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Evidence for transforming community services

Wellbeing and health inequalities

1

1

Top transformations 2

Transforming services 3

Transforming staff 10

Transforming systems 12

Summary: what works? 19

Transforming community services will lead to

more empowered, engaged and enlivened

people. The NHS aims to support people to

keep themselves well and ensure that

everyone has access to the right care in the

right place at the right time. We share the

lessons from more than 1000 studies focused

on improving wellbeing and reducing health

inequalities in community services.

Contents

The information in this document is drawn from a rapid evidence review. We searched 10 reference databases for systematic reviews,

randomised trials and observational studies available as of January 2009. Studies were screened for relevance and validity and key themes

were identified. This document provides a summary of only those interventions which are not widespread in the NHS and which have the

potential to transform community services. It is not an exhaustive overview of all literature identified.

2

Top transformations

Ten important issues identified by the research evidence that may improve

wellbeing and health inequalities are:

providing time and funds to test innovative approaches

undertaking an analysis of people’s needs to target services appropriately

asking people what services will meet their needs

proactively encouraging physical activity

setting up joint initiatives with education, social care and other services

taking services into the community using health buses, shops and local venues

training all staff in cultural and social sensitivity and health promotion

considering service users as care providers for themselves and others

using text messages, websites and technology to deliver care and share data

using campaigning and health promotion approaches to raise awareness

There is evidence that focusing on each of these issues may transform community

services, but many other initiatives may also be worthwhile.

3

3

The NHS is striving to improve the overall health of the population

and tackle health inequalities. This is both a high level policy goal,

and the backbone of practical services delivered day to day.

Transforming community services to further promote wellbeing and

reduce health inequalities may involve a myriad of changes. Many

thousands of studies have focused on specific interventions. Rather

than summarising every one, we concentrate on drawing out the

key themes that span many service redevelopments. Success

factors for transforming services in the community are divided into

who, what and where to target.

Who: targeting services

Needs assessments help target community services

Evidence suggests that it is important to develop mechanisms to

understand the health needs of local populations and profile the

causes of poor health such as socio-economic status, age and

ethnicity.1 Many innovative methods of needs analysis and

modelling have been developed, including visual representations of

determinants of health, mapping and online questionnaires.2,3

There is evidence that systematically examining health needs and

the determinants of poor health can improve community services.4

In Australia a small rural health service undertook a rigorous

evidence based needs assessment to plan transformations. The

needs assessment combined a socio-demographic, epidemiological

and community consultative approach. Evidence of best practice

was identified and the recommendations were used to develop new

services such as advocacy, care pathways, care coordination,

standardised multidisciplinary assessment and outcome based care

plans.5

Transforming services

4

Numerous similar studies from around the world have documented

changes in services as a result of needs analysis. An implication for

the NHS is the importance of systematic and standardised methods

of addressing community needs, with a focus on exploring the

determinants of health. Work has been done in some local areas,

but there is no consistent approach across the NHS, nor easy to

use tools, definitions or frameworks.

Ask service users how to redevelop services

The NHS wants to ensure that health services are accessible to all

and meet the diverse social, cultural and health needs of the

population. There are specific targets for people from black and

ethnic minority groups, but research in the UK and internationally

suggests that many other less advantaged groups require special

attention. In particular, services for homeless people, people with

learning disabilities, people with mental health needs, people who

speak languages other than English, travellers, offenders and

young people have been highlighted for attention.6,7

We reviewed studies from around the world and found that while

numerous interventions have been implemented to target and

support different groups, there is no ‘magic formula’ for enhancing

access to care or reducing health inequalities.

