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The UK Coalition Government's Big Society policy has highlighted the value of the contribution that local people can make to well-being in their own communities, and plans to increase the contribution of community groups and third sector organizations in delivering services. This paper attempts to unpick some of the challenges to delivering health improvement interventions within the Big Society framework, and offers suggestions to reduce risk and preserve the value of the unique contribution that local people can make. The challenges identified are: supporting and developing skills in social enterprise; demonstrating effectiveness to commissioners; supporting local enterprise while mindful of inequality; guarding against the third sector losing its dynamism; using volunteers to replace or complement existing services. We conclude that the drive to increase community sustainability through the involvement of individuals is laudable, and responds to potential flaws in the welfare state. In order to protect the most vulnerable, and ensure equity, any change will take time and resources. More efficient ways of meeting society's needs must be sought, but we recommend that a stepwise, supported and appropriately evaluated approach is essential, and equity of provision across communities and organizations must be a primary concern.

Context: Medical student numbers in England have increased by more than 60% over the last decade. The capacity of universities and the National Health Service (NHS) to deliver education and training to these expanded cohorts is not clear., Methods: We carried out an interview study in three English medical schools, involving 60 academic, administrative, clinical and managerial staff, sampled across disciplines., Results: Given the expansion in medical student numbers, capacity in medical schools must increase. This requirement has become even more immediate in light of the shift towards more resource-intensive curricula. However, the aims of the Research Assessment Exercise and NHS policies are at odds with attempts to build teaching capacity. Although monies have been made available to recruit new staff and to backfill clinical time spent teaching, the success of these strategies is questioned by interviewees. Other initiatives, such as the new consultant contract and educational quality assurance processes, have the potential to promote the importance of teaching but are presently perceived as being inadequate so to do. As was consistently expressed by interviewees, within the competing triad of research, service delivery and teaching, the latter is perceived as taking a poor third place., Conclusions: That research, service delivery and education are in competition will come as no surprise to UK academic staff. However, our results show a striking uniformity of opinion. We would question whether existing NHS and higher education policies enable medical schools and health care organisations to deliver education of the highest quality to the enlarged student population.

Health impact assessment (HIA) is a multidisciplinary aid to decision-making that assesses the impact of policy on public health and on health inequalities. Its purpose is to assist decision-makers to maximize health gains and to reduce inequalities. The 1999 Gothenburg Consensus Paper (GCP) provides researchers with a rationale for establishing community participation as a core value of HIA. According to the GCP, participation in HIA empowers people within the decision-making process and redresses the democratic deficit between government and society. Participation in HIA generates a sense that health and decision-making is community-owned, and the personal experiences of citizens become integral to the formulation of policy. However, the participatory and empowering dimensions of HIA may prove difficult to operationalize. In this review of the participation strategies adopted in key applications of HIA in the United Kingdom, we found that HIA's aim of influencing decision-making creates tension between its participatory and knowledge-gathering dimensions. Accordingly, researchers have decreased the participatory dimension of HIA by reducing the importance attached to the community's experience of empowerment, ownership and democracy, while enlarging its knowledge-gathering dimension by giving pre-eminence to "expert" and "research-generated" evidence. Recent applications of HIA offer a serviceable rationale for participation as a means of information gathering and it is no longer tenable to uphold HIA as a means of empowering communities and advancing the aims of participatory democracy.

Context In 2004, the English Public Health White Paper Choosing Health introduced 'health trainers' as new members of the National Health Service (NHS) workforce. Health trainers would offer one-to-one peer-support to anyone who wished to adopt and maintain a healthier lifestyle. Choosing Health implicitly envisaged health trainers working in community settings in order to engage 'hard-to-reach' individuals and other groups who often have the poorest health but who engage the least with traditional health promotion and other NHS services. Methods During longitudinal case studies of 6 local health trainer services, we conducted in-depth interviews with key stakeholders and analyzed service activity data. Findings Rather than an unproblematic and stable implementation of community-focused services according to the vision in Choosing Health, we observed substantial shifts in the case studies' configuration and delivery as the services embedded themselves in the local NHS systems. To explain these observations, we drew on a recently proposed conceptual framework to examine and understand the adoption and diffusion of innovations in health care systems. Conclusions The health trainer services have become more 'medicalized' over time, and in doing so, the original theory underpinning the program has been threatened. The paradox is that policymakers and practitioners recognize the need to have a different service model for traditional NHS services if they want hard-to-reach populations to engage in preventive actions as a first step to redress health inequalities. The long-term sustainability of any new service model, however, depends on its aligning with the established medical system's (ie, the NHS's) characteristics. [ABSTRACT FROM AUTHOR]

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Study aim: The aim of this project is to identify from a range of sources the factors associated with the success of a health impact assessment (HIA) in integrating health considerations into the final decision and implementation of a planned policy, programme, or project. Design: Three methods were adopted: (a) a review of HIA case studies; (b) a review of commentaries, reviews and discussion papers relating to HIA and decision making; and (c) an email survey of a purposive sample of HIA academics, HIA practitioners, and policymakers. Information was captured on the following characteristics: information on the year undertaken; geopolitical level; setting; sector; HIA type; methods and techniques used; identification of assessors. Main results: Two groups of factors were identified relating to the decision making environment and to the technical conduct of the HIA. With regard to the environment, striking a balance between decision maker ownership and HIA credibility; organisational, statutory and policy commitment to HIA, and the provision of realistic, non-controversial recommendations were cited as enablers to the integration of HIA findings into the decision making process. Barriers included a lack of knowledge of the policymaking environment by those conducting HIA. Regarding factors relating to the conduct of the HIA: use of a consistent methodological approach; inclusion of empirical evidence on health impacts; timing of the HIA congruent with the decision making process; involvement of expert HIA assessors; and shaping of recommendations to reflect organisational priorities were cited as enablers while lack of a standardised methodology; lack of resources and use of jargon were cited as barriers. Conclusions: The findings emphasise the importance of considering the politico-administrative environment in which HIA operates. The extent to which HIA fits the requirements of organisations and decision makers may be as important as the technical methods adopted to undertake it. [ABSTRACT FROM AUTHOR]

Discusses efforts of the government in Great Britain to assess the health impact of policies. Description of health impact assessment; Steps involved in health impact assessments, including screening, scoping, impact assessment, and policy modification; Consultations and literature reviews; Validation of the predictions of health impact assessments.

The National Strategy for Neighbourhood Renewal (NSNR) is a central component of British policy to reduce health disparities. This program seeks to improve local socioeconomic and physical environments through the intensive regeneration of disadvantaged communities. We describe the challenges facing evaluators tasked with assessing the impacts of 1 component of the NSNR--the New Deal for Communities initiative--and explore techniques that may be adopted in the evaluation process. (Am J Public Health. 2005;95:626-628.). [ABSTRACT FROM AUTHOR]