Editorials pilot schemes are not necessarily generalisable; pilot projects themselves get modified during implementation, so it is often not clear precisely what is being evaluated. Above all we tend to have far too short time horizons—as Enthoven himself emphasises. We rarely allow enough time to evaluate pilot, let alone national, policies. Maybe therefore the policy process that was actually followed in the 1990s—a policy of gradual adaptation—was the right one. After all it was this process that allowed Labour to build on Conservative achievements while denouncing them. Consider the widespread move from contracts to longer term agreements that took place in the mid-1990s, so preparing the way for Labour’s “abolition” of the market; or the total purchasing pilots, which prepared the way for primary care groups—thereby universalising fundholding while repudiating the concept. In turn, primary care groups and trusts could—in Enthoven’s view—lead to a reinvention of the internal market under a suitably “third way” label. If this happens, however, he thinks it essential to learn the lessons of the past and create the right conditions. There would have to be incentives to primary care groups and trusts to ensure more responsive and patient friendly services. Abandoning his usual sensible reservations about performance indicators, Enthoven suggests rewarding groups and trusts which make the greatest improvements in their patient satisfaction scores. Provider mergers which reinforce local
monopolies should be prevented. It might also be necessary to think hard about the appropriate size of primary care groups and trusts: fundholders could be entrepreneurial precisely because their purchasing power was limited and their decisions did not destabilise existing providers. Enthoven leaves us with two big questions, however. Firstly, is it possible to create and sustain a culture of innovation, efficiency, and good customer service in a public sector monopoly where demand exceeds supply and where individual units do not get more resources for caring for more patients? Secondly, can Labour achieve its objectives of modernising the NHS and making it responsive to the public without introducing consumer choice, competition, and substantially more resources? Enthoven is sceptical on both points. It will be interesting to see whether Labour ministers can prove him wrong: the odds are surely against them. Rudolf Klein emeritus professor of social policy and senior associate King’s Fund, London W1M 0AN
1 2 3 4
Enthoven AC. Reflections on the management of the National Health Service. London: Nuffield Provincial Hospitals Trust, 1985. Enthoven AC. In pursuit of an improving National Health Service. London: Nuffield Trust, 1999. Secretary of State for Health. Working for patients. London: HMSO, 1989. (Cmnd 555.) Le Grand J, Mays N, Mulligan JA, eds. Learning from the NHS internal market: a review of the evidence. London: King’s Fund, 1998.
Healthy living centres Deserve evaluation, even though evaluation is complex
he United Kingdom government has set aside £300m from the National Lottery to establish a network of “healthy living centres” around the country.1 Its aim is to improve health through community action and particularly to reduce inequalities in health in deprived areas. The support for healthy living centres therefore complements other strategies such as health action zones and local health improvement programmes. The initiative involves a considerable commitment of money and energy. How can we tell if this investment is worthwhile? The criteria for assessing applications for lottery funding rightly emphasise the importance of evaluation,1 but the difficulties should not be underestimated. Healthy living centres will take various forms and may exist as partnerships and networks rather than as new buildings. They are based on a recognition that determinants of poor health in deprived areas include economic, social, and environmental factors which are outside the influence of conventional health services.2 Any attempt to address these wider issues requires a coordinated approach from several agencies in the statutory and voluntary sectors. Most importantly, local communities must be involved in all aspects of developing and delivering projects. The ideas behind this initiative can be traced back to the Peckham Pioneer Health Centre in 1935. This centre was organised by its members and provided 1384
services such as antenatal clinics, sports clubs, musical events, and legal advice which crossed traditional boundaries between health, social, and leisure facilities.3 Several more recent projects have also been based on a holistic approach to health and a commitment to partnership with patients. For example, the Bromley by Bow Centre links health, education, arts, and the environment. Activities include a community education programme, a food cooperative, complementary therapies, and exercise classes.4 In Bristol, Knowle West Health Park is planned to include a new health centre, family centre, dance studio, community café, jogging track, and community gardens. Evaluation usually involves assessing progress towards objectives, based on a before and after study or comparison with another model of care. The objectives of healthy living centres are, however, often expressed in nebulous and idealistic terms: “ownership” and “empowerment” are not easily measured. Defining the intervention is problematic as the services included may vary over time. Assessing the impact of models of care on health is always difficult because of the long time lag between intervention and outcome, but the changes in local culture sought by healthy living centres may take generations to achieve. Even when outcomes can be measured (probably related to the process of care and intermediate outcomes such as healthy lifestyle behaviour) it will be difficult to BMJ VOLUME 319
