Joanne Gray

Responding to growing political concerns that posit health-related economic inactivity (HREI) as simultaneously a threat to economic growth and a matter of individual behaviour and labour market participation, this commentary critically interrogates the structural foundations of worklessness within capitalist polities. We argue that HREI cannot be understood as either a residual labour market issue or an individual problem of poor health. Rather, inactivity is symptomatic of deeper systemic logics that determine who is deemed economically valuable and who is rendered surplus. We examine contemporary UK ‘workfare’ policy, in which welfare payments are made conditional on work related activity, and thus extend labour market logics into health and welfare systems. These systems are increasingly tasked with prioritising productivity over care. Policy imperatives discipline the inactive through mechanisms such as activation, conditionality and welfare reform, while obscuring the structural determinants of ill health and labour market exclusion, reinforcing a moral economy in which health is instrumentalised for economic ends. This commentary champions a politics of care over activation whilst calling for a reimagining of the relationship between public health, work and employment; one that prioritises a politics of care, centring equity, solidarity and unconditional support whilst resisting reductionist, orthodox economic models that use labour market participation as a core measure of human value.

Background: Economic inactivity, the proportion of people aged between 16 and 64 years who are not in the labour force, has increased significantly since 2020. Long-term sickness is the most common reason for economic inactivity. In the North of England, economic activity is lower, and levels of poor health in the working age population are higher, than national averages. The international literature reports many interventions designed to reduce economic inactivity including those designed to ameliorate the impact of health conditions on work participation, however, there is a need for high-quality evidence of what works for people with health conditions living in the United Kingdom (UK), and in particular for those living in areas of high deprivation such as the North of England. Methods: We conducted a systematic review preregistered with the open science framework. We searched AMED, ASSIA, Business Source Premier, CINAHL, Cochrane Library, MEDLINE, ProQuest Dissertations & Theses Global, PsycARTICLES, Science Direct, and Scopus to November 2023. Eligibility criteria for selecting studies consisted of experimental and observational studies published or in grey literature that examined the efficacy or effectiveness of interventions in reducing economic inactivity in people with health conditions living in the UK. Two reviewers independently screened abstracts and full texts followed by data extraction and synthesis using the Narrative Synthesis Framework. Results: Twenty-seven reports detailing sixteen unique studies and eight different interventions met the eligibility criteria and were included in the review. There was conflicting evidence for the effectiveness of sanctions on economic inactivity and the most robust evidence for classic individual placement and support although more evidence is needed for time-limited individual placement and support. Included studies highlighted the importance of providing specialist employment advice via skilled and experienced advisors but conflicting evidence on combining employment advice with specific psychological therapies. Conclusions: Overall, we found limited robust evidence of what works in reducing health related economic inactivity, particularly for populations experiencing elevated levels of socio-economic deprivation. Open science framework preregistration: https://osf.io/aucz9 .

Despite social prescribing being promoted by the UK government for the last decade, the evidence supporting social prescribing remains weak and has mainly been confined to clinical contexts. Our study aimed to evaluate the impact of a Social Navigator (SN) service in South Tyneside on the health and well-being of users who experience financial hardship with complex health needs and limited access to mental health services. Using a mixed-methods design combining secondary analysis of service data (n=330), qualitative interviews with service users (n=15) conducted by peer researchers, and a social return On investment analysis that matched service data with health economic indicators from the UK Social Value Bank. Our findings demonstrate clear value for money with a £3 return for every £1 invested in the service, with a positive return confirmed in sensitivity analysis. SNs were able to improve the confidence of service users, with statistically significant changes across all eight confidence-related outcomes, and helped them to access other advice and financial services. This resulted in one-off financial gains (average £1237) and annual financial gains (average £1703) for service users. The interviews identified that relieving financial burden and stress improved the quality of life and mental well-being of users as a result of their involvement with the service. SN can break the cycle of multiple visits to crisis teams by building trusting relationships and providing emotional and practical support, while being responsive to the service users’ needs and available when they have needs. They play a key intermediary role in integrated care systems with a unique focus on the wider determinants of health and financial hardship, advocating for service users without time limits and navigating the complexities of the system across local government. Greater integration of local support services could be achieved by mapping all available pathways for support.