5

5

Three principles are common across the most successful

approaches:

targeting populations thought to be vulnerable for additional

support without waiting for requests

working with members of the targeted communities to

develop programmes and approaches that they feel are

appropriate and sensitive to their particular needs

asking people about their needs and desires and developing

services and systems to address these

For example, a UK study with people with learning disabilities found

that the top three things they wanted from health services were time

to talk, opportunities to see healthcare professionals other than

GPs, and explanations of health information in an informal setting

with no appointments.8

Another study in the UK found that dental services are particularly

inaccessible for minority ethnic groups from less advantaged socio-

economic groups. The key barriers were thought to be the structure

of primary dental care, cost and anxiety about accessing services.

Importantly, there was little evidence of differences in barriers to

access based on ethnicity alone. Social class was a contributing

factor. Suggested ways to increase access to dental care included

outreach activities, developing communication skills within primary

dental care practices and integration with other community health

services.

These examples highlight that many of the changes suggested by

service users are feasible and relatively small scale, but others

would require transformation of the broader system of care.

6

A great deal of research has examined ways to get service users

more involved in their care. People who are encouraged to

participate actively in their healthcare tend to have more favourable

health outcomes than those who do not.9

Merely providing information leaflets may not be satisfactory. One

randomised trial in the UK found that such leaflets might improve

satisfaction, but also increase unnecessary use of health services.

In this study, leaflets were mailed to 636 patients from five primary

care practices encouraging them to raise concerns and to discuss

symptoms or other health issues in primary care consultations. The

leaflet increased patient satisfaction with care. There was no

change in prescribing or referral, but people who received the

leaflet had more investigations during the consultation. Most extra

investigations were thought to be unnecessary by the doctor and by

the patient.

But leaflets signposting people to available services and posted

reminders to attend wellness checkups have been found to be

beneficial. For example, in Australia, a randomised trial of

reminders to visit community services found that children with

asthma had increased wellbeing and fewer emergency visits to

hospital.10

The NHS is focused on involved people in their care, but asking for

input into how to redevelop community services has staff and time

implications. Research suggests that appropriate staff training and

infrastructure is needed to involve service users effectively. One

review found that effective involvement methods require appropriate

skills, resources, and time to develop and follow good working

practices.11 Studies suggest that community health professionals

might find needs assessment, asking service users for their

opinions and true engagement ‘hard work’ and may not have the

skills to listen effectively or deal appropriately with feedback.12,13 Yet

little work has outlined the practical steps that community services

could take to address this. It is an area in need of further

consideration.

7

7

What: service delivery

Use campaign approaches to raise awareness

Public health teams in the NHS and internationally have long

recognised the value of health promotion strategies for enhancing

population wellbeing. These may involve media advertising, leaflets,

displays in health centres and shops, stickers, talks in schools and

‘shock advertisements’ which show potential negative health

impacts. These strategies have been used to good effect in

smoking cessation, nutrition, drink driving, bullying and benefit

fraud.

Campaigning approaches may have value for other components of

public health and, perhaps more innovatively, for directly

addressing discrimination and visible health inequalities. The

factors common to successful campaigns include a consistent

message used in all media, bright and clear branding, an active

message, a focus on potential benefits or risks to individuals and

encouragement to be proactive.

Proactively encourage physical activity

Of all the studies we reviewed, some of the most successful for

improving health and wellbeing focused on physical activity.14

These may involve supervised exercise programmes in health

centres or community venues, partnership approaches with leisure

facilities, group activities and programmes which include weekly or

monthly programme checks.15 Unsupervised programmes and

those which did not include charted progress over time were least

likely to be effective for long term gains in physical fitness and

weight loss.

