Professor Nicholas Goodwin

Building an affordable and effective national health system is a major preoccupation of governments around the world. Using illustrative case examples from different countries, this article provides an overview of the four principal components that make up the functions of a national health-care system - financing, purchasing (resource allocation), service provision, and stewardship. Each principal function is performed very differently internationally; this article provides a deconstruction of each, explaining and discussing these variances. It concludes with a discussion of those key system design factors that appear to contribute to the more effective national health-care systems.

Building an affordable and effective national health system is a major preoccupation of governments around the world. Using illustrative case examples from different countries, this article provides an overview of the four principal components that make up the functions of a national health-care system - financing, purchasing (resource allocation), service provision, and stewardship. Each principal function is performed very differently internationally; this article provides a deconstruction of each, explaining and discussing these variances. It concludes with a discussion of those key system design factors that appear to contribute to the more effective national health-care systems. © 2008 Copyright © 2008 Elsevier Inc. All rights reserved.

Background: Household air pollution is a leading health risk for global morbidity and mortality and a major health risk in South Asia. However, there are no prospective investigations of the impact of household air pollution on perinatal morbidity and mortality. Our trial aims to assess the impact of liquefied petroleum gas (LPG) for cooking to reduce household air pollution exposure on perinatal morbidity and mortality compared to usual cooking practices in Bangladesh. Hypothesis: In a community-based cluster randomised controlled trial of pregnant women cooking with LPG throughout pregnancy, perinatal mortality will be reduced by 35% compared with usual cooking practices in a rural community in Bangladesh. Methods: A two-arm community-based cluster randomised controlled trial will be conducted in the Sherpur district, Bangladesh. In the intervention arm, pregnant women receive an LPG cookstove and LPG in cylinders supplied throughout pregnancy until birth. In the control or usual practice arm, pregnant women continue their usual cooking practices, predominately traditional stoves with biomass fuel. Eligible women are pregnant women with a gestational age of 40¿120 days, aged between 15 and 49 years, and permanent residents of the study area. The primary outcome is the difference in perinatal mortality between the LPG arm and the usual cooking arm. Secondary outcomes include (i) preterm birth and low birth weight, (ii) personal level exposure to household air pollution, (iii) satisfaction and acceptability of the LPG stove and stove use, and (iv) cost-effectiveness and cost-utility in reducing perinatal morbidity and mortality. We follow up all women and infants to 45 days after the birth. Personal exposure to household air pollution is assessed at three-time points in a sub-sample of the study population using the MicroPEM¿. The total required sample size is 4944 pregnant women. Discussion: This trial will produce evidence of the effectiveness of reduced exposure to household air pollution through LPG cooking to reduce perinatal morbidity and mortality compared to usual cooking practices. This evidence will inform policies for the adoption of clean fuel in Bangladesh and other similar settings. Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12618001214224. Prospectively registered on 19 July 2019

Reform of the National Health Service in England will increase power and responsibility for family doctors. They will have a larger role in planning and buying health care including control of substantial budgets. This article examines the likely implications of the proposed reforms for primary care, and in particularly for family doctors. This article considers the effect of the new clinical role in commissioning health care, changes to the accountability structures, and the effect on competition and integration within health services. It also considers the effect of new financial incentives and the possibility of creating conflicts of interest. Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Background: All modern healthcare systems need to respond to the common challenges posed by an aging population combined with a growing number of patients with (complex) chronic conditions and rising patient expectations. Countries with 'stronger' primary care systems (e.g. the Netherlands and England) seem to be better prepared to address these challenges than countries with 'weaker' primary care (e.g. USA). The role of primary care in a health care system is strongly related to its organisation and funding, thus determining the starting point and the possibilities for change. Method: We selected the Netherlands, England, and USA as examples for the diversity of approaches to organise and finance health care. We analysed the main problems for primary care and reviewed strategies and practice models used to meet the challenges described above. Results: The Netherlands aim to strengthen prevention for chronic diseases, while England strives to improve the management of patients with multimorbidity, prevent hospital admissions to contain costs, and to satisfy the increased demand of patients for access to primary care. Both countries seek to reorganise care around the patient and place their needs at the centre. The USA has to provide sufficient workforce, organisation, and funding for primary care to ensure better access, prevention, and provision of chronic care for its population. Strategies to improve (trans-sectoral) cooperation and care coordination, a main issue in all three countries, include the implementation of standards of care and bundled payments for chronic diseases in the Netherlands, GP commissioning, federated and group practice models in England, and the introduction of the Patient-Centred Medical Home and accountable care organisations in the USA. Conclusion: Organisation and financing of health care differ widely in the three countries. However, the necessity to improve coordination and integration of chronic disease care remains a common and core challenge.