Background/Objectives: Heart disease is common in COPD, yet it is underdiagnosed and undertreated. Heart failure (HF) is undiagnosed in up to 20% of hospital inpatients. Hospitalised exacerbations of COPD (ECOPD) confer high mortality and readmission rates, with an elevated temporal cardiac risk. We performed a pilot randomised controlled trial examining the feasibility and effect of inpatient structured cardiac assessment (SCA) to diagnose and prompt guideline-recommended treatment of heart disease. Methods: A total of 115 inpatients with ECOPD were randomised 1:1 to receive usual care (UC) or SCA, comprising transthoracic echocardiography, CT coronary artery calcium scoring, 24 h ECG, blood pressure, and diabetes assessment. Follow-up was for 12 months. The prevalence of underdiagnosis and undertreatment of heart disease were captured, and potential outcome measures for future trials assessed. Results: Among patients undergoing SCA, 42/57 (73.7%) received a new cardiac diagnosis and 32/57 (56.1%) received new cardiac treatment, compared with 11/58 (19.0%; p < 0.001) and 5/58 (8.6%; p < 0.001) in the UC group. More patients in the SCA group were newly diagnosed with HF (36.8% vs. 12.1%; p = 0.002). When heart disease was diagnosed, the proportion receiving optimal treatment at discharge was substantially higher in SCA (35/47 (74%) vs. 4/11 (34%); p = 0.029). The occurrence of a major adverse cardiovascular event (MACE) showed promise as an appropriate clinical outcome for a future definitive trial. MACEs occurred in 17.2% in usual care vs. 10.5% in SCA in one year, with a continued separation of survival curves during follow up, although statistical significance was not shown. Conclusions: A structured cardiac assessment during ECOPD substantially improved diagnosis and treatment of heart disease. HF and coronary artery disease were the most common new diagnoses. Future interventional trials in this population should consider MACEs as the primary outcome.

Mental health crisis interventions involving police originated in the United States. In England and Wales, street triage services (a UK term used to describe urgent mental health and police interventions) were piloted in 2013. These models involve police and mental health services working together to ensure individuals receive the required support. Evaluation findings have shown inconsistent outcomes based on studies predominately limited to single sites. Evaluations to date have lacked theoretical consideration of the contexts and mechanisms triggering outcomes for service users. This review used a realist approach to develop an explanatory understanding of what happens in interventions involving the police responding to individuals experiencing a mental health crisis (underlying mechanisms), the contextual conditions surrounding the implementation of these interventions (context) and the outcomes produced as a result. The review was conducted using a two‐stage process. Stage one generated initial programme theories, which informed a systematic literature search (stage two), which further developed, tested theories. From 6461 potentially relevant papers identified in stage two, 19 papers were included. Extracted data were themed, prior to developing narrative and formulating programme theories. In six programme theories, spanning four themes were developed: role legitimacy of police as responders to mental health crises, using technology, complex decision‐making and responding to distress. Findings indicate that central to successful interventions involving the police in mental health crisis responses is the requirement of social relationships and joint working between police and mental health services to foster trust. Presented findings contribute to a more detailed understanding of mechanisms within interventions involving the police in mental health crisis responses. By generating evidence‐based understandings of the effective components of these support interventions, this research has potential to inform development of future such support at a time of significant policy changes impacting on the role of police as responders to mental health crises.

