Marmot places. An initiative that must be implemented in Catalonia

"Social Injustice is killing people on a grand scale’. (M.Marmot)

Health inequalities are the systematic differences in health between social groups. Where they are judged to be avoidable differences they are inequitable, unfair. 

Putting them right is a matter of social justice. Reducing these inequities requires actions to improve the social determinants of health – the social, economic, political, physical and cultural conditions that shape our lives and our behaviours.

 
The UCL Institute of Health Equity  established in 2011 and being led by Professor Sir Michael Marmot leads and collaborates on work that addresses the social determinants of health and improves health equity. The IHE created the concept of Marmot Places. 

A Marmot Place recognises that health and health inequalities are shaped by the social determinants of health (SDH) and takes action on these social determinants at a local level. 

Sometimes called the building blocks of health, these social determinants are the conditions in which people are born, grow, live, work and age, such as education, employment and housing, and lead to wide differences in people’s health and in their life expectancy. Many places across England and Wales have become Marmot Places putting health equity at the heart of their local strategies.

Becoming a Marmot Place: 

Marmot Places develop and deliver interventions and policies to improve health equity based on eight principles:

1. Give every child the best start in life. 
2. Enable all children, young people and adults to maximise their capabilities and have control over their lives. 
3. Create fair employment and good work for all. 
4. Ensure a healthy standard of living for all. 
5. Create and develop healthy and sustainable places and communities. 
6. Strengthen the role and impact of ill health prevention. 
7. Tackle racism, discrimination and their outcomes. 
8. Pursue environmental sustainability and health equity together.

Article: Public health and health inequalities: a half century of personal involvement Michael Marmot Journal of Public Health, 2022

LSE Health's Annual Lecture:: Social justice and health equity March 2025, M.Marmot

 

Photo Jordi Soldevila. Geometries de la injustícia II

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Managers in health care sector

Key ideas:

• The necessary skills of healthcare managers involve planning, organizing, implementing, monitoring, and evaluation skills.
• Management skills are focused on the use of organizational resources but they also have to center on the mobilization of the members of the organization.
• The good healthcare manager provides trust and confidence to staff and appreciates staff efforts.
• Communication and critical thinking skills, relational and organizations skills for healthcare management, were seen as essential competencies for development.
• Additional skills to manage subordinates and coordinate with top-level managers is necessary: like self-awareness, change management, and conflict resolution.
• Clarity on the roles and responsibilities of existing and new professionals working in healthcare is necessary.
• Interprofessional healthcare management can resolve the issue of superiority and inferiority among healthcare professions – medicine, nursing, allied health including laboratory and pharmacy, among others. It reinforces humility and teamwork while acknowledging the importance of each profession for the improvement of health.
• If a healthcare manager knows how to lead himself, it then becomes easier for him/her to familiarize and knowing more both the members and the organization well.
• Well-managed staff can lead to well-managed patients.
• Management skills can impact positively on patients’ health outcomes.
• Healthcare management is a profession

Bayot ML, Varacallo MA. Management Skills. [Updated 2023 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. 

Article

Photo Jordi Soldevila. Màcula de la “L” de l’espai Serrahima

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Centering Equity in the Implementation of Emerging Digital Health Technologies: AI, genomic medicine, digital media

Despite unprecedented spending on health in the United States and the rapid expansion in types and innovations of digital health technologies, many populations still get sick and die at higher rates than others. 

To address these persistent health inequities in the US, it will be crucial to center health equity in the implementation of digital health technologies, such as artificial intelligence or personalized genomic medicine. As the two nascent fields of health equity and digital equity find their footing after rapid implementation and scale-up in the post–coronavirus disease 2019 pandemic world, a focus on equitable implementation is particularly important to ensure that digital health technologies do not perpetuate or create new health inequities. However, to date, these fields have had a limited or siloed focus on equitable implementation.

This paper is the inaugural report in the RAND Center to Advance Racial Equity Policy Methods Volume series. This paper will be the first to center health equity in the implementation of digital health technologies by adapting a methodological framework for its implementation to support the planning and evaluation of digital health technologies. Without an explicit focus on equitable implementation, digital health technologies run the risk of further exacerbating existing health inequities or creating new ones. This paper offers approaches to policymakers, implementation scientists, clinical scientists, government regulatory bodies, and those working in the health and digital technology fields to take the lead in centering equity.