In contrast to the positive research about proactive physical activity

programmes, reviews of healthy eating programmes or motivational

interviewing for overweight people found that these can have mixed

effects.16 To optimise the benefits, there is a need for more focus on

new immigrants to developed countries who may not be used to the

diet, young children and men.17

8

Where: location

Use technology to deliver health messages

Research into the most appropriate location for delivering services

to promote wellbeing and reduce health inequalities often focuses

on physical locations. Over the past decade however, some of the

most transformational approaches have examined using technology

to promote public health, as well as monitoring and treating specific

conditions.18

There are numerous systematic reviews about the potential pros

and cons of delivering services for people with particular conditions

using telecare, but far less research is available about telecare for

health promotion. One promising approach involves using text

messages and emails to provide health promotion messages,

remind people about appointments, encourage healthy behaviours

such as nutrition and exercise and send positive messages to

improve mental attitudes. Text messages have been found to be

useful for young people, pregnant mothers and people with long

term conditions, although research is in the early stages.19

In the US, the YMCA set up a ‘Youth Institute’ to improve mental

wellbeing and help train young people. The innovative programme

uses learning about technology itself as a mechanism for promoting

positive youth development while enhancing the academic and

career readiness of low-income, culturally diverse, urban high

school students.20

Another trial evaluated an online initiative designed to alleviate body

image and eating problems in adolescent girls. Six 90 minute

weekly small group sessions were facilitated online by a therapist.

Compared to a control group, girls who used the system had

improved health and wellbeing that lasted over time. They were

enthusiastic about using the internet to access the programme and

this also allowed the initiative to reach girls from many different

locations simultaneously, including rural areas.21

9

9

Using technology to improve health and wellbeing is not without

limitations however. A health web portal aimed at promoting health

and wellbeing in Harlem, US found that some community members

were distrustful of health organisations and wanted much more

community-specific content than the developers had in mind. The

software was therefore customised to foster connections and

collaborations between community members and a diverse range of

health organisations. Despite this, the system received limited

use.22 A lesson for the NHS, which is reinforced by countless other

literature, is that use of technology merely to provide information is

unlikely to transform the delivery of care or have tangible benefits

for health and wellbeing.

Take services to the public

There is good evidence that providing care at home can improve

satisfaction, but perhaps increase costs.23 For health promotion

work this approach may not be feasible, but alternatives have been

tried. For example in Canada a ‘health bus’ has been used to take

health education and treatment services into local communities,

including supermarkets, community centres and sports grounds.24

This approach was found to be particularly beneficial for reaching

marginalised populations who may not visit community health

services and for reducing health inequalities.

Another approach involved taking sexual health education to sites

such as bars, streets, bus stops, shopping centres and other public

venues. A community health worker visited locations, spoke to

members of the public, and handed out leaflets. A random trial

found that this approach appeared to work well to raise awareness

and reduce the risk of dangerous sexual behaviour.25

Taking healthcare into workplaces has also been explored. One

randomised trial found that a short course run at a bus company

reduced back injuries and days off work. The result remained after

two years.26 Simple outreach may be worth considering by the NHS.

10

Train all staff in sensitivity and health promotion

In order to transform community services, rather than merely

implement new services, research suggests that a great deal rests

on the development and training of teams.27 NHS staff at every level

need to be fully educated and aware of the reasons for promoting

good health, differences between groups of people and strategies

for empowerment. Promoting health and wellbeing and reducing

health inequalities could be part of the job description of every team

member, and is something that would need to be a priority for every

member of staff in order to fully transform community services.28

In some parts of the US, students studying to become health

professionals or social workers complete mandatory courses on

cultural sensitivity. Competencies have been developed relating to

knowledge, values and skills in caring for older people from ethnic

minority groups. Following training students and staff say they feel

more confident working with people from different ethnic groups and

more sensitive to their needs.29 Models of cultural competency have

also been developed in the UK,30 but are applied in practice to a

varying extent.

There is conflicting research about the value of recruiting people

from diverse groups to provide health services. While there are

undoubted benefits from ensuring that the healthcare workforce is

diverse and reflects the broad community it serves,31 such

recruitment practices do not necessarily translate into improved

health outcomes. 32 Also, studies have pointed out that sometimes

particular equalities issues are prioritised over others. For instance,

a study in north west England found that South Asian women who

attempted suicide or self-harm can be marginalised due to a focus

on ethnicity rather than gender.33 In this instance, the study found

that the recruitment of staff of the same ethnic group as service

users was problematic rather than beneficial.

