Search

Background: Emerging research suggests exposure to high levels of air pollution at critical points in the life-course is detrimental to brain health, including cognitive decline and dementia. Social determinants play a significant role, including socio-economic deprivation, environmental factors and heightened health and social inequalities. Policies have been proposed more generally, but their benefits for brain health have yet to be fully explored. Objective and methods: Over the course of two years, we worked as a consortium of 20+ academics in a participatory and consensus method to develop the first policy agenda for mitigating air pollution's impact on brain health and dementia, including an umbrella review and engaging 11 stakeholder organisations. Results: We identified three policy domains and 14 priority areas. Research and Funding included: (1) embracing a complexities of place approach that (2) highlights vulnerable populations; (3) details the impact of ambient PM2.5 on brain health, including current and historical high-resolution exposure models; (4) emphasises the importance of indoor air pollution; (5) catalogues the multiple pathways to disease for brain health and dementia, including those most at risk; (6) embraces a life course perspective; and (7) radically rethinks funding. Education and Awareness included: (8) making this unrecognised public health issue known; (9) developing educational products; and (10) providing publicly available monitoring and screening tools. Policy Evaluation included: (11) engaging in co-production; (12) conducting complex systems evaluation; (13) attaching brain health to air pollution strategies and, in turn, attaching air pollution to brain health campaigns; and (14) evaluating air quality policies for their brain health benefits. Conclusion: Given the pressing issues of brain health, dementia and air pollution, setting a policy agenda is crucial. Policy needs to be matched by scientific evidence and appropriate guidelines, including bespoke strategies to optimise impact and mitigate unintended consequences. The agenda provided here is the first step toward such a plan.

Health inequalities provide a very good example of the complex relationship between the social contract, the political economy and the types and resourcing of policy responses. Despite an established evidence base about the material and structural causes of health inequalities, a narrow (medical) framing of health as the absence of disease and illness predominates across systems. In this respect, the NHS provides a form of collectivism that is valued by both the centre-left and the centre-right, given it does not unduly challenge the notion of individual rights and responsibilities within the social contract. Ultimately, the NHS is designed to deal with symptoms rather than the much more complex and deeply ingrained social inequalities causing them. The political economy is a key component in a complex systems approach to understanding health inequalities but policy development has not been calibrated accordingly, which goes a long way in explaining the persistence of these inequalities.

Social mobility is a big deal in debates about social policy. However, it is tied to notions of equality of opportunity and individual responsibility for upward mobility that tend to marginalise the significance of inequalities in condition and the lack of movement towards the top of society for social circulation. Despite growing concerns about the availability of opportunities for large sections of society, the political economy continues to respond to and foster individualism in society. The social mobility agenda, therefore, plays a role in delegitimising alternative (and more egalitarian) conceptions of the social contract. It is argued that the nature of social mobility (and a tendency towards a post-democratic social contract) in England is more significant for social policy design than social policy design is for social mobility policy.

This chapter focuses on globalisation, the political economy and social policy, including how the wealthy capitalist economies have been complicit in strengthening the hand of capital. The global ‘race to the bottom’ has limited the ‘possibility space’ for social policy development through lowering corporation taxes, deregulating financial and labour markets and cutting welfare spending. Focusing on examples of climate change adaptation and the COVID-19 pandemic, the consequences of neoliberalism for social policy delivery are explored. Reduced capacity and increased fragmentation have impacted on the resilience of health and social care systems to external shocks. Neoliberalism and NPM have weakened the local state in England and, therefore, its role in shaping the social contract. In considering devolution, it is argued that greater powers and resources will enhance the responsiveness and accountability of the local state to its citizens and strengthen local democracy. Finally, Brexit is explored as a consequence of the social contract and a possible intensification of its trajectory.

