in BMC Nursing

BACKGROUND:Practice nurses have a key role within UK general practice, especially since the 2004 GMS contract. This... more BACKGROUND:Practice nurses have a key role within UK general practice, especially since the 2004 GMS contract. This study aimed to describe that role, identify how professionally supported they felt and their career intentions. An additional aim was to explore whether they felt isolated and identify contributory factors.METHODS:A cross-sectional questionnaire survey in one large urban Scottish Health Board, targeted all practice nurses (n = 329). Domains included demographics, workload, training and professional support. Following univariate descriptive statistics, associations between categorical variables were tested using the chi-square test or chi-square test for trend; associations between dichotomous variables were tested using Fisher's Exact test. Variables significantly associated with isolation were entered into a binary logistic regression model using backwards elimination.RESULTS:There were 200 responses (61.0% response rate). Most respondents were aged 40 or over and were practice nurses for a median of 10 years. Commonest clinical activities were coronary heart disease management, cervical cytology, diabetes and the management of chronic obstructive pulmonary disease. Although most had a Personal Development Plan and a recent appraisal, 103 (52.3%) felt isolated at least sometimes; 30 (15.5%) intended leaving practice nursing within 5 years.Isolated nurses worked in practices with smaller list sizes (p = 0.024) and nursing teams (p = 0.003); were less likely to have someone they could discuss a clinical/professional (p = 0.002) or personal (p < 0.001) problem with; used their training and qualifications less (p < 0.001); had less productive appraisals (p < 0.001); and were less likely to intend staying in practice nursing (p = 0.009). Logistic regression analysis showed that nurses working alone or in teams of two were 6-fold and 3.5-fold more likely to feel isolated. Using qualifications and training to the full, having productive appraisals and planning to remain in practice nursing all mitigated against feeling isolated.CONCLUSIONS:A significant proportion of practice nurses reported feeling isolated, at least some of the time. They were more likely to be in small practices and more likely to be considering leaving practice nursing. Factors contributing to their isolation were generally located within the practice environment. Providing support to these nurses within their practice setting may help alleviate the feelings of isolation, and could reduce the number considering leaving practice nursing

"They think we're OK and we know we're not". A qualitative study of asylum seekers' access, knowledge and views to health care in the UK

by Kate O'Donnell

Authored by Catherine O'Donnell, Maria Higgins, Rohan Chauhan and Kenneth Mullen and published in BMC Health Services Research

BackgroundThe provision of healthcare for asylum seekers is a global issue. Providing appropriate and culturally... more BackgroundThe provision of healthcare for asylum seekers is a global issue. Providing appropriate and culturally sensitive services requires us to understand the barriers facing asylum seekers and the facilitators that help them access health care. Here, we report on two linked studies exploring these issues, along with the health care needs and beliefs of asylum seekers living in the UK.MethodsTwo qualitative methods were employed: focus groups facilitated by members of the asylum seeking community and interviews, either one-to-one or in a group, conducted through an interpreter. Analysis was facilitated using the Framework method.ResultsMost asylum seekers were registered with a GP, facilitated for some by an Asylum Support nurse. Many experienced difficulty getting timely appointments with their doctor, especially for self-limiting symptoms that they felt could become more serious, especially in children. Most were positive about the health care they received, although some commented on the lack of continuity. However, there was surprise and disappointment at the length of waiting times both for hospital appointments and when attending accident and emergency departments. Most had attended a dentist, but usually only when there was a clinical need. The provision of interpreters in primary care was generally good, although there was a tension between interpreters translating verbatim and acting as patient advocates. Access to interpreters in other settings, e.g. in-patient hospital stays, was problematic. Barriers included the cost of over-the-counter medication, e.g. children's paracetamol; knowledge of out-of-hours medical care; and access to specialists in secondary care. Most respondents came from countries with no system of primary medical care, which impacted on their expectations of the UK system.ConclusionMost asylum seekers were positive about their experiences of health care. However, we have identified issues regarding their understanding of how the UK system works, in particular the role of general practitioners and referral to hospital specialists. The provision of an Asylum Support nurse was clearly a facilitator to accessing primary medical care. Initiatives to increase their awareness and understanding of the UK system would be beneficial. Interpreting services also need to be developed, in particular their role in secondary care and the development of the role of interpreter as patient advocate.