The paper, first describe the persistent health inequities in the United States and how the rapid adoption of digital health technologies can perpetuate those inequities. Then they discuss challenges and limitations of Implementation Science (IS) in centering equity in the rapid adoption of digital health technologies and translating these technologies into equitable improvements in public health. Next, they provide examples of how IS process and evaluation frameworks can be adapted to focus on digital and health equity to leverage emerging health technologies to course correct and address inequitable health outcomes.

Finally, they discuss how these adapted IS process and evaluation frameworks can be applied to address the pitfalls—and realize the promise—of three emerging fields at the intersection of racial and digital health equity: (1) genomic medicine, (2) artificial intelligence (AI) (specifically large language models [LLMs]), and (3) participatory digital media (e.g., blogs, digital stories).

Photo Jordi Soldevila. Gaza. Geometries de la injustícia

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The state of science in Catalonia

The Catalan Foundation for Research and Innovation (FCRI), a private organisation set up in 1986, that disseminates research and innovation among society to promote scientific culture, careers in science and Technology and public-private relationships and entrepreneurship publishes its first report about the state of the science in Catalonia

The report starts from the analysis of the key elements that have allowed Catalonia to become a pole of knowledge and talent in Europe over the last two decades, both in the scientific research carried out in the universities and in the research centers, large scientific infrastructures and scientific parks.

The report highlights the main strengths of the Catalan research system, in terms of scientific publication and the management of research projects and the training of research staff. It also values ​​the capacity of the Catalan system for attracting Spanish and European competitive funds, and the fact that the research policies entrusted to 25 years have allowed Catalonia to be recognized internationally as a center for knowledge and talent.

The document also highlights five conditions in favor to the research ecosystem such as 

• the approval of the National Pact for the Knowledge Society, 
• the recovery in Catalonia de Department of Research and Universities, 
• the European strategy of the European Green Deal, 
• the Next Generation projects 
• the future Catalan Science Law. 

The report puts the attention to the measures that should be introduced into the knowledge system to guarantee the continuity of scientific quality indicators and the ability to attract competitive research funds: 

• the increase public and private investment in R+D+I, 
• support for the professional career of researchers 
• improve in the field of transfer and innovation. 

In the areas for improvement, the work points to the aging of the teaching and research staff, the difficulty for young people to start and consolidate a scientific career and the more than difficult reconciliation of family and work, which mainly affects female talent. The report is in favor of more internationalizing the workforce and encouraging the recruitment and retention of international talent. 

In terms of funding, the report emphasizes the need to substantially increase public and private investment in R+D+I, currently below the European average indicators. The report also recommends the necessity to connect the research and innovation ecosystem (the universities, research centers, sicentific parks...) with industrial and technological companies.  

Web access: https://estatciencia.fundaciorecerca.cat/

Report and indicators

photo Jordi Soldevila. Homenatge a Toni Catany. Plat Pobre

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Recessions and health

Recessions are complex events that affect personal health and behavior via various potentially opposing mechanisms. While recessions are known to have negative effects on mental health and lead to an increase in suicides, it has been proven that they reduce mortality rates.

A general health policy agenda in relation to recessions remains ambiguous due to the lack of consistency between different individual- and country-level approaches. However, aggregate regional patterns provide valuable information, and local social planners could use them to design region-specific policy responses to mitigate the negative health effects caused by recessions.

Pros

1. Substantial country-level research shows that mortality declines (i.e. people live longer) during recessions.
2. Recessions can make more time available for individuals to lead a healthy lifestyle.
3. Motor vehicle deaths have been shown to decrease during recessions.
4. Some studies suggest that during recessions the stigma of being unemployed decreases.

Cons

1. A plethora of individual-level studies show that recessions lead to adverse mental health, especially for working-age and low-income people.
2. The number of suicides appears to increase during periods of recession.
3. Income loss due to recessions decreases investments in health-enhancing goods and services.
4. Austerity measures that may be common during recessions, such as budget cuts to social welfare, mainly affect vulnerable population groups and the long-term unemployed.

AUTHOR’S MAIN MESSAGE

Evaluations of the health-related impacts of economic recessions have shown inconsistent results. However, if recessions cause a greater deterioration in individuals’ mental health and a larger number of suicides, then governments should be motivated to work even harder to recover the world’s economies after downturns occur. 

