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Over the past four decades, the share of income devoted to health care nearly tripled. If policy is unchanged, this trend is likely to continue. Should Americans decide to rein in the growth of health care spending, they will be forced to consider whether to ration care for the well-insured, a prospect that is odious and unthinkable to many. This book argues that sensible health care rationing can not only save money but improve general welfare and public health. It reviews the experience with health care rationing in Great Britain. The choices the British have made point up the nature of the options Americans will face if they wish to keep public health care budgets from driving taxes ever higher and private health care spending from crowding out increases in other forms of worker compensation and consumption. This book explains why serious consideration of health care rationing is inescapable. It also provides the information policymakers and concerned citizens need to think clearly about these difficult issues and engage in an informed debate.

The pressure to contain health expenditures is unprecedented. In England a flattening of the health budget but increasing demand led the National Health Service (NHS) to seek reductions in health expenditures of 17 percent over four years. The spending cuts were to be achieved through improvements in service quality and efficiency, including reducing the use of ineffective, overused, or inappropriate procedures. However, the NHS left it to the local commissioning (or funding) organizations, known as primary care trusts, to determine what steps to take to reduce spending. To assess whether the initiative had an impact, we examined six low-value procedures: spinal surgery for lower back pain, myringotomy to relieve eardrum pressure, inguinal hernia repair, cataract removal, primary hip replacement, and hysterectomy for heavy menstrual bleeding. We found significant reductions in three of the six procedures-cataract removal, hysterectomy, and myringotomy-in the program's first year, compared to prior years' trends. However, changes in the rates of all examined procedures varied widely across commissioning organizations. Our findings highlight some of the challenges of making major budget cuts in health care. Reducing ineffective spending remains a significant opportunity for the US health care system, and the English experience may hold valuable lessons.

To assess attributions for overweight and the level of support for policy initiatives in Great Britain. Cross-sectional. Respondents indicated their agreement (5-point scales: strongly disagree to strongly agree) to three potential causes of overweight (environment, genes, willpower) and five policies (free weight-loss treatment, taxing unhealthy foods, healthy lifestyle campaigns, food labelling, advertising restrictions). Data were collected as part of a computer-assisted, face-to-face Omnibus survey of adults (aged >15 years) from across Great Britain in April 2012 carried out by a market research company. A population-representative sample of British adults (n 1986). More people attributed overweight to the food environment (61 %) and lack of willpower (57 %) than to genes (45 %). Policy support was highest for healthy lifestyle campaigns (71 %) and food labelling (66 %), and lowest for taxing unhealthy foods (32 %). Food environment attributions were associated with higher support for all policies (P < 0·001). Genetic attributions were associated with higher support for free weight-loss treatments and healthy lifestyle campaigns (P < 0·001), but not other policies. Attributions to lack of willpower were not associated differentially with support for any policies (P > 0·01). Belief that overweight is caused by the food environment or genes – both seen as outside individual control – was associated with greater support for government policies to prevent and treat obesity. Improving awareness of the multiple causes of obesity could facilitate acceptance of policy action to reduce obesity prevalence.

In 2010, immediately before the United States of America (USA) implemented key features of the Affordable Care Act (ACA), 18% of its residents younger than 65 years lacked health insurance. In the USA, gaps in health coverage and unhealthy lifestyles contribute to outcomes that often compare unfavourably with those observed in other high-income countries. By March 2014, the ACA had substantially changed health coverage in the USA but most of its main features--health insurance exchanges, Medicaid expansion, development of accountable care organizations and further oversight of insurance companies--remain works in progress. The ACA did not introduce the stringent spending controls found in many European health systems. It also explicitly prohibits the creation of institutes--for the assessment of the cost-effectiveness of pharmaceuticals, health services and technologies--comparable to the National Institute for Health and Care Excellence in the United Kingdom of Great Britain and Northern Ireland, the Haute Autorité de Santé in France or the Pharmaceutical Benefits Advisory Committee in Australia. The ACA was--and remains--weakened by a lack of cross-party political consensus. The ACA's performance and its resulting acceptability to the general public will be critical to the Act's future.

Breastfeeding is the most accessible and cost‐effective activity available to public health and has been shown to be one of the most effective preventive measures mothers can take to protect their children's health. Despite the well‐documented benefits, the UK has one of the lowest breastfeeding rates in the world. The Becoming Breastfeeding Friendly (BBF) toolkit was developed through highly structured technical and academic collaboration, led by Yale University. It provides an evidence‐based process to help countries assess their breastfeeding status and readiness to scale up, and identifies concrete measures countries can take to sustainably increase breastfeeding rates, based on data‐driven recommendations. BBF is grounded in the Breastfeeding Gear Model complex adaptive systems framework which is made up of eight simultaneous conditions that sustain breastfeeding. In 2018, a committee of multi‐agency stakeholders implemented the BBF process in England, collecting evidence to score the ‘gear’ components of England's breastfeeding environment against 54 benchmarks. The Training and Programme Delivery gear received the highest score, attributable to existing learning outcomes for health professionals and practitioners, peer supporters and specialist services, although there is a need for greater coordination and integration. The lowest scores were given for Promotion and Coordination, Goals and Monitoring due to the lack of a dedicated national strategy for breastfeeding and poor sharing of localised strategies and programmes. The process generated clear recommendations highlighting the need for more robust routine infant feeding data collection and reporting, and the necessity for strengthening leadership, monitoring and oversight to scale up and sustain breastfeeding. England has one of the lowest breastfeeding rates in the world. We used the Becoming Breastfeeding Friendly evidence‐based process to assess England's breastfeeding status and readiness to scale up, identifying concrete measures to sustainably increase breastfeeding rates based on data‐driven recommendations. Here we discuss England's need for more robust routine infant feeding data collection and reporting, and the necessity for strengthening leadership, monitoring and oversight to scale up and sustain breastfeeding. Key messages England's overall weighted Becoming Breastfeeding Friendly (BBF) Index score was 1.1 (range 0–3) representing a moderate scaling up environment (range 1.1–2.0). Five gears: Political Will, Legislation and Policies, Funding and Resources; Training and Programme Delivery and Research and Evaluation scored at a moderate gear strength, while the remaining three gears—Advocacy, Promotion and Coordination Goals and Monitoring—were weak. The BBF process for England highlighted substantial gaps in the current breastfeeding practice data and recommended that more robust routine, population‐level infant feeding data collection and reporting is initiated that goes beyond 6–8 weeks and up to 2 years. The process identified that the lack of a national infant feeding co‐ordinator role or national breastfeeding committee had resulted in no dedicated workplan and a lack of advocacy for breastfeeding programmes. The need for greater future coordination, strategic goal setting and consistent monitoring was recommended to strengthen the breastfeeding environment.