This chapter explores a number of issues associated with intergenerational standards of living and of relevance to the legitimacy of the social contract. Younger generations are experiencing downward trends in real wages and growing costs of living, while the development of social policies geared towards active ageing runs counter to the trajectory and ‘possibility space’ of the political economy. The concentration of wealth in too few hands contributes to declining living standards and rates of growth. However, instead of giving consideration to a politics of redistribution, there has been a turn to identity-based politics and a focus on discourse, which distracts attention from failings in the political economy. The COVID-19 crisis and, potentially more significantly, artificial intelligence (AI) and automation pose systemic challenges that may require fundamental change in the political economy and, as such, offer opportunities for a more redistributive social contract and social policy development.

The UK is one of the most regionally unequal countries in the developed world. The centralisation of political, economic, cultural and policy systems in London has influenced the management of globalisation, deindustrialisation and neoliberalism within the UK, favouring the capital and embedding a spatial imbalance in the economy and society. Regional and local inequalities in, for example, education, health, labour markets and standards of living are consequences of the (mis)management of the political economy. Public ownership of land and housing have come under sustained attack and the large-scale privatisation of these has changed the role and capacity of the local (in particular) state and should be interpreted as fostering, and responding to, individualism within the social contract. All of these things stem from a selective and inconsistent application of the non-interventionist and market-oriented logic of financial capitalism.

Background Area-based initiatives that include a focus on community empowerment are increasingly being seen as potentially an important way of improving health and reducing inequalities. However, there is little empirical evidence on the pathways between communities having more control and health outcomes. Purpose To identify pathways to health improvement in a community-led area-based community empowerment initiative. Methods Longitudinal data on mental health, community control, area belonging, satisfaction, social cohesion and safety were collected over two time points, 6 months apart from 48 participants engaged in the Big Local programme, England. Qualitative comparative analysis (QCA) was used to explore pathways to health improvement. Results There was no clear single pathway that led to mental health improvement but positive changes in ‘neighbourhood belonging’ featured in 4/5 health improvement configurations. Further, where respondents experienced no improvement in key social participation/control factors, they experienced no health improvement. Conclusion This study demonstrates a potential pathway between an improvement in ‘neighbourhood belonging’ and improved mental health outcomes in a community empowerment initiative. Increasing neighbourhood belonging could be a key target for mental health improvement interventions.

Background Many health outcomes for children and young people in England, UK remain poor compared to international peers, with persistent inequalities across the country. Our study sought to understand, from the perspectives of local stakeholders, the key factors affecting the development and implementation of policy to improve child health and reduce inequalities. Methods We carried out a detailed case study in an English local authority area. Our fieldwork comprised: documentary review of local policies, observation of key strategic and operational meetings and semi-structured interviews with local stakeholders. We followed Jessop's (2016) approach in using specific policy areas and policies (mental health, obesity and the early years) as 'entry points' to understand the local context. Results First, and most importantly, there was an overriding consensus that local action to reduce inequalities in child health is hampered by a persistent unequal distribution of the social determinants of health. Second, local stakeholders highlighted the damaging impact of austerity measures and poverty in the UK, which, they argued, had impacted most upon the most vulnerable. Third, while national policies often provided a framework and incentive for local action, there was an emphasis on the importance of local knowledge and place-based approaches, developed through close work with communities. Conclusions Our study highlights the need for progressive policies to begin to reduce the uneven distribution of the social determinants of health to enable local stakeholders to make progress in tackling inequalities in child health. It emphasises the futility of funding national policies to improve child health and reduce inequalities in the context of greatly reduced budgets for local authorities. National policy should also facilitate the mobilisation of context specific knowledge, produced in conjunction with community members. Key messages Our work evidences the pressing need to address structural inequalities and adequately resource and facilitate work to reduce inequalities at a local level. National policy should facilitate the mobilisation of context specific knowledge, produced in conjunction with community members.

This paper critically discusses the utility of using qualitative comparative analysis (QCA) in geographical research following the ‘complexity turn’. Although QCA methodology has increasingly been applied in other social science disciplines, it is not widely used by geographers. The major benefit of QCA is that it can handle complexity by exploring different pathways that generate the same outcome, which applies to much spatial research. Significantly, QCA is case – rather than variable – oriented, which is hugely important when considering the significance of context. In this paper we illustrate how QCA can be applied in the discipline of geography through a case study of area-level health resilience. We argue that QCA can be usefully applied to such geographical questions as it aids our understanding of the complex processes that lead to spatial variations in health. Moreover, QCA enables geographical research to bridge the quantitative–qualitative divide. We conclude that QCA has great potential for exploring the complex, spatial factors that influence area-level health resilience by being context-sensitive and case-oriented. We make the case for applying this methodology in future geographical research.

