In the three years since the law on adult deceased organ donation consent in England changed to include an opt-out system, there has been no discernible change to donation rates. The lack of a positive impact on donation rates was predicted by many of those who took part in debates before and during the passage of the Bill through Parliament. This invites the question as to why England moved to an opt-out system for organ donation despite equivocal evidence of likely benefit and opposition from expert health professional organisations. To address this question qualitative analyses of Parliamentary debates on organ donation was undertaken. This revealed a shift from a dominant position, which gave primacy to the evidence of likely effects, towards a more normative position where a deemed consent option was viewed as the ‘correct thing to do’ and the limited and conflicting evidence viewed in a positive light. By 2017, following Wales's move to an opt-out system, together with continued lobbying for similar changes for England by professional and patient groups, alongside sustained public popularity for organ donation, the balance of opinion had shifted towards a system where deemed consent would become the default position for most English adults

While debate on how best to pay for social care in England continues, information about public attitudes on this issue is limited. We asked representative samples of the public whether care costs for older people should be met by the state, met by the service user or shared between state and user. We used an online survey of people aged 18–75 (n = 3,000) and interview survey of people aged 65 and over (n = 466). Respondents were given four vignettes (two home care, two residential care) and asked who should pay at different levels of user resources; and how much users should contribute when costs were shared. Fewer than one-fifth of the online sample and one-quarter of the interview sample considered that the state should meet the full costs whatever users’ resources; considerably lower proportions believed that users should meet the full costs in all cases. Two-thirds of the online sample and half the interview sample thought costs should be shared. The proportion of costs that users should contribute was relatively low (20–50 per cent, varying by user resources). The study illustrates that public views elicited through vignettes can provide evidence to inform policy on social care funding.

Metaphors are inescapable in human discourse. Policy researchers have suggested that the use of particular metaphors by those implementing policy changes both influences perceptions of underlying reality and determines what solutions seem possible, and that exploring ‘practice languages’ is important in understanding how policy is enacted. This paper contributes to the literature exploring the generative nature of metaphors in policy implementation, demonstrating their role in not just describing the world, but also framing it, determining what is seen/unseen, and what solutions seem possible. The metaphor ‘care pathway’ is ubiquitous and institutionalised in healthcare. We build upon existing work critiquing its use in care delivery, and explore its use in health care commissioning, using evidence from the recent reorganisation of the English NHS. We show that the pathways metaphor is ubiquitous, but not necessarily straightforward. Conceptualising health care planning as ‘designing a pathway’ may make the task more difficult, suggesting a limited range of approaches and solutions. We offer an alternative metaphor: the service map. We discuss how approaches to care design might be altered by using this different metaphor, and explore what it might offer. We argue not for a barren language devoid of metaphors, but for their more conscious use.

In 2012, the Government invited local councils in England to participate in a pilot programme to test direct payments in residential care. While the programme was set up to allow for comprehensive summative evaluation, the uptake of direct payments in residential care was substantially lower than anticipated, with only 40 people in receipt of one at the end of the programme. Drawing on qualitative data collected for the evaluation, this paper aims to understand better the barriers to implementing direct payments in residential care. Evidence from the use of direct payments in domiciliary care identified gatekeeping by council frontline staff as a major barrier for service users to access direct payments. Our findings suggest that, whilst selectivity of both service users and providers was an integral part of the programme design, gatekeeping does not fully explain the poor take-up. Other factors played a part, such as lack of clarity about the benefits of direct payments for care home residents, the limited range and scope of choice of services for residents, and concerns from care providers about the financial impact of direct payments on their financial sustainability.