Asylum seekers' expectations of and trust in general practice: a qualitative study

by Kate O'Donnell

Authored by Catherine O'Donnell, Maria Higgins, Rohan Chauhan and Kenneth Mullen and published in British Journal of General Practice

Background: The UK has substantial minority populations of short-term and long-term migrants from countries with... more Background: The UK has substantial minority populations of short-term and long-term migrants from countries with various types of healthcare systems. Aim: This study explored how migrants' previous knowledge and experience of health care influences their current expectations of health care in a system relying on clinical generalists performing a gatekeeping role. Design of study: Two qualitative methods. Setting: Glasgow, UK. Method: Focus groups or semi-structured interviews were conducted with 52 asylum seekers. Analyses identified several areas where previous experience affected current expectations. An overview of health systems in each country of origin was established by combining responders' accounts with World Health Organization statistics. Results: Asylum seekers had previous experience of a diverse range of healthcare systems, most of which were characterised by a lack of GPs and direct access to hospital-based specialists. For some responders, war or internal conflict resulted in a complete breakdown of healthcare systems. Responders' accounts also highlighted the difficulties that marginalised groups had in accessing health care. Although asylum seekers were generally pleased with the care they received from the NHS, there were areas where they experienced difficulties: confidence in their GP and access to hospital-based specialists and medication. These difficulties encountered might be explained by previous experience. Conclusion: GPs and other healthcare professionals need to be aware that experience of different systems of care can have an impact on individuals' expectations in a GP-led system. If these are not acknowledged and addressed, a lack of confidence and trust in the GP may undermine the effectiveness of the clinical consultation.

Do health improvement programmes fit with MRC guidance on evaluating complex interventions?

by Kate O'Donnell

Authored by Mhairi Mackenzie, Catherine O'Donnell, Emma Halliday, Sanjeev Sridharan, Steve Platt and published in the British Medical Journal

Normalisation process theory: a framework for developing, evaluating and implementing complex interventions

by Kate O'Donnell

Authored by Elizabeth Murray, Shaun Treweek, Catherine Pope, Anne MacFarlane, Luciana Ballini, Chris Dowrick, Tracy Finch, Anne Kennedy, Frances Mair, Catherine O'Donnell, Pauline Ong, Tim Rapley, Anne Rogers, Carl May and published in BMC Medicine

BACKGROUND:The past decade has seen considerable interest in the development and evaluation of complex interventions... more BACKGROUND:The past decade has seen considerable interest in the development and evaluation of complex interventions to improve health. Such interventions can only have a significant impact on health and health care if they are shown to be effective when tested, are capable of being widely implemented and can be normalised into routine practice. To date, there is still a problematic gap between research and implementation. The Normalisation Process Theory (NPT) addresses the factors needed for successful implementation and integration of interventions into routine work (normalisation).DISCUSSION:In this paper, we suggest that the NPT can act as a sensitising tool, enabling researchers to think through issues of implementation while designing a complex intervention and its evaluation. The need to ensure trial procedures that are feasible and compatible with clinical practice is not limited to trials of complex interventions, and NPT may improve trial design by highlighting potential problems with recruitment or data collection, as well as ensuring the intervention has good implementation potential.SUMMARY:The NPT is a new theory which offers trialists a consistent framework that can be used to describe, assess and enhance implementation potential. We encourage trialists to consider using it in their next trial

What is the 'problem' that outreach work seeks to address and how might it be tackled? Seeking theory in a primary health prevention programme

by Kate O'Donnell

Mackenzie,M.; Turner,F.; Platt,S.; Reid,M.; Wang,Y.; Clark,J.; Sridharan,S.; O'Donnell,C.
BMC Health Services Research 2011; 11: 350