Governments should acknowledge that the potential impact of recessions on people’s health depends on the extent to which people are protected from vulnerability. Welfare policies, such as labor market programs, debt relief programs, and access to health and mental health services, should thus play a significant role as a mediator in the relationship between recessions and health.

Nick Drydakis Professor in Economics and Director of the Centre for Pluralist Economics, Anglia Ruskin University, UK 

Article

photo: Joan Miró Couple d'amoureux aux jeux de fleurs d'amandier

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Integrated Care (IC) and utilization: some evidence

Is integration of primary, secondary and social care better for patients and is it cost effective? Andrew Street, Professor of Health Economics, discusses a recent paper he published with co-authors Anne Mason and Panagiotis Kasteridis, which evaluated the cost-effectiveness of integrated care (IC) programmes in South Somerset for people with long-term conditions.

Objectives: As part of the Vanguard programme, two integrated care models were introduced in South Somerset for people with complex care needs: the Complex Care Team and Enhanced Primary Care. The authors assessed their impact on a range of utilization measures and mortality. 

• Complex Care Team (CCT), provides senior medical input, care coordination, and a personalized care plan to support self-care.
• Staffed by GPs with expertise in chronic care management, complex care nurses and other keyworkers, the CCTs aim to prevent avoidable hospitalizations or, for those in hospital, to support appropriate inpatient care.

Methods: They used monthly individual-level linked primary and secondary care data from April 2014 to March 2018 to assess outcomes before and after the introduction of the care models. The analysis sample included 564 Complex Care Team and 841 Enhanced Primary Care cases that met specific criteria. 

They employed propensity score methods to identify out-of-area control patients and difference-in-differences analysis to isolate the care models’ impact. 

Results: They found no evidence of significantly reduced utilization in any of the Complex Care Team or Enhanced Primary Care cohorts. The death rate was significantly lower only for those in the first Enhanced Primary Care cohort. 

Conclusions: The integrated care models did not significantly reduce utilization nor consistently reduce mortality. Future research should test longer-term outcomes associated with the new models of care and quantify their contribution in the context of broader initiatives.

Watch Andrew Street explaining the article (5m) 

Article (pdf) Evaluating integrated care for people with complex needs (2021)

Photo Richard Long 2012 A circle in Antartica

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false optimism not to be at risk of COVID-19

 

 

 

 

 

Koula Asimakopoulou et al. from King’s College London investigated comparative optimism for infection and recovery from COVID-19, and the implications this may have on the second wave and the possible lockdown. The study found that during the first lockdown period, most respondents believed that compared to others, they were unlikely to be at risk of COVID-19.

Data were collected through an international survey (N = 6485) exploring people’s thoughts and psychosocial behaviours relating to COVID‐19. The paper reports UK data.

They found the belief that negative events surrounding risk and recovery from COVID‐19 are perceived as more likely to happen to others rather than to oneself. Researchers believe that comparative optimism may have brought out the anecdotally observed, lack of compliance with lockdown guidelines in the UK. People who believe COVID‐19 is less likely to happen to them than to others may infer that their actual risk is much smaller than that communicated in the media, and thus the strict adherence to lockdown restrictions is unnecessary in their case.

The results showed how participants overwhelmingly believed that as compared to people of their age and gender, they were somewhat or extremely unlikely to have accidentally infected people with COVID‐19 in the past and to infect others or get infected themselves in the next month. They were also comparatively optimistic, but to a lesser extent, about their likelihood of getting hospitalized due to COVID‐19, finding themselves in an ICU, being ventilated, and making a full recovery.

In contrast, participants showed comparative pessimism about COVID‐19 infections in the more distant future. As compared to the average person of their age and gender they felt likely to get infected by COVID‐19 in the next year and to develop COVID‐19‐related symptoms. The authors argued that this finding supports earlier research that shows that people who have experienced some ill health tend to unduly exaggerate their future risk of experiencing further ill health. One important difference between COVID‐19 and other risks is that controlling the pandemic was very much placed in the hands of individuals restricting their lives in the UK—as seen in the slogan urging people to ‘Stay at home’. It is reasonable that participants would reason that in the long term, staying at home would be less possible, plausible or practical. Feeling that compliance with social distancing rules cannot be maintained indefinitely may thus explain these perceptions, in line with research showing that high prevalence negative events may engender comparative pessimism.

