Cam Donaldson

It is increasingly recognised that ‘big problems’ in health and social care require well-designed solutions and robust evaluation, including attention to costs as well as outcomes. This is especially important in the pervasive environment of resource scarcity. Decisions need to be made that consider not only whether and how an intervention works but also affordability and efficiency in different circumstances and populations. As researchers tackle these complex issues, interest in bringing together realist and economic evaluation is growing. Responding to this, we discuss how using programme theory within a novel realist economic evaluation approach can be used in articulating how interventions may (or may not) bring about cost-effective change. We identify what initial programme theory in realist economic evaluation might look like in practice, drawing on data from three pilot realist economic evaluation studies.

For some years, the number of new GPs going into partnership across the whole of the UK has been decreasing, while the number of GPs exiting partnerships has been increasing.^1,2 These trends show no sign of reversing and there are no longer enough partners to sustain many partnerships. There are a number of causes, including continued NHS austerity, the COVID-19 pandemic, and changing workforce patterns, with growing numbers of GPs opting for salaried and part-time working.^1–3 There is an urgent need, therefore, across all four nations of the UK to identify viable alternative ownership models for primary care. Given the central role played by general practice in the NHS, this needs to happen before a tipping point is reached from which it would be difficult to return.

Background: The United Kingdom is experiencing worrying trends in population health. Policy needs to shift ‘upstream’ to address fundamental causes. Universal Basic Income has emerged as one response to tackling these health issues. A Universal Basic Income would provide a new form of societal safety net through a regular, unconditional cash payment to all individuals in society. However, with scarce public resources and competing upstream income-based policies, such as a Minimum Income Guarantee, implementing transformative initiatives, such as Universal Basic Income, without a public mandate is unlikely. Currently, we do not know the extent to which the general public value different income-based policies, including when wider impacts, such as health outcomes, are explicitly stated. Objective: This feasibility study had two broad aims. First, to determine which income-based policies to select for valuation, based on their importance to stakeholders and coverage of a range of characteristics and outcomes; second, to design and test a framework, and associated methods, for stated preference elicitation. Design and methods: Six income-based policy scenarios – Universal Basic Income, Minimum Income Guarantee, Negative Income Tax, Participation Income, Targeted Basic Income and Universal Credit – were identified and developed through literature searches, stakeholder interviews (n = 13) and consultation with our General Public Panel. Policy scenarios were described in terms of five policy characteristics and impact described qualitatively based on three outcomes – overall population health, health inequality and income inequality. Three trade-off-based stated preference methods – choice, ranking and willingness to pay – were used to elicit preferences. All methods adopted a socially inclusive perspective. Think-aloud and open-ended interview questions were asked to explore respondents’ understanding of the survey methods and explore the reasons for respondents’ decisions. Participants: For the main survey, 50 members of the general public were sampled across Glasgow and Newcastle using recruitment targets for age, gender, education, income, employment status, ethnicity, benefits, voting preferences and health status. Results: Respondents understood the policy scenarios, the perspective they were asked to adopt when constructing their values and the task they were asked to complete in each of the survey methods. Relatively few respondents had fully inconsistent preferences, there was no evidence of a labelling effect and introducing information on outcomes did not impact preferences. The type of policy seems to matter, with respondents making trade-offs between policy type and the outcomes of improving overall health, health inequalities and/or income inequalities; there is also evidence of preference heterogeneity. Limitations: Our small sample precludes claims about the generalisability of the findings. We focused on a subset of policy characteristics, outcomes were described qualitatively across three levels and the size of the monetary payments from the policies was not explicitly stated. Conclusions: Overall, results suggest it is feasible to elicit public preferences for income-based policies with different policy characteristics when health and non-health outcomes are made explicit, using trade-off-based stated preference questions. Future work: This feasibility study has laid the groundwork for a larger, nationally representative study that could provide much-needed new insights to inform policymaking around implementing transformative policies for tackling health inequalities. Funding: This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR153096.