The value of training in health promotion is illustrated by studies of

NHS smoking cessation services. Although these services have

varying levels of success, the best performing programmes targeted

at pregnant women all had in common systematic and detailed

training of midwives in how to refer pregnant smokers. Other key

success factors in these programmes included offering flexible

home visits and providing intensive multi-session treatment

delivered by a small number of dedicated staff – but good training in

health promotion and specific smoking cessation practices

underpinned success.34

Transforming staff

11

11

Consider service users as care providers

Often when considering the health and social care workforce,

planners and policy makers focus on practitioners and managerial

staff. Yet, service users and members of the public are a valuable

resource in promoting wellbeing and reducing health inequalities.35

Strategies such as peer education, buddying, mentoring

programmes and peer-led services have been found to improve

satisfaction with care and cultural appropriateness.36,37 Peer-led

services in public health and mental health have been found to

have equal clinical outcomes to those led by professionals in many

cases,38,39 although systematic reviews have found mixed evidence

of the success of using lay workers.40

Promoting self care and self management is now a mainstay of

health policy in the NHS, but it is innovative to take this one step

further and view service users not only as active participants in their

care but also the leaders of their care – for themselves and

potentially for others. For example in the US, peer educators have

provided sexual health information and support to homeless

women. Peer educators were equally likely to improve health

outcomes as nurses.41

Drawing on the expertise of service users to help lead and manage

care would have a range of implications for the NHS. Firstly, there

would need to be appropriate training for service users so they felt

comfortable within the system. Secondly, there would need to be

extensive staff development, so teams accepted the value of

service users as care providers without feeling threatened and so

staff were able to provide appropriate levels of support. There

would need to be more focus on administrative support, so that

service users could concentrate on their key role rather than being

caught up in paperwork or bureaucracy. Sensitive monitoring

strategies would need to be developed to ensure quality at the

same time as valuing diversity and difference in terms of how lay

people may offer services.

12

There is evidence that the way healthcare is funded and

incentivised has a significant impact on accessibility, the emphasis

placed on public health and reducing health inequalities. Some

healthcare systems have undergone large scale redesign in order

to reduce health inequalities. For example, in New Zealand

minorities experience significant health disparities related to both

ethnicity and deprivation. The average life expectancy for

indigenous New Zealanders is nine years less than for other New

Zealanders. The government recently introduced a set of primary

care reforms aimed at improving health and reducing disparities by

reducing co-payments, moving from fee-for-service to capitation,

promoting population health management and developing a not for

profit infrastructure with community involvement to deliver primary

care.42 Such widespread transformation to payment structures,

contracts and commissioning may not be planned for the NHS, but

there are other aspects of system redesign (rather than reform or

total transformation) that can be learned from other countries.

Initiatives developed in partnership are sustainable

Research from around the world suggests that innovative

transformation to promote wellbeing and reduce inequality requires

partnership throughout the health system and collaborative working

with other sectors.43 In particular, there is a need to plan

strategically and work on a day to day basis with housing, social

services, education, benefits services, employment services, the

voluntary sector, the police and offender rehabilitation services.44

The education sector has a special role to play in helping to

educate children and parents about healthy eating and physical

activity from an early age. Joint health and education sector

programmes on nutrition, exercise and sexual activity have been

found to be beneficial. Key success factors in school based

programmes include school organisation, a detailed curriculum on

the topic area, staff development, using peer resources, including

parent education, and school-community linkages.45

Transforming systems

13

13

Example of partnerships with voluntary groups

In Australia, the ‘Listening to Ethnic Communities about

Diabetes’ programme has developed culturally

appropriate health promotion and healthcare services for

minority ethnic groups. One of the critical success factors

was that while the project was grounded in a health

promotion framework, the lead agency did not have a

great deal of health expertise. Instead, the lead agency

was experienced in building relationships with ethnic

communities. This allowed for a shift in traditional power

structures as the communities were given a real voice and

decision-making powers. Health service providers brought

clinical knowledge to the table, but it was the involvement

of minority group organisations and ethnic community

representatives that enabled the project to develop

services that were relevant and accessible to the target

community. The project used strategies that reflect the

cultural practices and preferences of the target

communities because these communities were partners in

building the programme.46 This has implications for the

NHS, suggesting that there is much to learn from the

voluntary sector and from partnership work with other

agencies.

