This paper reports on the findings of a research project that examined the changes to the public health system in England introduced in 2013. Drawing on case study research and two national surveys the findings explore the impact of organisational change on the composition and role of public health teams. Views and experiences were obtained from public health leaders involved in the transfer of staff and functions from the National Health Service in England to local authorities. National surveys at two points in time aimed to compare and contrast views on the evolving changes. The new organisational and managerial arrangements had enabled public health professionals to widen their work and influence, and public health skills and budgets were welcomed by those in local government. Initially, in some areas, directors of public health were less certain of the benefits of the transfer to local government compared to high levels of confidence expressed by elected members, but perspectives changed over time and moved closer together. National headline figures were found to mask high levels of turbulence and churn being experienced by individual authorities identified in the case study research, and the trend of reducing capacity through cuts to staff, budget and services was a cause for serious concern.

Background: The wide-ranging program of reforms brought about by the Health and Social Care Act (2012) in England fundamentally changed the operation of the public health system, moving responsibility for the commissioning and delivery of services from the National Health Service to locally elected councils and a new national public health agency. This paper explores the ways in which the reforms have altered public health commissioning. Methods: We conducted multi-methods research over 33 months, incorporating national surveys of Directors of Public Health and local council elected members at two time-points, and in-depth case studies in five purposively selected geographical areas. Results: Public health commissioning responsibilities have changed and become more fragmented, being split amongst a range of different organisations, most of which were newly created in 2013. There is much change in the way public health commissioning is done, in who is doing it, and in what is commissioned, since the reforms. There is wider consultation on decisions in the local council setting than in the NHS, and elected members now have a strong influence on public health prioritisation. There is more (and different) scrutiny being applied to public health contracts, and most councils have embarked on wide-ranging changes to the health improvement services they commission. Public health money is being used in different ways as councils are adapting to increasing financial constraint. Conclusions: Our findings suggest that, while some of the intended opportunities to improve population health and create a more joined-up system with clearer leadership have been achieved, fragmentation, dispersed decision-making and uncertainties regarding funding remain significant challenges. There have been profound changes in commissioning processes, with consequences for what health improvement services are ultimately commissioned. Time (and further research) will tell if any of these changes lead to improved population health outcomes and reduced health inequalities, but many of the opportunities brought about by the reforms are threatened by the continued flux in the system.

Background Following the Health and Social Care Act in England, public health teams were formally transferred from the NHS to local authorities in April 2013. Methods Online survey of Directors of Public Health (DsPH) in local authorities in England (n = 152) to investigate their experience within local government 1 year on. Tests of association were used to explore relationships between the perceived integration and influence of public health, and changes in how the public health budget was being spent. Results The organization of and managerial arrangements for public health within councils varied. Most DsPH felt that good relationships had been established within the council, and the move had made them more able to influence priorities for health improvement, even though most felt their influence was limited. Changes in commissioning using the public health budget were already widespread and included the de-commissioning of services. Conclusions There was a widespread feeling amongst DsPH that they had greater influence since the reforms, and that this went across the local authority and beyond. Public health's influence was most apparent when the transfer of staff to local government had gone well, when collaborative working relationships had developed, and when local partnership groups were seen as being effective.

Purpose – The purpose of this paper is to evaluate the needs of stroke survivors and the impact of a Life After Stroke service on users, and to explore the effectiveness of a service provided by a third sector organisation working closely with other stroke service provision. Design/methodology/approach – Review of management documents and reports, polling views of 128 service users through a nationally recognised survey designed to assess the service impact, and using interviews and focus groups to gain a deeper understanding of the value and impact of the service from a range of professionals involved with delivering stroke care. Survey response rates were similar to that experienced nationally and the age/gender profile of respondents suggested they were representative. Findings – The service was highly regarded by service users as providing personal, practical and emotional support from people who were knowledgeable and accessible in acute hospitals. From the wider perspective, professionals involved in the stroke pathway saw the service as complementing the acute hospital provision and the stroke community nursing team. The organisation providing the support service worked effectively across health and social care boundaries and built on their existing links and trusted relationships. Originality value – This adds to the evidence that the personal impact of stroke is substantial, and on being discharged from acute care many survivors will still have considerable needs. For those responsible for meeting these needs, the particular model of delivering stroke support evaluated here has been found to have considerable merits and resilience in the changing landscape of tighter resources and NHS restructuring.