BACKGROUND:Preventive approaches to health are disproportionately accessed by the more affluent and recent health... more BACKGROUND:Preventive approaches to health are disproportionately accessed by the more affluent and recent health improvement policy advocates the use of targeted preventive primary care to reduce risk factors in poorer individuals and communities. Outreach has become part of the health service response. Outreach has a long history of engaging those who do not otherwise access services. It has, however, been described as eclectic in its purpose, clientele and mode of practice; its effectiveness is unproven.Using a primary prevention programme in the UK as a case, this paper addresses two research questions: what are the perceived problems of non-engagement that outreach aims to address; and, what specific mechanisms of outreach are hypothesised to tackle these.
METHODS:Drawing on a wider programme evaluation, the study undertook qualitative interviews with strategically selected health-care professionals. The analysis was thematically guided by the concept of 'candidacy' which theorises the dynamic process through which services and individuals negotiate appropriate service use.
RESULTS:The study identified seven types of engagement 'problem' and corresponding solutions. These 'problems' lie on a continuum of complexity in terms of the challenges they present to primary care. Reasons for non-engagement are congruent with the concept of 'candidacy' but point to ways in which it can be expanded.
CONCLUSIONS:The paper draws conclusions about the role of outreach in contributing to the implementation of inequalities focused primary prevention and identifies further research needed in the theoretical development of both outreach as an approach and candidacy as a conceptual framework

Delivering a national programme of anticipatory care in primary care: a qualitative study

by Kate O'Donnell

O'Donnell,C.A.; Mackenzie,M.; Reid,M.; Turner,F.; Clark,J.; Wang,Y.; Sridharan,S.; Platt,S.
British Journal of General Practice 2012; 62: e288-e296

Background: Primary prevention often occurs against a background of inequalities in health and health care. Addressing... more Background: Primary prevention often occurs against a background of inequalities in health and health care. Addressing this requires practitioners and systems to acknowledge the contribution of health-related and social determinants and to deal with the lack of interconnectedness between health and social service providers. Recognising this, the Scottish Government has implemented a national programme of anticipatory care targeting individuals aged 45-64 years living in areas of socioeconomic deprivation and at high risk of cardiovascular disease. This programme is called Keep Well.

Aim: To explore the issues and tensions underpinning the implementation of a national programme of anticipatory care.

Design and setting: A qualitative study in five Wave 1 Keep Well pilot sites, located in urban areas of Scotland, and involving 79 general practices.

Method: Annual semi-structured interviews were conducted with 74 key stakeholders operating at national government level, local pilot level and within general practices, resulting in 118 interviews. Interview transcripts were analysed using the framework approach.
Results: Four underlying tensions were identified. First, those between a patient-focused general-practice approach versus a population-level health-improvement approach, linking disparate health and social services; secondly, medical approaches versus wider social approaches; thirdly, a population-wide approach versus individual targeting; and finally, reactive versus anticipatory care.

Conclusion: Implementing an anticipatory care programme to address inequalities in cardiovascular disease identified several tensions, which need to be understood and resolved in order to inform the development of such approaches in general practice and to develop systems that reduce the degree of fragmentation across health and social services

Reaching the hard-to-reach? Conceptual puzzles and challenges for policy and practice.

by Kate O'Donnell

Mackenzie,M.; Reid,M.; Turner,F.; Wang,Y.; Clark,J.; Sridharan,S.; Platt,S.; O'Donnell,C.
Journal of Social Policy 2012 (on-line first)

Choice, risk and trust - the policy context and mammography screening

by Karen Willis

Open-access chapter in edited text:
Uchiyama, N. & Nascimento, M., 2012, Mammography - Recent Advances, Intech publishers, Croatia.