14

Studies have also highlighted the positive impact of improved

housing conditions on health.47 In England, a number of

partnerships between voluntary sector home improvement

agencies, local authorities and the health sector have already been

implemented. The most successful programmes to date include

schemes providing information and training for health and social

care sector staff, joint approaches to falls prevention, hospital

discharge services and initiatives to address cold, damp housing.48

Partnerships within the health sector are important too. There have

been studies of how dental care can be used to support improved

general health. For instance, two publicly funded dental clinics in

the US took part in a comparative study. In one clinic practitioners

were trained to conduct a tobacco-use assessment and provide a

brief cessation intervention for all smokers. In the other clinic,

everyone received usual dental care. Most patients were from low

income households and minority ethnic groups. People who

received cessation advice from their dentist were more likely to quit

and remain tobacco-free after one year. The study demonstrated

that short simple interventions, delivered in alternative settings such

as dental surgeries, can have an impact.49 In England, some

dentists already take part in local enhanced services for smoking

cessation programmes. Such partnerships may be worth

investigating further.

There are also examples of partnerships with the private sector.

Birmingham OwnHealth is a partnership between a PCT (the

commissioner), a private sector provider (Pfizer Health Solutions),

and NHS Direct (subcontracted by the private sector). The

programme uses NHS Direct nurses and call centre facilities to

proactively support people with long term conditions with the aim of

increasing self management and reducing unnecessary use of

health services, especially unplanned admissions. People with

conditions such as diabetes and heart disease are sourced from GP

lists and invited to enrol in the telephone care management

programme. Participants receive regular telephone calls which

involve checks on symptoms, motivational interviewing and

information to support self management. This programme is about

improving wellbeing rather than treating conditions. The programme

reported measurable improvements in motivation to change,

healthy behaviour and dietary change and a trend towards reduced

use of hospital services.50

Partners need to be carefully chosen however. Studies in Australia

found that partnerships with supermarkets to promote healthy

eating were not always successful because supermarkets had

competing priorities: financial gains from ‘junk food’ were more

attractive than long term gains in population health.51

15

15

Sharing information and building infrastructure

Developing infrastructure to support partnership working and share

information is important for providing seamless care. Studies from

the UK and abroad have highlighted the necessity for strong

information systems to support preventive community services, but

there is mixed evidence of success in practice.

Some systems use web based tools to share information about

innovation and improved services. For instance, the US Agency for

Healthcare Research and Quality (AHRQ) has set up the

‘Healthcare Innovations Exchange’ website

(www.innovations.ahrq.gov). This is designed to be a national

electronic learning hub for sharing health service innovations and

bringing innovators and adopters together. The database contains

thousands of case studies, spanning community services and

secondary care. The database is well used, especially for

networking purposes. Something similar could be set up on a

regional or national scale for health and social care in the UK,

building on the other formal knowledge transfer networks already

available.

Other systems focus on storing information about service users and

linking this to good practice guidelines. In Australia, one study

examined the development and dissemination of best practice

guidelines supported by an electronic client register, recall and

reminder systems, staff training and audit and feedback. The aim

was to improve health and wellbeing among minority ethnic groups

in rural locations. Three year monitoring showed that these

initiatives were associated with initial improvements in the quality of

care, but this was not sustained over time.52 Many thousands of

studies from around the world have similar findings.