The implication for a second lockdown is that where people's experience so far may be that they have not been ill with COVID, they are likely to be even more comparatively optimistic than they were in March. Thinking that COVID has not happened to you so far so it is unlikely to happen to you now, can be even more dangerous than it was earlier in the spring. Both comparative optimism and comparative pessimism may have important consequences for people’s psychological well‐being and their likelihood of engaging in risk behaviours or responding to further lockdown measures.

Acces article (pdf free) Comparative optimism about infection and recovery from COVID‐19; Implications for adherence with lockdown advice

photo: Càpsules de confinament. Museu Can Framis Fundació Vilacasas. 2020 

Obra 'Sense títol' d'Eulàlia Valldosera, (Vertical)

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Florence Nightingale bicentenary 2020

Florence Nightingale "the Lady of the Lamp" was born on May 12, 1820, in Florence. This 2020 the worldwide celebrates of Florence Nightingale’s bicentenary. In her honour The World Health Organisation have named 2020 the Year of the Nurse and Midwife.

Despite family pressures to marry and live as a conventional wealthy woman, she considered her dedication to nursing to be a response to the call of God to care for the sick. Her success in radically lowering the death rate of wounded soldiers in the Crimean War led to society’s acceptance of her proposals for better sanitation and nutrition, accurate medical knowledge, and professionally trained nurses.

While Nightingale is best known worldwide for revolutionising nursing and healthcare through her campaigning for health reform, her far-reaching recommendations were based on impressive statistical work and popularised through pioneering data visualisation and her evidence-based approach to healthcare.

Florence Nigthtingale was the first female fellow in 1858 from Royal Statistical Society. The Significance magazine from Royal Statistical Society and American Statistical Association has published a special issue: Significance magazine, 2020, Volume 17, Issue 2: Florence Nightingale

More information:
Celebrating Nightingale 2020 Bicentenary
Mujeres con ciencia: Florence Nightingale (in spanish)
Florence Nightingale foundation
Guys and St Thomas Hospital

picture: Helping the wounded. Shutterstock/Everett Historical
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poverty and health

Michaela Benzeval et al. published in 2014 in The Joseph Rowntree Foundation the report How does money influence health?

The study explores the association between income and health throughout the life course and within families. Researchers reviewed theories from 272 wide-ranging papers, most of which examined the complex interactions between people’s income and their health throughout their lives.

The research identifies four main ways money affects people’s wellbeing:

1. Material: Money buys goods and services that improve health. The more money families have, the better the goods they can buy.
2. Psychosocial: Managing on a low income is stressful. Comparing oneself to others and feeling at the bottom of the social ladder can be distressing, which can lead to biochemical changes in the body, eventually causing ill health.
3. Behavioural: For various reasons, people on low incomes are more likely to adopt unhealthy behaviours – smoking and drinking, for example – while those on higher incomes are more able to afford healthier lifestyles.
4. Reverse causation (poor health leads to low income): Health may affect income by preventing people from taking paid employment. Childhood health may also affect educational outcomes, limiting job opportunities and potential earnings.

These pathways are all likely to be important and interact across people’s lives in a complex web of links between income and health. The broader context is also important. Living on a low income in a country with a well-developed welfare state is unlikely to have the same health-damaging effects as living in one with poorer provision for healthcare and education.

Given this complexity of interconnection between people’s income and health, a broad approach to improving the health of those with limited resources is important.
Acces full report

photo: Toni Catany

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healthcare organisations struggling to improve quality

Identifying characteristics associated with struggling healthcare organisations may help inform improvement.

The article published in BMJ Quality and Safety in july 2018 is a systematic reveiw of qualitative studies that evaluated organisational characteristics of healthcare organisations that were struggling as defined "by below-average performance in patient outcomes (eg, mortality) or quality of care metrics (eg, Patient Safety Indicators)".

33 articles from multiple countries and settings (eg, acute care, outpatient) with a diverse range of interviewees (eg, nurses, leadership, staff) were included in the final analysis.

Five domains characterised struggling healthcare organisations: 

1. Poor organisational culture (limited ownership, not collaborative, hierarchical, with disconnected leadership), 
2. Inadequate infrastructure (limited quality improvement, staffing, information technology or resources), 
3. Lack of a cohesive mission (mission conflicts with other missions, is externally motivated, poorly defined or promotes mediocrity), 
4. System shocks (ie, events such as leadership turnover, new electronic health record system or organisational scandals that detract from daily operations), 
5. Dysfunctional external relations with other hospitals, stakeholders, or governing bodies.