This chapter presents an international overview of the differing policy contexts in countries with mammography... more This chapter presents an international overview of the differing policy contexts in countries with mammography screening programs. It then explores the intersections between scientific knowledge, policy making and individual decision making with
particular reference to the age at which screening should begin. Using research conducted with women in three different policy settings (two in Australian states and one in a
Swedish county), it explores the differing ideas that form a crucial part of women’s decisions to participate in screening. While most research focuses on women who don’t
participate in screening (there is a vast literature about the ‘underutilisation’ of mammography screening), we can learn much about health behaviour by talking with women who have chosen to be screened. This is particularly the case where screening is contentious.

The research at each of the sites comprised qualitative interviews with women aged 40-49 years who had participated in screening. Interestingly, the risk of breast cancer is not the
main reason that women choose to be screened. For women in rural Uppsala, Sweden, trust in authorities was the dominant discourse; for women in rural Victoria, discourses of rights
and choice predominated; and for women in rural Tasmania, trust in technology was a key reason for participating in screening. Women in rural areas also utilise services that are delivered in their local area because they highly value regional health services. These ideas are necessarily bound up in sociological concepts of choice, trust and risk.

A Health Advocacy Approach to Social Justice

by Toi Scott

Capstone/Thesis. Co-authored with Josh I. Lapps.

Opportunity in Complexity: Applied Whole Systems Design in Healthcare Innovation

by Renee Davis

Written as a final synthesis paper for the Whole Systems Design program of the Center for Creative Change at Antioch University Seattle.

We currently face what's known as a wicked mess of healthcare problems. A Whole Systems Design approach can lead the... more We currently face what's known as a wicked mess of healthcare problems. A Whole Systems Design approach can lead the way for the development of a system that's effective, sustainable and accessible. This paper is an exploration of such an approach and how it might be applied to healthcare innovation today.

Coal An Impure Fuel Source: Radiation Effects of Coal-fired Power Plants in Turkey

by Prof.Dr. İbrahim USLU

Hacettepe Journal of Biology and Chemistry volume 38 Issue 4 pp 259-268 2010
ibrahim Uslu, F. Gökmeşe

Turkish coal is generally poor quality and the levels of chemical and radiological toxic trace elements in it are... more Turkish coal is generally poor quality and the levels of chemical and radiological toxic trace elements in it are higher with respect to mean values of activity concentrations given in United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) Report. The main pathways through which the population living around soal-fired power plant (CFPP) is exposed to natural radionuclides are external and internal (ingestion and inhalation) dose and fly ash particles are the major component of the risk. It is estimated that the people working or living near the CFPP in Turkey receive a dose in between 0.1 mSv to 1 mSv extra from CFPP because nearly all the region of Turkey uranium (U) and thorium (Th) content in the coal are higher than 5 ppm to 7 ppm and around 25 ppm to 40 ppm respectively. Continuous monitoring is essential to determine occupational exposure levels in all stages of the coal fuel-cycle and proper measures should be taken to prevent direct contact of the ash pile with the top soil and local drainage systems.

Radiological Considerations in Nuclear Ship Visits

by Prof.Dr. İbrahim USLU

Turkish Journal of Nuclear Science 16(1989) pp:43-51
ibrahim Uslu, G.G. Yülek. G. Aksu
keywords: nuclear ship radiological consideration

In this study radiological aspects of nuclear ships has been reviewed and the results of some measurements of early... more In this study radiological aspects of nuclear ships has been reviewed and the results of some measurements of early warning system stations and radionuclide concentration in sea water have been given and discussed from the data during one of the nuclear ship visit of a Turkish Port.

Radiaoctivity in Cigarette

by Prof.Dr. İbrahim USLU

Turkish Journal of nuclear Sciences Volume 25 no:2 pp 1998
ibrahim Uslu, E. Tanker, M.L. Aksu

Cigarette is known to be hazardous to health due to nicotine and tar it contains. This is indicated on cigarette... more Cigarette is known to be hazardous to health due to nicotine and tar it contains. This is indicated on cigarette packets by health warnings. However there is less known hazard of smoking due to intake of radioactive compounds by inhalation. This study dwells upon the radioactive hazard of smoking.