It appears that electronic information systems, training and

reminder systems alone are not sufficient to improve wellbeing and

reduce health inequalities. What may be missing is a culture of

continual innovation, staff motivation to acknowledge and celebrate

difference, and an integrated system-wide approach. An electronic

client record and reminder system may be of limited benefit if that

information cannot be shared with other sectors and used to

support a person holistically.

16

Cash incentives are probably not the answer

It is uncertain whether providing additional funds directly to socially

or economically disadvantaged families improves health and

wellbeing. A systematic review of nine trials with more than 25,000

participants found that providing money directly to disadvantaged

families with the aim of improving children’s health had mixed

results. Although some studies suggested that financial support

could have some impacts on wellbeing, the review concluded that

providing money to families generally did not improve health and

wellbeing overall.53 Such schemes are also fraught with practical

difficulties including setting criteria for participation, determining

eligibility and monitoring appropriate use of funds. It would seem

that this may not be a useful initiative to try in the NHS at this time,

although the review has significant implications for policies such as

individually held health and social care budgets. The difference

between the reviewed studies and individual budgets is that in the

case of this research families were given cash to spend as they

wished, rather than allocated a budget from within which health and

social care organisations could arrange services.

Allow time to build innovative services

One of the key lessons learned from programmes around the world

is that transformation requires innovation and improvement. This

cannot be forced or mandated; it must be nurtured and protected.

There have been critiques of past of initiatives which aim to

promote wellbeing and reduce inequalities, but which are too ‘rule

driven’:

“First, the Department of Health guidelines for smoking cessation

provide quite prescriptive directions as to the nature of service

implementation, restricting the ability of services to develop service

models to meet the needs of disadvantaged groups. Second,

although supposedly intended to promote locally innovative

solutions to tackle health problems such as smoking, the

imposition of government controls in HAZ programmes has

militated against such innovation. As a result ... there is little scope

for experimentation in this area and a clear opportunity is being

missed.” 54

17

17

There are several evidence-based approaches that the NHS can

undertake to adopt and spread innovation:55

1. Build on previous NHS experience of what has and hasn’t worked and

try quality improvement collaboratives and professional networks.

2. Engage frontline staff to mobilise commitment to change.

3. Adopt a campaigning approach to support action on key priorities,

such as the US IHI 100,000 lives campaign on patient safety.

4. Support leaders and innovators through training and by creating time

to concentrate on creating and developing new ideas.

5. Make it easy to find and share knowledge about innovations. Like

many large and complex organisations, the NHS is weak in sharing

information and helping staff find out what has been tried elsewhere

and whether it works.

6. Learn from organisations that have a track record of innovation such

as the US Veterans’ Health Administration which focused on

organisational turnaround using leadership from the top, structured

communication through internal newsletters, emails and meetings,

using collaboratives, a formal framework of spread and using a

checklist to rate improvement and innovation potential.

7. Value and celebrate innovation and innovators, including local and

regional innovation awards and tolerating the ‘maverick’ ways of

working that people in these roles often exhibit, rather than seeking to

ensure conformity with a corporate culture.

8. Foster links with private sector organisations

9. Recognise and nurture innovation brokers or change champions

10. Use competition and incentives to drive innovation

In order to ‘transform’ community services innovation is required.

Some of the commonly documented characteristics of innovative

organisations involve:

Strong, clearly expressed shared values

A strong, clearly communicated sense of history

Intense customer focus

Cultures that encourage openness and playfulness

Celebrate successes constantly

Clear focus on trends, even those that do not seem to

directly affect current businesses

Cross functional teams

An appreciation of the individuals working with them and

everything they can bring to the organisation

But more than anything, innovation requires time, space and a

commitment to testing new ideas. Managers and practitioners need

to have time ‘off the treadmill’ of day to day work to think about

ways of doing things differently.