Many characteristics shared by struggling organisations were counter to characteristics associated with high-performing organisations. For example, while disconnected leaders and non-collaborative environments were frequently found in struggling organisations, engaged leadership and a collaborative organisational culture are associated with high performance. Furthermore, a ‘flat’ or team-based approach to problems is often associated with high performance, whereas they found hierarchical culture in struggling organisations.

System shocks’ was a domain unique to struggling organisations. Although not all change necessarily causes disruption, being unprepared or unrealistic about the effort required can demotivate and anger staff. To prevent disastrous consequences, shocks must be anticipated and addressed. When shocks cannot be anticipated, leaders may directly address shocks to reduce negative consequences and potentially create positive change.

The study has important implications. The findings suggest that health systems preparing for large-scale organisational change should adequately prepare in order to prevent system shocks, which, counterintuitively, may impede change. Also the study underscores the importance of context, organisational climate and related factors in determining hospital performance. 

Open access article: Characteristics of healthcare organisations struggling to improve quality: results from a systematic review of qualitative studies (2019)

photographer: Leopoldo Pomés (1931-2019). Foto Colectània 
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New organisational models of primary care to meet the future needs of the NHS

The NHS in England (the same occurs in Spain) faces several future challenges for primary care, including an ageing population, increasing numbers of patients with multiple long-term conditions and a limited workforce. The Health Education England Primary Care Workforce Commission  set out to identify innovative models of primary care that will meet these future challenges.

RAND Europe was commissioned in 2015 to present a brief overview of reports from professional bodies and policy-focused organisations — from England and internationally — that describe new models for delivering primary care. These models include:

• Models that introduce new roles, or change existing roles, in general practice (e.g. introducing physician associates and pharmacists into general practice, extending roles for allied health professionals and primary care nurses);

• Models of collaboration among professionals and among the primary care, secondary care and social care sectors (e.g. 'micro-teams', GPs and specialists working together and/or specialists working in the community, extended roles for community pharmacists); and
• New organisational forms for general practice (e.g. primary care federations or networks, super-practices, regional multipractice organisations, community health organisations, polyclinics and multispecialty community providers).

The review concluded that there is no ‘one size fits all’ model for delivering primary care and that the way in which changes are implemented may be as important as the model of change itself. Although several cross-cutting principles of good practice were identified. These are design principles from delivering primary care adapted from Smith et al. (2013)

• Entry to the system: patients should be able to speak to a senior health professional as early as possible and both within and out of hours.
• Specialists and generalists: there is a range of ways in which specialists and generalists could work more effectively together. Patients should have the minimum number of separate visits and consultations that are necessary, with access to specialist advice in appropriate locations
• Continuity and access: patients should be offered continuity of relationship where this is important, and access at the right time when it is required.
• Anticipatory and multidisciplinary care: care should be proactive and population-based where possible, especially in relation to long-term conditions.
• Multimorbidity: care for frail people with multimorbidity should be tailored to the individual needs of patients, in particular for people in residential care or nursing homes.
• Patient self-management: where possible, patients should be supported to identify their own goals and manage their own condition(s) and care, drawing on health professional support as needed.
• Making the most of the multidisciplinary team: primary care should be delivered by a multidisciplinary team in which full use is made of all the team members’ skills.
• Patient records: there should be a single electronic patient record that is accessible by relevant organisations and that can be read and, perhaps in future be added to, by the patient.
• Quality and information: primary care organisations should use, and make publicly available in real time, information about the quality and outcomes of care.
• Organisation and management: Primary care should have professional and expert management, leadership and organisational support.

photo: Josep Guinovart (2003) El cor de l'era (on es pot aprendre com destriar el blat de la palla)
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The Spanish National Health Service: chinese porcelain

 

The principles and goals of the Spanish National Health System focus on universality, free access, equity and fairness of financing. The evolution of performance measures over the last decade shows the resilience of the health system to the recent economic crisis. In terms of mortality and self perceived health it does not seem to have affected heavily at least in the sort term, although some structural reforms may be required in the medium and long term, specially to avoid the increasing income inequality, poverty, and risk of social exclusions that worsen the health indicators.