Over recent years there have been several political imperatives in the UK directed toward children's palliative care and ensuring that services are high-quality, coordinated, family-centred, and able to meet the needs of children with complex disabilities. In addition, in 2010 the health and social care regulation authority in England-the Care Quality Commission (CQC)-aligned hospices with regulation and inspection requirements. This context has acted as a driver for the creation of effective education and training to ensure a skilled and expert workforce. Against this backdrop, this paper describes a project to develop a learning and development strategy for Children's Hospices across London (CHaL). CHaL educators worked with a research team to develop a unified strategy that was based on evidence of good practice, embedded in required CQC outcomes, and validated with a wider audience. The resultant strategy contains a set of four key leaming and development principles that are applicable and transferable across different hospices.

Headache is the most common neurological symptom presenting to general practitioners (GPs). Identifying factors predicting outcome in patients consulting their GPs for headache may help GPs with prognosis and choose management strategies which would improve patient care. We followed up a cohort of patients receiving standard medical care, recruited from 18 general practices in the South Thames region of England, approximately 9 months after their initial participation in the study. Of the baseline sample (N¼255), 134 provided both full baseline and follow-up data on measures of interest. We determined associations between patients' follow-up scores on the Headache Impact Test-6 and baseline characteristics (including headache impact and frequency scores, mood, attributions about psychological/ medical causes of their headaches, satisfaction with GP care and illness perceptions). Greater impact and stronger beliefs about the negative consequences of headaches at baseline were the strongest predictors of poor outcome at follow-up.

CHSS undertook to support Kent and Medway Commissioning Support (KMCS: acting on behalf of East Kent Hospitals University NHS Foundation Trust and NHS Canterbury and Coastal Clinical Commissioning Group) in undertaking an independent analysis of a consultation on Outpatient services in East Kent. The aim of the consultation was to gain opinions from the public of a proposed Outpatient Clinical Strategy that intends to improve local access to, and facilities for, Outpatient services, and to offer a wider range of services on each site. CHSS advised on the survey, evaluated the consultation process, ran focus groups and carried out quantitative and qualitative analysis of the responses gathered during the consultation period (9th December 2013 to 17th March, 2014 - originally 9th March but period was extended). Ethical approval was not required for a consultation process, but ethical principles have been adhered to regarding data confidentiality and informed consent for the focus groups.

The 2012/13 survey is the fifth in a series of surveys on patient satisfaction with inpatient and daycare services carried out by Help the Hospices and the Centre for Health Services Studies at the University of Kent, with previous surveys being completed in 2004/05, 2006/07, 2008/09 and 2010/11. All hospices across the UK were invited to take part in the 2012/13 Patient Survey and 20 hospices participated between November 2012 and May 2013. The method of data collection was a self-completion questionnaire, with one questionnaire for adult users of daycare services and another for inpatient services. Each hospice distributed a questionnaire and an accompanying information letter to inpatients at discharge and to daycare patients at discharge or after two months of attending daycare. The survey included respite patients, those being discharged for terminal care at home, and readmissions even though the latter group may have been given the opportunity to complete the questionnaire more than once.

The Stroke Association commissioned CHSS to evaluate the effectiveness of the Life After Stroke service in Eastern and Coastal Kent in meeting the needs of stroke survivors in the first twelve months after their discharge from hospital care. The evaluation was required to measure the impact of these support services on the lives of stroke survivors and their carers, also to assess the effectiveness of the way the service was being delivered and how well it was working with other agencies. The evaluation was conducted over a two year period, from May 2010 to April 2012. A mixed methods approach was taken to evaluate the Life After Stroke service. The quantitative approach was based on the views of 98 stroke survivors who completed postal questionnaires and on data from quarterly management reports. The qualitative part of the evaluation was face-to-face interviews and focus groups with stroke survivors, carers, with those providing the Life After Stroke service, and with a small number of wider stakeholders working in NHS acute hospitals and commissioning organisations.