Objectives: Applying social prescribing to non-clinical areas such as mental health, and underlying causes including financial hardship, is essential to support integrated care across the UK health and care system. There is inconclusive evidence on effectiveness of these services with a need for more mixed-methods research to understand if and how link worker roles improve outcomes for patients in communities. Our study aimed to evaluate the impact of a Social Navigators (SN) service in South Tyneside on the health and wellbeing of users who experience financial hardship and present with complex health needs. Design: mixed methods study combing secondary analysis of service data with semi-structured interviews, conducted by peer researchers, and a Social Return On Investment analysis that matched service data with health economic indicators from the UK Social Value Bank. Setting: metropolitan borough of South Tyneside, UK (population n=151,133), ranked 3 ^rd for employment, 13 ^th for income, and 15 ^th for health in term of most deprived areas out of 326 UK authorities. Participants: 330 service users who engaged with the service between 2021-23. Most users are vulnerable with two-thirds being economically inactive, the majority earning less than £10,000, and 86% suffering with one or more health issues, with mental ill health being most common (58%). Interviews with15 service users opportunistically sampled from service database. Intervention: Social Navigators working with residents who experience frequent financial hardship to identify and address underlying causes, by increasing their access to advice, health, employment and financial services, and building their skills and confidence in order to reduce health inequalities and dependency on crisis intervention. Results: Our findings demonstrate clear value for money with a £3 social return for every £1 invested in the service with a positive return confirmed in sensitivity analysis. SN were able to improve service users’ confidence, with statistically significant changes across all eight confidence-related outcomes, and helped them to access other advice and financial services. This resulted in one-off financial gains (on average £1,237) and annual financial gains (on average £1,703) for service users. The interviews identified that relieving financial burden and stress improved the quality of life for and mental wellbeing of users as a result of their involvement with the service. Conclusions: SN break the cycle of multiple visits to crisis teams by building trusting relationships and providing emotional and practical support, while being responsive to the service users’ needs. They play a key intermediary role in integrated care systems that is unique in its focus on the wider determinants of health and financial hardship, advocating for service users without time limits, and navigating the complexities of the system across local government. There is a need for better signposting and joining up of services to achieve a more whole systems approach to enhancing health & well-being in the community, while supporting the mental wellbeing of SN. Article Summary: Strengths and limitations of this study: This is the first-mixed methods evaluation of social prescribing in the UK, focusing on the link between financial hardship and mental health. Applying a mixed-methods design allowed for combing local service monitoring data with national survey data to perform a Social Return on Investment analysis. Adding insights from service users through qualitative interviews granted the researchers insights in what outcomes mattered most to them and illuminated the mechanisms that they felt contributed to those outcomes. Using peer researchers to collect data from service users allowed for richer data collection through existing trusted relationships, while potential bias was checked through triangulation of different data sources. Closing gaps in local data collection, including longer-term follow-up data, and aligning data collection to national survey data would allow for more robust and less conservative SROI analysis.

Surgical intervention for thoracic aortic aneurysms is high risk. Understanding changes in health-related quality of life before and after endovascular stent grafting and open surgical repair can aid treatment decision-making. The Effective Treatments for Thoracic Aortic Aneurysms (‘ETTAA’) study (ISRCTN04044627) was a longitudinal, observational study. Adults with new/existing arch or descending thoracic aortic aneurysms greater than or equal to 4 cm in diameter were followed from 2014 to 2022. Five domains of health-related quality of life (Mobility, Self-Care, Usual Activities, Pain/Discomfort, and Anxiety/Depression) were recorded using the EuroQoL, five dimensions, five levels (‘EQ-5D-5L’) questionnaire and analysed using a range of longitudinal mixed models. Of 886 thoracic aortic aneurysm participants, 824 completed at least 2 questionnaires. Patients had slightly worse health-related quality of life than age-matched norms. Without surgery, deterioration occurred over time in Mobility (0.072/year (95% c.i. 0.042 to 0.101), P < 0.001) and Self-Care (0.039/year (95% c.i. 0.018 to 0.061), P < 0.001) in both sexes and Pain/Discomfort in women (0.069/year (95% c.i. 0.020 to 0.118), P = 0.005). For 6 weeks after endovascular stent grafting, there was a significant impairment in Self-Care (0.214 (95% c.i. 0.112 to 0.316), P < 0.001) and (for women only) in Usual Activities (0.625 (95% c.i. 0.338 to 0.911), P < 0.001), which then returned to pre-endovascular stent grafting levels. Six weeks after open surgical repair, the impairment in health-related quality of life was greater (Mobility 0.492 (95% c.i. 0.314 to 0.669), Self-Care 0.474 (95% c.i. 0.364 to 0.583), Usual Activities 1.469 (95% c.i. 1.042 to 1.896), and Pain/Discomfort 0.561 (95% c.i. 0.363 to 0.760), all P < 0.001) and took longer to return to pre-open surgical repair levels, partly due to increased complications and longer hospitalization. Anxiety/Depression decreased after open surgical repair (−0.214 (95% c.i. −0.326 to −0.101), P < 0.001). Age, sex, frailty, smoking, New York Heart Association class, and chronic obstructive pulmonary disease were significantly associated with health-related quality of life. Without intervention, health-related quality of life declines as age increases. Changes in health-related quality of life should contribute to surgical treatment decision-making.