18

An example of putting new ideas into practice is the The Humboldt-

Del Norte Independent Practice Association in the US. Similar to a

practice based commissioning group, it was formed to give

clinicians more ‘clout’ when negotiating contracts and services. The

Practice Association wanted to spread the use of a registry for

people with diabetes in the community, to improve quality of care

and ensure that people’s symptoms were controlled. Registries

were not common among primary practitioners so the Association

took a ‘big bang’ approach – installing the concept into as many

practices as possible. The Association leaders called a meeting

attended by all practices and outlined how the registry might work,

with a focus on the benefits to practices and patients. The registry

was rolled out to as many practices as possible simultaneously. It

was designed to be easy for practices to use, with data

automatically loaded from practice records. Medical assistants at

each practice were taught to use the registry and the Association

funded web access and computers if necessary.

The messages used to promote the registry were tailored to meet

the concerns of different groups of practices and GPs. For example

some were focused on saving money or being paid more under

pay-for-performance schemes, others were concerned with making

their own work life easier and others were eager to improve patient

satisfaction or improve the quality of care.

The learning point is that innovation in community services can take

place within practice based commissioning groups and other

localised networks as long as there is leadership, adequate

resourcing, and ongoing support. This group relied on the passion

of a champion to identify an innovation and spread the idea. What is

interesting for the NHS is how key stakeholders were targeted and

the value of thinking about the incentives and motivating factors for

different audience groups – and spreading appropriate messages to

those groups.

Work in the NHS has found that innovations in service delivery can

rarely if ever be copied. Instead, they must be adapted and

customised to fit differences in organisational contexts and

variations in receptiveness to new ways of working. A number of

factors influence the uptake of innovations in service delivery,

including leadership by chief executives and senior managers,

clinical engagement and ownership of new ways of working, training

and development to support changes in practice, the time and

resources available to implement innovations, and alignment with

performance management and incentive systems.56 The complexity

of organisational change in healthcare means there are no magic

bullets or shortcuts in improving community services, but allowing

managers and practitioners the time and space to develop and test

new ideas is key.

19

19

This overview has briefly outlined lessons from research into

improving health and wellbeing and reducing health inequalities in

community services. More than 1000 studies were screened so we

have included just a small number of illustrative examples of key

points. We focused not on examining individual services or models

of care, but rather potential high impact changes that cut across all

pathways.

We have summarised some of the potential priorities for further

consideration in the table.

Priorities for further consideration are based on an assessment of

the amount of evidence available, the quality of evidence, the effect

of interventions and the extent to which initiatives are already being

implemented in the NHS or might be a significant change or

transformation. It is important to emphasise that not all possible

interventions are listed here. Also, in many cases there is not a

strong evidence base. This does not mean that an intervention does

not work well; only that it has not been well researched. For this

reason, the Department of Health used the evidence as just one of

the components considered when developing high impact changes.

Expert opinion, consensus workshops and other methods were

used to form a well rounded picture, underpinned by this rapid

evidence review.

Intervention Evidence quality Effect Priority

Provide time and funds to test innovation

High Positive H

Partner with other parts of the health system

High Positive H

Partner with other sectors High Positive H

Focus on proactive physical activity programmes

High Positive H

Collect data for needs analysis High Positive H

Target support to groups with specific needs

High Positive H

Use campaigns to promote wellbeing and public health

High Positive M

Support self care High Mixed M

Support service users as providers of care

Medium Mixed M

Develop information sharing systems

Medium Mixed M

Take services to clients Medium Mixed M

Use texts and other technology to motivate service users

Low Positive M

Train staff in diversity Low Positive M

Train staff in health promotion Low Positive M

Pay people and families directly to take part

High Negative L

Focus on dietary programmes High Negative L

Develop cultural competencies for staff

Medium Mixed L

Reform payment structures Medium Mixed L

Use guidelines to teach clinicians to engage people

Medium Mixed L

Use websites for health info Medium Mixed L

Summary: what works?

20

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