Telehealth and telecare innovations have the potential to improve quality of life, reduce unnecessary hospital and care home admissions, and support care integration by providing care and disease management from multi-disciplinary care teams linked remotely to users. About 1.7 million people benefit from telecare services in the UK, but telehealth services have only around 5000 users, many of whom receive services through the Department of Health's Whole System Demonstrator (WSD) Pilot Programme. There is an identifiable chasm between early adopters and wider uptake of telehealth and telecare solutions. Key barriers include lack of robust evidence on cost-effectiveness, of a consumer market and of interoperability of the technology between service sectors, and the implications for professionals and organisations of changing their established methods of practice. Telehealth and telecare could be combined to provide a common platform to integrate care for people requiring both health and social care support, but relatively few people are judged suitable for joint care. This is related both to the nature of the technology and the profile of those people who can use it, and to the different ways in which health and social care systems assess who is most 'at risk', which makes it difficult to assess which individuals might best benefit from an integrated response to their care needs. While there is considerable interest and policy momentum behind the adoption and diffusion of telehealth and telecare in England, more understanding of their benefits is required to convince commissioners and providers of its potential. © Pier Professional Ltd.

Scoping studies have been used across a range of disciplines for a wide variety of purposes. However, their value is increasingly limited by a lack of definition and clarity of purpose. The UK's Service Delivery and Organisation Research Programme (SDO) has extensive experience of commissioning and using such studies; twenty four have now been completed. This review article has four objectives; to describe the nature of the scoping studies that have been commissioned by the SDO Programme; to consider the impact of and uses made of such studies; to provide definitions for the different elements that may constitute a scoping study; and to describe the lessons learnt by the SDO Programme in commissioning scoping studies. Scoping studies are imprecisely defined but usually consist of one or more discrete components; most commonly they are non-systematic reviews of the literature, but other important elements are literature mapping, conceptual mapping and policy mapping. Some scoping studies also involve consultations with stakeholders including the end users of research. Scoping studies have been used for a wide variety of purposes, although a common feature is to identify questions and topics for future research. The reports of scoping studies often have an impact that extends beyond informing research commissioners about future research areas; some have been published in peer reviewed journals, and others have been published in research summaries aimed at a broader audience of health service managers and policymakers. Key lessons from the SDO experience are the need to relate scoping studies to a particular health service context; the need for scoping teams to be multi-disciplinary and to be given enough time to integrate diverse findings; and the need for the research commissioners to be explicit not only about the aims of scoping studies but also about their intended uses. This necessitates regular contact between researchers and commissioners. Scoping studies are an essential element in the portfolio of approaches to research, particularly as a mechanism for helping research commissioners and policy makers to ask the right questions. Their utility will be further enhanced by greater recognition of the individual components, definitions for which are provided. © 2008 Anderson et al; licensee BioMed Central Ltd.

This article summarises the results of a review of the impact of research funded by the NHS Service Delivery and Organisation Research and Development (SDO) Programme. The review draws primarily on the HERG Payback model, and the outputs and outcomes of SDO research are summarised in each of the five Payback domains: service delivery, policy, practice, research and capacity building. The article also discusses conceptual and methodological problems in identifying and attributing research impact that have been raised by the SDO impact review. © The Policy Press.