The optimal balance between central governmental authority and the degree of autonomy of local public bodies is an enduring issue in public policy. The UK National Health Service is no exception, with NHS history, in part at least, a history of repeated cycles of centralisation and decentralisation of decision-making power. Most recently, a significant reorganisation of the NHS in 2012–13 was built around the creation of new and supposedly more autonomous commissioning organisations (Clinical Commissioning Groups – CCGs). Using Bossert's (1998) concept of ‘decision space’, we explored the experiences of local commissioners as they took on their new responsibilities. We interviewed commissioning staff from all of the CCGs in two regional health care ‘economies’, exploring their perceptions of autonomy and their experiences over time. We found significant early enthusiasm for, and perceptions of, increased autonomy tempered in the vertical dimension by increasingly onerous and prescriptive monitoring regimes, and in the horizontal dimension by the proliferation of overlapping networks, inter-organisational groups and relationships. We propose that, whatever the balance between central and local control that is adopted, complex public services require some sort of meso-level oversight from organisations able to ‘hold the ring’ between competing interests and to take a regional view of the needs of the local health system. This suggests that local organisational autonomy in such services will always be constrained.

In England, policy piloting has become firmly established in almost all areas of public policy and is seen as good practice in establishing ‘what works’. However, equating piloting with evaluation can risk oversimplifying the relationship between piloting and policy-making.

Using three case studies from health and social care – the Partnerships for Older People Projects (POPP) pilots, the Individual Budgets pilots and the Whole System Demonstrators (WSD) – the paper identifies multiple purposes of piloting, of which piloting for generating evidence of effectiveness was only one. Importantly, piloting was also aimed at promoting policy change and driving implementation, both in pilot sites and nationally. Indeed, policy makers appeared to be using pilots mainly to promote government policy, using evaluation as a strategy to strengthen the legitimacy of their decisions and to convince critical audiences. These findings highlight the ambiguous nature of piloting and thus question the extent to which piloting contributes to the agenda of evidence-based policy-making.

In considering issue expertise in policymaking, we unpack differences in the supply and types of expertise with attention to the presumed privileged role of the bureaucracy. Our empirical investigation is based on witness testimonies of congressional hearings for a policy area involving various forms of expertise – critical infrastructure protection policymaking. Three sets of findings stand out. One set substantiates the role of the bureaucracy as an important information conduit while also showing it is not a primary source of issue expertise. A second set shows how differences in issue maturity and salience affect the demand for and supply of expertise. A third set illustrates the influence of a small cadre of hyper-expertise in drawing attention to problems and solutions across different venues. These findings challenge the conventional view of the bureaucracy in policymaking while expanding the understanding of different sources of information and types of issue expertise in policymaking.

The electrical heating of Ni/Al laminate foils allows interrogation of phenomena at heating rates as high as 10^12 K/s. In the 2011 Fall MRS meeting, we reported on emission spectra from rapidly heated Ni/Al laminates resolved temporally over 350 ns, which provided qualitative evidence of rapid and exothermic vapor phase mixing of Ni and Al in these experiments which we term electrical explosions. These results were significant, because thermal diffusion processes normally limit Ni/Al reactions to much slower energy release rates, potentially limiting their applications. Here we present further evidence of exothermic Ni/Al mixing, quantified by experimental velocity measurements of encapsulation material and interpreted by numerical calculations of energy partitioning into different processes. These calculations agreed well with experiments from different Al, Cu, and Ni samples, sputter-deposited and lithographically patterned into bow-tie bridge structures. Velocity measurements of up to 5 km/s for 11.5 μm thick parylene encapsulation layers were accurately predicted using a single, empirical fitting parameter which depended on the electrical circuit used. The calculations also agreed with encapsulation layers accelerated by electrically exploded Ni/Al laminates as long as an additional 1.2 kJ/g of energy was included in the model. This value is precisely the enthalpy of mixing between Ni and Al, and therefore quantifies the transduction of energy into encapsulation layer kinetic energy.