Here we have some ligth about some policy iniciatives and reforms that experts said should be adressed in the Spanish National Health System

• Cuadernos Económicos de ICE  scientific journal edited by the Secretariat of State for Trade (Government of Spain) since 1977. The current issue published in january 2019. Eight articles written by well known researchers from health economics and public health reviewing these hot topics: 

1. The arrival of new technologies with innovative mechanisms and health financing decisions.
2. Areas of public-private collaboration in health systems. focusing on continuing medical education, health research and health care management.
3. The healthcare management, its quality and the consideration of the impact of this quality on health outcomes.
4. The hospital expenditure and hospitalization evolution in the Spanish National Health System (SNS), during the period 2004-2009 and 2010-2015, analyzing their trends and medical practice variability between health areas.
5. Coordination between the health care system and the long-term care system.
6. Public health go beyond the performance of health care services. Health problems are global and require actions at a global level.
7. Good governance is a prerequisite for changing the health policy and the design of the National Health System in the right direction. Good governance in terms of: prioritization, comprehensive health policy, leadership, national health agency, and cultural and intellectual environment.
8. Economic crisis and health: lessons learned and recommendations for the future,

  Acces Full issue (pdf)  CICE Issue (2018)

• The European Observatory on Health Systems and Policies released a new health system review (HiT) on Spain.

Acces (pdf) Spain HiT (2018)

photo: "Homeless", 2005. google search words: name of the 25th richest people in the world in 2004 by Forbes (Joan Fontcuberta)  
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10 years of The Catalan Institute for the Evaluation of Public Policies (Ivàlua)

The Catalan Institute for the Evaluation of Public Policies (Ivàlua) was created 10 years ago. It's a public institution depending of the Government of Catalonia. The board of trustees is made up of the founding Academic Institutions (UPF), public institutions (Ministry of the Vice-presidency and of the Economy and Finance, DIBA, CTESC, CIC)

Ivalua promotes the evaluation of public policies among the Catalan public administrations, non-profit entities that pursue objectives that are of public interest and among citizens in general,

The evaluation is a tool for improving government performance and democratic accountability. To accomplish its mission, Ivàlua is guided by the following strategic lines:

• Evaluation of public policies and advisory activities
• Training and generation of training resources
• Promotion and dissemination of evaluation

Ivàlua has traditionally and naturally specialised in social policies, employment policies and educational policies (in this field jointly with Fundació Jaume Bofill they are promoting the #WhatWorks in Education movement)

All the activities done during these 10 years have been done with Independence, Technical Rigor to generate evidence and with maximum Transparency at all times. In their website you can download all the Evaluations carried.

Congratulations!!!

photo: Ivalua Team; Marc Balaguer, Mireia Climent, Núria Comas, Marçal Farré, Laura Kirchner, Jordi Miras. Erika Pérez, Ramon Sabes-Figuera, Jordi Sanz, Anna Segura, Federico Todeschini, Frederic Udina.
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Back to basics: the 7 enemies of evidence-based policy

Evidence-based policy is focused on research-based evidence to inform policymakers about “what works” and thereby produce better policy outcomes.

Graham Leicester in his 20th century article - 1999- brings us a number of factors that he suggests inhibits the adoption of the evidence based policy



What we could do against them?

1. Recognise that these enemies are everywhere not only in the governing machine. In the universities, research centres, ... 
2. We live in a risk society and the whole society is a laboratory. All the things that happen are real life experiences with risky technologies, not experiments conducted in laboratory controlled conditions. That means that when they go wrong—and it is axiomatic in the scientific model that they must go wrong if progress is to be made—they do so for real. There needs to be a much closer relationship therefore between government and research evidence. 
3. The political management of the evidence in our ‘risk society’ is even more important than the evidence itself. Researches have an obligation not only to be as rigorous as possible, but also to recognise that their research has a political dimension. What they choose to investigate, how and when they present the findings are part of the risk management process. They are all agents of change.
4. Technological advance is giving a new opportunities to get to grips with complexity. The increase in processing capacity makes all sorts of things possible in the management of complex systems. There is now a capacity for instant information gathering and analysis which makes all policy into a continuous real-time experiment. The researcher’s role will be to monitor, evaluate and adjust continuously. 
5. We must work harder to develop better data, and true indicators of what really matters to us as a society. We need data that answers the question ‘why’ as well as ‘how much’ or ‘how many’? We need indicators which can stand proxy for the general health of society, measures of the vital signs.