In November 2012, the Centre for Health Services Studies at the University of Kent was commissioned by NHS Kent and Medway to conduct a rapid (23 day) appraisal of the SHREWD system and the way it was currently operating across Kent and Medway. SHREWD - Single Health Resilience Early Warning Database - is an "online, real-time early warning and decision support tool", developed by Transforming Systems (a human systems focused software development company) in collaboration with NHS Kent and Medway, partners within the Medway health system, and the University of Greenwich, with financial support from the South East Coast Strategic Health Authority. It is a system designed to be accessed and updated by partners within a local health system in order to share 'system critical' information.

The 2010/11 survey is the fourth in a series of surveys on patient satisfaction with inpatient and daycare services. Carried out by Help the Hospices and the Centre for Health Services Studies at the University of Kent, with previous surveys being completed in 2004/05, 2006/07 and 2008/09. All hospices across the UK were invited to take part in the 2010/11 Patient Survey and 39 hospices participated between September 2010 and May 2011.

This project lays the foundation for the development of a sustainable and unified approach to learning and development by bringing together policy, practice and evidence, and interfacing with regulatory requirements that have recently been strengthened for hospices and that are inspected by the Care Quality Commission (CQC). It commences with CHaL's vision for learning and development, follows with project description and methods, and summarises the initial scoping conducted to underpin the strategy. The subsequent analytical and conceptual development of the strategy is described, alongside a rational for aligning thinking with the CQC essential standards that are inspected. The project had a unique opportunity to link in to a set of three national workshops for hospices arranged by Children's Hospices UK (CHUK) and working with CQC that served to act as a consultation forum; this process is described.

1. This report describes findings from a survey of general practices in Kent and Medway, giving the views of practice managers and practice nurses with regard to training needs. The focus is on the training needs of nurses in general practice in order for them to run clinics for patients with long term conditions such as asthma, diabetes and heart disease. 2. The aims of the study were: To understand varying levels at which practice nurses across the county are working in the provision of care of patients with long term conditions, so that appropriate levels of training can be commissioned. To determine likely training needs which will then inform the training provision commissioned by the Kent & Medway General Practice Staff Training Team for practice nurses across the county. To provide Kent & Medway General Practice Staff Training Team with data relating to likely future training needs as a proxy for future course commissioning at a variety of levels.

A health needs assessment for Gypsy and Traveller communities in Kent would ideally describe the size of traveller population, patterns of health and illness experienced, uptake of health services and the outcomes from these encounters. However, precise numbers and locations of the traveller population in Kent are not available. Although accommodation needs assessments have been carried out regarding the number of pitches and sites, there is a lack of comprehensive data because to date neither the Census nor the NHS has recorded Gypsies or Travellers as a distinct ethnic category. There is no up to date local health profile of Gypsies and Travellers or readily available data on how this community uses health services.

This report provides an account of the methods and findings of Phase 2 of the Privacy and Dignity in Continence Care for Older People study funded by the Royal College of Physicians and the British Geriatrics Society. The overall objectives of this two year project were to: • Identify and validate person-centred attributes of dignity in relation to continence; • Develop reflective guidelines for dignified care; • Produce recommendations for best practice.

The 2008 Guernsey 'Healthy Lifestyle' Survey asked questions on general health, smoking, diet, exercise, drinking, stress, sunbathing, and utilisation of various services. The data will be used to evaluate the effectiveness of current programmes, and to review Health Promotion priorities. This was the fifth Guernsey 'Healthy Lifestyle' Survey - the first was completed in 1988, and they have taken place at five-yearly intervals. The Survey was again conducted in collaboration with three main group Family Practices on the island, and our thanks are due to them for their co-operation and help in the random selection of adult patients from their practice lists.