Fish consumption is the major dietary source of EPA and DHA, which according to rodent experiments may reduce body fat mass and prevent obesity. Only a few human studies have investigated the association between fish consumption and body-weight gain. We investigated the association between fish consumption and subsequent change in body weight. Women and men (n 344 757) participating in the European Prospective Investigation into Cancer and Nutrition were followed for a median of 5·0 years. Linear and logistic regression were used to investigate the associations between fish consumption and subsequent change in body weight. Among women, the annual weight change was 5·70 (95 % CI 4·35, 7·06), 2·23 (95 % CI 0·16, 4·31) and 11·12 (95 % CI 8·17, 14·08) g/10 g higher total, lean and fatty fish consumption per d, respectively. The OR of becoming overweight in 5 years among women who were normal weight at enrolment was 1·02 (95 % CI 1·01, 1·02), 1·01 (95 % CI 1·00, 1·02) and 1·02 (95 % CI 1·01, 1·04) g/10 g higher total, lean and fatty consumption per d, respectively. Among men, fish consumption was not statistically significantly associated with weight change. Adjustment for potential over- or underestimation of fish consumption did not systematically change the observed associations, but the 95 % CI became wider. The results in subgroups from analyses stratified by age or BMI at enrolment were not systematically different. In conclusion, the present study suggests that fish consumption has no appreciable association with body-weight gain.

Whether there are differences between countries in the validity of self-reported diet in relation to BMI, as evaluated using recovery biomarkers, is not well understood. We aimed to evaluate BMI-related reporting errors on 24 h dietary recalls (24-HDR) and on dietary questionnaires (DQ) using biomarkers for protein and K intake and whether the BMI effect differs between six European countries. Between 1995 and 1999, 1086 men and women participating in the European Prospective Investigation into Cancer and Nutrition completed a single 24-HDR, a DQ and one 24 h urine collection. In regression analysis, controlling for age, sex, education and country, each unit (1 kg/m2) increase in BMI predicted an approximately 1·7 and 1·3 % increase in protein under-reporting on 24-HDR and DQ, respectively (both P < 0·0001). Exclusion of individuals who probably misreported energy intake attenuated BMI-related bias on both instruments. The BMI effect on protein under-reporting did not differ for men and women and neither between countries on both instruments as tested by interaction (all P>0·15). In women, but not in men, the DQ yielded higher mean intakes of protein that were closer to the biomarker-based measurements across BMI groups when compared with 24-HDR. Results for K were similar to those of protein, although BMI-related under-reporting of K was of a smaller magnitude, suggesting differential misreporting of foods. Under-reporting of protein and K appears to be predicted by BMI, but this effect may be driven by ‘low-energy reporters’. The BMI effect on under-reporting seems to be the same across countries.

Since 2001, implementation of a New Zealand’s Primary Health Care Strategy (the Strategy) has led to an increase in the proportion of primary health care services which are publicly funded, the development of 82 primary health organisations (PHOs) to oversee primary health care services and universal public capitation funding of PHOs. This approach has replaced the previous system of fee-for service targeted public subsidies paid to individual general practitioners (GPs). Patient copayments, although at a reduced level but still set by individual practitioners, have remained a core feature of the system.

This paper focuses on the implementation and impact of key policy changes over the first five years of the Strategy. Although patient copayments have fallen and consultation rates have increased, the new funding and payment system has raised a number of unresolved issues – whether to retain the new universal funding system or revert to the former targeted approach; how to achieve the potential gains from capitation when GPs continue to receive their income from a variety of sources and in a variety of different ways; and how to manage the potential for ‘cream skimming’.

Recent improvements in access may, in time, improve health status and reduce inequalities in health, but there is no guarantee that a universal system will necessarily improve average health or reduce inequalities. Much depends on the services being delivered and the populations that are benefiting most – something New Zealand needs better evidence on before determining future policy directions in primary health care.

The objective of this study was to test whether the relatively new, noninvasive technique of extracorporeal shock-wave lithotripsy (ESWL) for renal stones resulted in a measurably better outcome from the patients' point of view than percutaneous surgery. The claimed superiority of ESWL was not demonstrated with the data available.