Reading for Wellbeing (RfW) is a pilot initiative, aimed at improving mental health and well-being through supporting access and increasing opportunities to read for pleasure. RfW was implemented across six North-East local authorities in England and employed Community Reading Workers to support access to books and reading for targeted populations. The current study used realist methodology to understand context, potential mechanisms of action, acceptability and reported outcomes. Data generation and analysis were conducted iteratively, using focus groups, interviews and observations. The analysis of the collated data highlighted that a positive attitude towards reading and a desire for social connections were significant motivators for engagement with RfW. This paper postulates eight programme theories relating to that context, which describe key mechanisms within RfW linked to engagement with reading, well-being, connections and practice. The paper concludes that previous notions of positivity associated with reading for pleasure enable participants to experience RfW as a positive social encounter. This positive social encounter enhances participants’ multiple resistance resources such as increased sense of self-efficacy and connectedness that could impact on their sense of well-being.

Repair of thoracic aortic aneurysms with either endovascular repair (TEVAR) or open surgical repair (OSR) represents major surgery, is costly and associated with significant complications. The aim of this study was to establish accurate costs of delivering TEVAR and OSR in a cohort of UK NHS patients suitable for open and endovascular treatment for the whole treatment pathway from admission and to discharge and 12-month follow-up. A prospective study of UK NHS patients from 30 NHS vascular/cardiothoracic units in England aged ≥18, with distal arch/descending thoracic aortic aneurysms (CTAA) was undertaken. A multicentre prospective cost analysis of patients (recruited March 2014–July 2018, follow-up until July 2019) undergoing TEVAR or OSR was performed. Patients deemed suitable for open or endovascular repair were included in this study. A micro-costing approach was adopted. Some 115 patients having undergone TEVAR and 35 patients with OSR were identified. The mean (s.d.) cost of a TEVAR procedure was higher £26 536 (£9877) versus OSR £17 239 (£8043). Postoperative costs until discharge were lower for TEVAR £7484 (£7848) versus OSR £28 636 (£23 083). Therefore, total NHS costs from admission to discharge were lower for TEVAR £34 020 (£14 301), versus OSR £45 875 (£43 023). However, mean NHS costs for 12 months following the procedure were slightly higher for the TEVAR £5206 (£11 585) versus OSR £5039 (£11 994). Surgical procedure costs were higher for TEVAR due to device costs. Total in-hospital costs were higher for OSR due to longer hospital and critical care stay. Follow-up costs over 12 months were slightly higher for TEVAR due to hospital readmissions.