It is important for researchers not only to gather the evidence to describe what is happening and how society is changing, but to provide explanations about why these changes are occurring, and then ideally to suggest things that might be done to adjust the system accordingly.

As a Citizens we want evidence-based policy NOT "policy-based evidence": where evidence is typically used as a weapon — mangled and used selectively in order to claim that it supports a politician’s predetermined position

Acces to the article (restricted): The seven enemies (1999)

photo: Game of Thrones. Jon Snow: You know nothing and Book
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wrong pockets problem and pay for success

The wrong pockets problem: a situation in which we would have better outcomes if one institution or sector invested money, but because the primary benefit accrues to another institution or sector there is no incentive to make that investment. This problem describes a situation where the entity that bears the cost of implementing a practice including an evidence based best practice does not receive a commensurate benefit. Because the costs outweigh the benefits for that implementing governmental actor, projects in the public interest do not receive sufficient resources. Thus, project investment is suboptimal, and overall social welfare is in equilibrium suboptimal. Sustained inefficiency is the norm.

This wrong pockets problem particularly affects prevention programs, whether they are behavior modification programs, public health programs, structural prevention programs, or broad policy changes. Despite a growing body of empirical evidence rigorously demonstrating the effectiveness of many programs across numerous social services, advances in the implementation of evidence-based practices has been slow.

Pay for success (PFS) tries to solve the worng pockets problem: It is an innovative financing mechanism that shifts financial risk from a traditional funder—usually government—to a new investor, who provides up-front capital to scale an evidence-based social program to improve outcomes for a vulnerable population. If an independent evaluation shows that the program achieved agreed-upon outcomes, then the investment is repaid by the traditional funder. If not, the investor takes the loss.

Key drivers of the model:

• Pay for outcomes: With PFS, the government only pays for new programs if they meet agreed-upon results, shifting away from traditional outputs-focused funding that does not account for whether a program is having the intended impact;
• Scale evidence-based policymaking: PFS funds tests of potential social programs, amplifies the evidence-base around promising programs, and scales proven programs with a strong evidence base, allowing governments to invest in what is working;
• Shifts risk to new actors: Setting up a new program is risky for governments, both financially and politically. PFS shifts that risk to an outside funder and bypasses typical bureaucratic challenges.

Examples of pay for success financing: The Social impact bonds (SIBs)

Some interesting articles by Urban institute:

• Solving the Wrong Pockets Problem (2015)
• What is pay for success

Social impact bons in health:

• Some problems with Social impact bonds in health: Article (2013)
• Social impact bonds in health: Article (2015)
• Impact Bonds in Health. Seminar (2017)
• Social impact bonds in health and social care: Article (2017)

photo: LIFE; Peter Stackpole (1958)
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Alan Maynard arrived at York when I was born

Alan Maynard was the greatest influencer in the field of health economics.

Alan arrived at York as a graduate student in economics in 1967, when I was born. In 1978 he created York’s MSc in health economics, and in 1983 he founded the Centre for Health Economics (CHE), where he was Director until 1995. CHE has had a major influence on health policy and the development of health economics, and continues to flourish.

He was founding editor of Health Economics, now a leading journal in the field, and later had a hand in creating two other thriving institutions: the York Health Economics Consortium and the Centre for Reviews and Dissemination.

Maynard matters. Critical thinking on health policy. 
This edited volume is a book with two parts:

Part One of the book consists of a set of short pieces written by Alan’s colleagues, celebrating his contributions to different areas of academic and public life. Part Two contains a selection of Alan’s work.
As Tony Culyer says you will meet seven Maynards in these pages:

1. The health economics pioneer: cost-effectiveness studies, health service inequalities and economics of mental health, an analytical approach to health service design and management.
2. The high class journalist: Innumerable think pieces in the Health Service Journal. Often scathing, often ironic, often right, NEVER dull.
3. The high class academic: Founding editor of a great journal: Health Economics.
4. The policy wonk: His impact on family doctor fund-holding, the creation of NICE, workforce contracting.
5. The academic manager: Founding director of the Centre for Health Economics
6. The teacher: Insightful, amusing (often hilarious) but wise and caring too. Never without a box of Kleenex for those who found the going tough.
7. The NHS chair: York Hospital NHS Foundation Trust for 12 years, Vale of York NHS Commissioning Group 2012-15.