Public—private partnerships (PPPs) have become a prominent feature of contemporary public policy. Although research shows variation in the contractual configuration of partnerships, there is little evidence of how these shape service and workforce organization. Through comparative ethnographic research on two PPP health care providers in the English National Health Service, this article develops the idea that PPPs exhibit \"tight\" and \"loose\" arrangements that relate to \"downstream\" service and workforce management. It induces four empirically grounded mediating factors to describe this relationship. The first relates to the \"dependence\" between partners in terms of financing, strategy, and resource sharing; the second to the \"strategic orientation\" of leaders; the third to the composition of the \"professional workforce\"; and the fourth to the \"management approach\" to service and workforce organization. The article contributes to the research literature by exploring the contingencies in how PPPs are operationalized on the ground.

Context: This article compares the United Kingdom's and the United States' experiences with expensive cancer drugs to illustrate the challenges posed by new, extremely costly, medical technologies. Methods: This article describes British and American coverage, access, and cost-sharing policies with regard to expensive cancer drugs and then compares the costs of eleven such drugs to British patients, American Medicare beneficiaries, and American patients purchasing the drugs in the retail market. Three questions posed by these comparisons are then examined: First, which system is fairer? In which system are cancer patients better off? Assuming that no system can sustainably provide to everyone at least some expensive cancer drugs for some clinical indications, what challenges does each system face in making these difficult determinations? Findings: In both the British and American health care systems, not all patients who might benefit from or desire access to expensive cancer drugs have access to them. The popular characterization of the United States, where all cancer drugs are available for all to access as and when needed, and that of the British NHS, where top-down population rationing poses insurmountable obstacles to British patients' access, are far from the reality in both countries. Conclusions: Key elements of the British system are fairer than the American system, and the British system is better structured to deal with difficult decisions about expensive end-of-life cancer drugs. Both systems face common ethical, financial, organizational, and priority-setting challenges in making these decisions.

Objective. We examine how the economic crisis has affected individuals’ use of routine medical care and assess the extent to which the impact varies depending on national context. Methods. Data from a new cross-national survey fielded in the United States, Great Britain, Canada, France, and Germany are used to estimate the effects of employment and wealth shocks and financial fragility on the use of routine care. Results. We document reductions in individuals’ use of routine nonemergency medical care in the midst of the economic crisis. Americans reduced care more than individuals in Great Britain, Canada, France, and Germany. At the national level, reductions in care are related to the degree to which individuals must pay for it, and within countries, reductions are linked to shocks to wealth and employment and to financial fragility. Conclusions. The economic crisis has led to reductions in the use of routine medical care, and systems of national insurance provide some protection against these effects.

BACKGROUND: Few studies have quantified levels of habitual physical activity across the entire intensity range. We aimed to describe variability in total and intensity-specific physical activity levels in UK adolescents across gender, socio-demographic, temporal and body composition strata. METHODS: Physical activity energy expenditure and minutes per day (min/d) spent sedentary and in light, moderate, and vigorous intensity physical activity were assessed in 825 adolescents from the ROOTS study (43.5% boys; mean age 15.0 ± 0.30 years), by 4 days of individually calibrated combined heart rate and movement sensing. Measurement days were classified as weekday or weekend and according to the three school terms: summer (April-July), autumn (September-December), and spring (January-March). Gender and age were self-reported and area-level SES determined by postcode data. Body composition was measured by anthropometry and bio-electrical impedance. Variability in physical activity and sedentary time was analysed by linear multilevel modelling, and logistic multilevel regression was used to determine factors associated with physical inactivity (<60 min moderate-to-vigorous intensity physical activity/d). RESULTS: During awake hours (15.8 ± 0.9 hrs/d), adolescents primarily engaged in light intensity physical activity (517 min/d) and sedentary time (364 min/d). Boys were consistently more physically active and less sedentary than girls, but gender differences were smaller at weekends, as activity levels in boys dropped more markedly when transitioning from weekday to weekend. Boys were more sedentary on both weekend days compared to during the week, whereas girls were more sedentary on Sunday but less sedentary on Saturday. In both genders light intensity physical activity was lower in spring, while moderate physical activity was lower in autumn and spring terms, compared to the summer term; sedentary time was also higher in spring than summer term. Adolescents with higher fatness engaged in less vigorous intensity physical activity. Factors associated with increased odds of physical inactivity were female gender, both weekend days in boys, and specifically Sunday in girls. CONCLUSIONS: Physical activity components vary by gender, temporal factors and body composition in UK adolescents. The available data indicate that in adolescence, girls should be the primary targets of interventions designed to increase physical activity levels.