27 NOVEMBER 1999
Editorials determine whether any improvements are related to the healthy living philosophy or to better buildings, greater resources, and influx of new staff. Before and after studies will be confounded by the many other changes that will occur while a centre is being developed. Finally, there is a problem of generalisability. Since a central feature of healthy living centres is that they respond to local needs and priorities, each project will be different. These problems are, however, common to the evaluation of all complex policy initiatives. A considerable body of experience exists from evaluations in fields such as education and crime policy5 which can inform the evaluation of healthy living centres. A simple and useful guide to evaluation has recently been produced by the Health Education Authority,6 and parallels can be drawn with the evaluation of health action zones.7 Healthy living centres should define aims and objectives which are based on an assessment of local health needs and which take account of local people’s priorities. An evaluation plan should identify a clear pathway which links health problems, activities that are intended to address these problems, expected outcomes (with measurable indicators), and longer term aims. Clarification of the theory underlying a project (why an activity should lead to the predicted outcomes), along with detailed monitoring of the delivery of activities, can increase the confidence with which changes can be attributed to the intervention. Qualitative as well as quantitative approaches are necessary to determine not only whether objectives are achieved but also how they are achieved or why they are not. This understanding will be improved by accumulating evidence of different types from several perspectives and sources. A thorough understanding of the local context is also important. The aim of the
evaluation should be to determine why a programme works, for whom, and in what circumstances.5 The healthy living centres movement is encouraging innovation but is largely based on rhetoric rather than evidence. Some enthusiasts for healthy living centres are sceptical about whether the ideals can be reduced into measurable objectives—but their scepticism is matched by those who believe that user participation in planning health care and interagency partnerships are simply exercises in political correctness. What is clear is that traditional models of health care have failed to reduce the differentials in health experienced between rich and poor communities.8 The ineffectiveness of existing services, the recognition of the wide ranging influences on health, and the changing relationship between consumers and providers of services (not just in health care) are all strong arguments in favour of the development and evaluation of healthy living centres. Chris Salisbury consultant senior lecturer in general practice Division of Primary Health Care, University of Bristol, Bristol BS8 2PR ([email protected]
1 2 3 4 5 6 7
Department of Health. Healthy living centres. London: NHS Executive, 1999. (HSC 1999/008.) Gabbay J. Our healthier nation. BMJ 1998;316:487-8. Ashton J. The Peckham Pioneer Health Centre: a reappraisal. Community Health 1977;8:132-8. Ramm C. A healthy living centre in the community. Nursing Times 1998;94:52-3. Pawson R, Tilley N. Realistic evaluation. London: Sage, 1997. Meyrick J, Sinkler P. An evaluation resource for healthy living centres. London: Health Education Authority, 1999. Judge K, Bauld L, Wehner S, Benzeval M, Wigglesworth R, Robinson R, et al. Health action zones: learning to make a difference. Canterbury: PSSRU, 1999. Davey-Smith G, Morris J. Increasing inequalities in health. BMJ 1994;309:1453-4.
Postnatal dexamethasone in preterm infants Is potentially lifesaving, but follow up studies are urgently needed
BMJ VOLUME 319
Clinical research must determine whether treatments enhance lives, make little difference, cause significant harm, or do several of these things. This is well illustrated by the epidemic of blindness due to retrolental fibroplasia that affected thousands of preterm babies in the 1950s.1 Although oxygen was accepted as lifesaving in severe respiratory distress syndrome, randomised controlled trials showed that its unrestricted use could also cause permanent visual impairment. The risk is minimised with modern oxygen therapy, which is strictly controlled. The lesson is that new treatments need to be tested with randomised trials that are large enough and with follow ups long enough to provide robust data on all clinically important endpoints.1 2 Dexamethasone for chronic lung disease in preterm infants may be a similar case where we need better data from larger trials with longer follow up. In the past two decades dexamethasone has gained wide acceptance in routine practice for the postnatal 27 NOVEMBER 1999
treatment or prevention of chronic lung disease in preterm infants. Although dexamethasone is commonly associated with transient side effects, several randomised trials have shown that it rapidly reduces oxygen requirements and shortens the duration of ventilation.3 However, the longer term impact of postnatal dexamethasone on mortality and morbidity in survivors is less clear. The table shows hospital mortality in all randomised studies of postnatal dexamethasone which have been identified and critically appraised according to the methods of the Cochrane Collaboration. These are arranged in groups, prespecified by the Cochrane reviewers, by onset of treatment: (a) early postnatal ( < 96 hours),4 (b) moderately early postnatal (7-14 days),5 and (c) delayed ( > 3 weeks).6 There was a trend to lower mortality after moderately early dexamethasone, but not after early or delayed therapy. Of concern, however, is the suggestion of a risk of cerebral palsy.7-9 The table summarises the best currently 1385