This article discusses the experiences of the NHS Service Delivery and Organisation Research and Development Programme (the SDO) in transferring knowledge from research into practice. In the context of relevant theories, four main difficulties in achieving knowledge transfer are described and two modes of knowledge production are uncovered: one being discipline based, and the other valuing research for its usefulness. In attempting to hold a balance between the two modes, the article shows how the SDO has dealt with the difficulties in knowledge transfer and concludes that a key to successful knowledge transfer is to achieve significant interaction between decision makers and research commissioners at the earliest possible stage. © The Policy Press.

This article presents findings from a wider UK Department of Health funded evaluation of English Primary Care Groups (PCGs) and Trusts (PCTs). It presents qualitative research into the experiences of general practitioners (GPs) in these PCG/Ts and explores the extent to which GPs manage, or are managed by, these new organizations. Using the framework of stratification theory, the paper explores whether there is any evidence to suggest PCTs will strengthen collective medical control over resource allocation whilst fending off management control of clinical decision-making. It also examines whether individual GPs not involved at board level feel a loss of control over decisions and their own clinical practice. A stratified random sample of 20 GPs was selected for in-depth interview. The in-depth interviews were designed to capture the full complexity and variety of GPs' experiences that routinely available data could not capture. GPs were anxious that clinical decisions were, or could, be overridden by other concerns such as cost control. The extent to which primary care professionals leading PCGs and PCTs could fend off managerial control was doubted. However, whilst GPs felt under threat, this was more an anticipated threat than a reality. GPs within PCG/Ts seem prepared to accept a degree of standardization if they feel that this is consistent with good clinical care. However, although there was the impression of greater central control, PCGs and PCTs and Government policies did not appear to have made an impression on clinical autonomy. © Health Services Management Centre 2004.

Primary care trusts can be torn between the need for critical mass and the danger of losing local vision and ownership; mergers are politically unpopular and fraught with difficulty. A review of Trafford South PCT stakeholders enabled a range of organisational models to be tested. The result was the creation of a 'joint and integrated management structure' for the two Trafford PCTs.

Primary care trust commissioning is not advanced and there is little evidence of PCTs influencing hospital services. Any further NHS reorganisation would hamper the development of commissioning. PCTs need to engage more GPs in the task of commissioning services. PCTs' ability to move work round on a cost per case basis should strengthen their hand in commissioning from hospitals.

Over the last ten years the traditional role of primary care in Great Britain has been undergoing major changes with the major impact being the introduction of what is termed "GP fundholding", a process by which GPs hold budgets to purchase care from hospitals on behalf of their patients. This paper addresses how the system of fundholding operates in practice and points out the difference between the new and the previous system in which the health authority would plan care for the whole of a district and costs by hospitals would be covered by an all-inclusive system. The paper studies the rationale of the introduction of the fundholding and examines the evidence on how successful the approach has been. With reference to a systematic literature review of the evidence on fundholding's outcomes undertaken by the author, the paper examines the evidence for and against fundholding under the following headings: efficiency, equity, quality, choice and responsiveness. The paper then addresses more recent changes to the British health care system and shows how these have changed the role of the family doctor irrevocablly.

Objectives: To summarise the findings from a comprehensive review of research on the effects of the three main elements of the quasi-market reforms of the UK National Health Service (NHS) introduced in 1991/92: - General practices becoming fundholders by volunteering to purchase elective care for their patients; - Health authorities becoming purchasers of emergency, unplanned and elective services, together with a range of alternatives to fundholding operating under their auspices; - The conversion of providers of hospital and community health services to NHS trusts separate from their local health authorities. Methods: Published and unpublished studies which included any data on the impact of the three main planks of the quasi-market changes, produced between 1991 and late 1998, were identified using a combination of electronic databases, library catalogues at the King's Fund, London, bibliographies, reference lists of individual studies, a survey of NHS directors of public health and consultations with subject area experts. Each main element of the quasi-market was assessed in relation to its impact on: efficiency (primarily productivity); equity; quality; choice and responsiveness; and accountability. Results: There was relatively little measurable change that could be related unequivocally to the core mechanisms of the quasi-market. Conclusions: The incentives were generally too weak and the constraints too strong to generate the consequences predicted by either proponents or critics of the quasi-market. On the other hand, the way in which the NHS operates was changed irrevocably by the reforms.