Background: The management of chronic thoracic aortic aneurysms includes conservative management, watchful waiting, endovascular stent grafting and open surgical replacement. The Effective Treatments for Thoracic Aortic Aneurysms (ETTAA) study investigates timing and intervention choice. Objective: To describe pre- and post-intervention management of and outcomes for chronic thoracic aortic aneurysms. Design: A systematic review of intervention effects; a Delphi study of 360 case scenarios based on aneurysm size, location, age, operative risk and connective tissue disorders; and a prospective cohort study of growth, clinical outcomes, costs and quality of life. Setting: Thirty NHS vascular/cardiothoracic units. Participants: Patients aged > 17 years who had existing or new aneurysms of ≥ 4 cm in diameter in the arch, descending or thoracoabdominal aorta. Interventions: Endovascular stent grafting and open surgical replacement. Main outcomes: Pre-intervention aneurysm growth, pre-/post-intervention survival, clinical events, readmissions and quality of life; and descriptive statistics for costs and quality-adjusted life-years over 12 months and value of information using a propensity score-matched subsample. Results: The review identified five comparative cohort studies (endovascular stent grafting patients, n = 3955; open surgical replacement patients, n = 21,197). Pooled short-term all-cause mortality favoured endovascular stent grafting (odds ratio 0.71, 95% confidence interval 0.51 to 0.98; no heterogeneity). Data on survival beyond 30 days were mixed. Fewer short-term complications were reported with endovascular stent grafting. The Delphi study included 20 experts (13 centres). For patients with aneurysms of ≤ 6.0 cm in diameter, watchful waiting was preferred. For patients with aneurysms of > 6.0 cm, open surgical replacement was preferred in the arch, except for elderly or high-risk patients, and in the descending aorta if patients had connective tissue disorders. Otherwise endovascular stent grafting was preferred. Between 2014 and 2018, 886 patients were recruited (watchful waiting, n = 489; conservative management, n = 112; endovascular stent grafting, n = 150; open surgical replacement, n = 135). Pre-intervention death rate was 8.6% per patient-year; 49.6% of deaths were aneurysm related. Death rates were higher for women (hazard ratio 1.79, 95% confidence interval 1.25 to 2.57; p = 0.001) and older patients (age 61–70 years: hazard ratio 2.50, 95% confidence interval 0.76 to 5.43; age 71–80 years: hazard ratio 3.49, 95% confidence interval 1.26 to 9.66; age > 80 years: hazard ratio 7.01, 95% confidence interval 2.50 to 19.62; all compared with age < 60 years, p < 0.001) and per 1-cm increase in diameter (hazard ratio 1.90, 95% confidence interval 1.65 to 2.18; p = 0.001). The results were similar for aneurysm-related deaths. Decline per year in quality of life was greater for older patients (additional change –0.013 per decade increase in age, 95% confidence interval –0.019 to –0.007; p < 0.001) and smokers (additional change for ex-smokers compared with non-smokers 0.003, 95% confidence interval –0.026 to 0.032; additional change for current smokers compared with non-smokers –0.034, 95% confidence interval –0.057 to –0.01; p = 0.004). At the time of intervention, endovascular stent grafting patients were older (age difference 7.1 years; 95% confidence interval 4.7 to 9.5 years; p < 0.001) and more likely to be smokers (75.8% vs. 66.4%; p = 0.080), have valve disease (89.9% vs. 71.6%; p < 0.0001), have chronic obstructive pulmonary disease (21.3% vs. 13.3%; p = 0.087), be at New York Heart Association stage III/IV (22.3% vs. 16.0%; p = 0.217), have lower levels of haemoglobin (difference –6.8 g/l, 95% confidence interval –11.2 to –2.4 g/l; p = 0.003) and take statins (69.3% vs. 42.2%; p < 0.0001). Ten (6.7%) endovascular stent grafting and 15 (11.1%) open surgical replacement patients died within 30 days of the procedure (p = 0.2107). One-year overall survival was 82.5% (95% confidence interval 75.2% to 87.8%) after endovascular stent grafting and 79.3% (95% confidence interval 71.1% to 85.4%) after open surgical replacement. Variables affecting survival were aneurysm site, age, New York Heart Association stage and time waiting for procedure. For endovascular stent grafting, utility decreased slightly, by –0.017 (95% confidence interval –0.062 to 0.027), in the first 6 weeks. For open surgical replacement, there was a substantial decrease of –0.160 (95% confidence interval –0.199 to –0.121; p < 0.001) up to 6 weeks after the procedure. Over 12 months endovascular stent grafting was less costly, with higher quality-adjusted life-years. Formal economic analysis was unfeasible. Limitations: The study was limited by small numbers of patients receiving interventions and because only 53% of patients were suitable for both interventions. Conclusions: Small (4–6 cm) aneurysms require close observation. Larger (> 6 cm) aneurysms require intervention without delay. Endovascular stent grafting and open surgical replacement were successful for carefully selected patients, but cost comparisons were unfeasible. The choice of intervention is well established, but the timing of intervention remains challenging. Future work: Further research should include an analysis of the risk factors for growth/rupture and long-term outcomes. Trial registration: Current Controlled Trials ISRCTN04044627 and NCT02010892. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 6. See the NIHR Journals Library website for further project information.