Obituary

photos: York daffodils. Heslington Hall by W. Monkhouse (1860)
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clinical trails, conflicts of interest

"if professional societies and medical institutions do not demonstrate vigorous self- regulation and a commitment to keeping patients interests paramount, public trust may diminish, and more external regulation may be imposed" (Bernard Lo)

"Particularly attention must be paid when researchers offer some medical benefit that can be integrated easily into a course of treatment. Although subjects in these trials are offered a treatment of unproven efficacy, many mistakenly believe that they are receiving cutting-edge treatment guaranteed to improve their condition. This therapeutic misconception may be reinforced when subjects receive the experimental treatment from the same physician who has administered all of their care in the past, in contrast to being referred to a clinical investigator located in an academic setting with a reputation for conducting research" (Karine Morine, et al)

• Article (*.pdf): Managing conflicts of interest in the conduct of clinical trials (2002)
• Article (*.pdf): The future of conflicts of interest: A call for professional standards (2012)

photo: (*) Photosolde
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winter is coming and there's no bed in hospital that can resist it

The Nuffield Trust is looking closely at some of the big issues behind pressure on the NHS in winter months. Prof John Appleby Director of Research and Chief Economist presents some solutions:

• For some hospitals, the answer is simple: providing more beds and more staff will help them weather the storm through winter.
• For most others, recording bed occupancy in real time rather than taking a snapshot each day will help them to better coordinate the flow of patients.
• And for virtually all, reducing delays once patients are medically fit to leave hospital is essential.

Recent articles to look forward by Nuffield Trust and The Health Foundation in relation to winter pressures:

1) Winter bed pressures (2016)
2) How to help health care flow to winter pressures (different materials) 

and the Report of the Health Committee appointed by the House of Commons to examine the policy, administration and expenditure of the Department of Health and its associated bodies

3) 3rd Report - Winter pressure in accident and emergency department (2016)

Photo: Aaron Harris / Reuters (2014)
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Three Dialogues in: Ethics applied to companies and organizations

The Fundació Factor Huma in collaboration with the Obra Social "la Caixa", organized three workshops related to Ethics applied to companies and organizations.

The purpose was to create a common ethical reflection shared between the academic and business worlds. The 3 workshops where about:

• Ethics and Governance
• Ethics and Management
• Ethics and People

The workshop was conducted by the expert Begoña Roman, who in every session focused the topic to be deliberate.

• Begoña Román Maestre holds a PhD in philosophy from the University of Barcelona. Between 1996 and 2007 she headed the Department of Ethics at University Ramon Llull (Barcelona) and she is currently professor in the Faculty of Philosophy of the University of Barcelona. In addition, she is Chairperson of the Ethics Committee of Catalonian Social Services and member of Bioethics Committee of Catalonia. Her area of specialization is Bioethics and Ethics applied to professional and organizational environments.

Access to sessions: Diàlegs

You will find the videos of each session with the Begoña Roman speeches and access to document with an abstract of the key note speech and the conclusion of the workshop.

photo: (*) Photosolde
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Could an Integrated Delivery System be a cure for fragmentation in Catalonia?

An Integrated Delivery System (IDS) defined by Alain C. Enthoven  is an organized, coordinated, and collaborative network that:

(1) links various healthcare providers, via common ownership or contract, across 3 domains of integration—economic, noneconomic, and clinical—to provide a coordinated, vertical continuum of services to a particular patient population or community

(2) is accountable, both clinically and fiscally, for the clinical outcomes and health status of the population or community served, and has systems in place to manage and improve them.

With all of the following  characteristics:

1. Shared values and goals; 
2. Aligned incentives; 
3. Physicians leadership; 
4. Comprehensive records; 
5. Shared practice guidelines; 
6. A culture of teamwork; 
7. Integration across care settings; 
8. And a focus on populations as well as individuals.

Here there is the article explaining what is an IDS. A. Enthoven (2009) Integrated Delivery Systems: The Cure for Fragmentation: 

Alain C. Enthoven said in 2007 in a Nuffield Trust (UK) seminar:
"Integration is about relationships between people. These relationships are not informal friendships. They have to be worked on and built professionally if clinical integration is to be meaningful and sustained through good and bad times. Effective integration takes years to develop, and is not a quick fix".

We should explore more this idea in Catalonia.

photo: (*) Photosolde
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