Vulnerability to extreme weather events reflects the type, severity, and duration of the exposure, in addition to the attributes that make individuals and physical and social infrastructures susceptible to damage. Older populations are a demographic group likely to be at risk, despite their considerable capacity for adaptation and resilience. The vulnerability (and resilience) of older people significantly depends on the types and strengths of connections across complex systems of health and social care, upon which a substantial proportion of older people depend. In many areas of the world, there is growing emphasis on strategies to recognize, sustain, and strengthen this “nexus” of critical connections. This chapter considers people and climate change in a Western European context using illustrations from research in England, which focuses on the impacts of extreme weather events on the built infrastructure supporting older people’s health and social care delivery.

Our findings contribute to a growing international literature on how conceptual models from complexity theory may be relevant to inform planning in health and social care systems, helping to adapt and improve preparedness and resilience to extreme weather events. We focus on findings from two case studies in England and their relationship to national policy for adaptation. Complexity theory helped to frame strategies for planning for events that are emergent and unpredictable. We find from our case studies that, in spite of the uncertainty involved, some ‘principles’ derived from parts of the literature on complexity theory may provide a helpful framework for the development of more robust preparedness strategies in the health and social care sector. By viewing health and social care as a ‘system of systems’, adaptation planning recognises the interrelationships of built, institutional and social infrastructures. The idea of local systems, with variable, path-dependent attributes, which are partially closed, but permeable to other parts of the wider network, leads to an actionable model of adaptation which emphasises the potential value of local self-organisation, but also underlines the importance of co-evolution across the wider system and the vital role of national initiatives and support for adaptation strategies. The value of sharing experience from local case studies across the national system, as well as among local partners, is very apparent in the experience reported here.

Background This paper explores the value of qualitative comparative analysis (QCA) in public health research using the example of a pilot case management intervention for long-term incapacity benefit recipients. It uses QCA to examine how the ‘health improvement’ effects of the intervention varied by individual and service characteristics. Methods Data for 131 participants receiving the intervention were collected over 9 months. Health improvement was measured using the EuroQual Visual Analogue Scale. Socio-demographic, health behaviour data were also collected. Data on service use was obtained from the provider's client records. Crisp set QCA was conducted to identify which individual and service characteristics were most likely to produce a health benefit after participation in the intervention. Results Health improvement was most likely amongst younger participants, men aged over 50 and those with an occupational history of skilled manual work or higher and less likely amongst older women, those with a musculoskeletal condition and those with semi- or un-skilled backgrounds. Service characteristics had no impact. Conclusions The QCA identified potential causal pathways for health improvement from the intervention with important potential implications for health inequalities. QCA should be considered as a viable and practical method in the public health evaluation tool box.

Background Extreme weather events (EWEs) can significantly impact on mortality and morbidity in the UK. How EWE guidance is disseminated and applied across health and social care systems, at the local, operational level, is not well understood. Methods This exploratory study develops tools and resources to assist local stakeholders to cascade national ‘all weather’ EWE guidance across local systems. These resources are also used to evaluate the local interpretation and implementation of this advice and guidance within three local authority areas. In total, five discussion group meetings were held and 45 practitioners took part in the study. A thematic analysis was conducted. Results The main themes emerging from the analysis related to awareness of PHE guidance for EWE preparedness, data sharing feasibility, community engagement, specific conditions in remote rural areas and capacity of frontline staff. Conclusions The relative difficulty in finding where the study 'best fits’ on local stakeholders’ agendas suggests that year-round and preparedness planning for EWEs may not have been considered a high priority in participating areas. This study adds to the relatively limited evidence internationally concerning the practical implementation at local level of national adaptation advice and guidance and potential barriers to achieving this.