The 2008/09 survey is the third in a series of surveys on patient satisfaction with inpatient and daycare services carried out by Help the Hospices and the Centre for Health Services Studies at the University of Kent, with previous surveys being completed in 2004/05 and 2006/07. All hospices across the UK were invited to take part in the 2008/09 Patient Survey and 52 hospices participated between July 2008 and February 2009. The method of data collection was a self-completion questionnaire, with one questionnaire for adult users of daycare services and another for inpatient services. Each hospice distributed a questionnaire and an accompanying information letter to inpatients at discharge and to daycare patients at discharge or after two months of attending daycare. The survey included respite patients, those being discharged for terminal care at home, and readmissions even though the latter group may have been given the opportunity to complete the questionnaire more than once. There were 2222 replies, 1259 from daycare users and 963 from inpatients. For the 50% of hospices that supplied sufficient details on distribution, there was an overall response rate of 62% for daycare, and 41% for inpatients. Results are shown separately for the two services, and as well as the figures for all hospices, the report gives the results for hospices that achieved the benchmark figure of 40 responses. Results in 2008/9 were similar to the previous survey with the many patients expressing high levels of satisfaction with the services they received.

Introduction to the quantitative evaluation KCC's New Opportunities to work (Kent NOW) programme aimed to get long-term (2 years or more) Incapacity Benefit claimants back to work. CHSS was asked to evaluate the programme. This brief report covers the quantitative evaluation and supplements the qualitative evaluation report 'Evaluation of Kent County Council's Kent New Opportunities to Work ('Kent NOW') programme', written by Rachel Black and Susan Kenyon in January 2008.

1. This research project was commissioned by NHS Eastern & Coastal Kent PCT (ECK PCT) as part of its clinical workforce development to look at reasons why there are comparatively fewer GP trainers and training practices in East Kent compared to other areas. ECK PCT wished to commission research to understand the current low level of provision among GP training and to use the research results to improve the provision of GP training placements in the NHS Eastern and Coastal Kent area. 2. The report summarises the findings of the various stages of the report, including the literature review, interview study, and survey and makes a number of recommendations.

The PHOENIX project aims to examine the impact of structural changes to the health and care system in England on the functioning of the public health system, and on the approaches taken to improving the public's health. The scoping review has now been completed. During this phase we analysed: Department of Health policy documents (2010-2013), as well as responses to those documents from a range of stakeholders; data from 22 semi-structured interviews with key informants; and the oral and written evidence presented at the House of Commons Communities and Local Government Committee on the role of local authorities in health issues. We also gathered data from local authority (LA) and Health and Wellbeing Board (HWB) websites and other sources to start to develop a picture of how the new structures are developing, and to collate demographic and other data on local authorities. A number of important themes were identified and explored during this phase. In summary, some key points related to three themes - governance, relationships and new ways of working - were: The reforms have had a profound effect on leadership within the public health system. Whilst LAs are now the local leaders for public health, in a more fragmented system, leadership for public health appears to be more dispersed amongst a range of organisations and a range of people within the LA. At national level, the leadership role is complex and not yet developed (from a local perspective). Accountability mechanisms have changed dramatically within public health, and many people still seem to be unclear about them. Some performance management mechanisms have disappeared, and much accountability now appears to rely on transparency and the democratic accountability that this would (theoretically) enable. The extent to which 'system leaders' within PHE are able to influence local decisions and performance will depend on the strength of relationships principally between the LA and the local Public Health England centre. These relationships will take time to develop. Many people have faced new ways of working, in new settings, and with new relationships to build. Public health teams in LAs have faced the most profound of these changes, having gone from a position of 'expert voice' to a position where they must defend their opinions and activities in the context of competing demands and severely restricted resources. Public health staff may require new skills, and may need to seek new 'allies' to thrive in the new environment. HWBs could be crucial in bringing together a fragmented system and dispersed leadership. The next phase of data collection will begin in March with the initiation of case study work. National surveys will be conducted in June/July this year (2014), and at the same time the following year. In this work, we will further explore the following themes: relationships, governance, decision making, new ways of working, and opportunities and difficulties.