This study aimed to assess and compare the utilization of preventive and other health services and the cost or availability in different regions of Europe, before and during the economic crisis. The data used in the study were obtained from Wave 8 of the Survey of Health, Ageing and Retirement in Europe (2019/2020) and Wave 1 data (2004/5), with a sample size of 46,106 individuals aged ≥50 across 27 countries, adjusted to represent a population of N = 180,886,962. Composite scores were derived for preventive health services utilization (PHSU), health care services utilization (HCSU), and lack of accessibility/availability in health care services (LAAHCS). Southern countries had lower utilization of preventive services and higher utilization of other health services compared to northern countries, with a significant lack of convergence. Moreover, the utilization of preventive health services decreased, whereas the utilization of secondary care services increased during the austerity period. Southern European countries had a significantly higher prevalence of lack of accessibility. An increase in the frequency of lack of accessibility/availability in health care services was observed from 2004/5 to 2019/20. In conclusion, our findings suggest that health inequalities increase during crisis periods. Therefore, policy interventions could prioritize accessibility and expand health coverage and prevention services.

In 2008, the UK entered a period of economic recession followed by sustained austerity measures. We investigate changes in inequalities by area deprivation and urbanicity in incidence of severe mental illness (SMI, including schizophrenia-related disorders and bipolar disorder) between 2000 and 2017.
We analysed 4.4 million individuals from primary and secondary care routinely collected datasets (2000-2017) in Wales and estimated the incidence of SMI by deprivation and urbanicity measured by the Welsh Index of Multiple Deprivation (WIMD) and urban/rural indicator respectively. Using linear modelling and joinpoint regression approaches, we examined time trends of the incidence and incidence rate ratios (IRR) of SMI by the WIMD and urban/rural indicator adjusted for available confounders.
We observed a turning point of time trends of incidence of SMI at 2008/2009 where slope changes of time trends were significantly increasing. IRRs by deprivation/urbanicity remained stable or significantly decreased over the study period except for those with bipolar disorder sourced from secondary care settings, with increasing trend of IRRs (increase in IRR by deprivation after 2010: 1.6 % per year, 95 % CI: 1.0 %-2.2 %; increase in IRR by urbanicity 1.0 % per year, 95 % CI: 0.6 %-1.3 %).
There was an association between recession/austerity and an increase in the incidence of SMI over time. There were variations in the effects of deprivation/urbanicity on incidence of SMI associated with short- and long-term socioeconomic change. These findings may support targeted interventions and social protection systems to reduce incidence of SMI.

Over the past decade, there have been significant and unequal cuts to local authority (LA) budgets, across England. Cultural, environmental and planning (CEP) budgets have been cut by 17% between 2011 and 2019. This funding supports services such as parks, leisure centres, community development and libraries, all of which have potential to influence population mental health. We therefore investigated whether cuts to CEP services have affected mental health outcomes and the extent to which they have contributed to mental health inequalities between areas.
Using fixed effects regression applied to longitudinal LA-level panel data in England, we assessed whether trends in CEP spend were associated with trends in mental health outcomes, between 2011 and 2019. The exposure was CEP spend and the primary outcome was the LA-average Small Area Mental Health Index (SAMHI). Additionally, we considered subcategories of CEP spend as secondary exposures, and antidepressant prescription rate and self-reported anxiety levels as secondary outcomes, both aggregated to LA-level. We adjusted all models for confounders and conducted subgroup analysis to examine differential mental health effects of spending cuts based on the level of area deprivation.
The average decrease in CEP spend of 15% over the period was associated with a 0.036 (95% CI: 0.005, 0.067) increase in SAMHI score, indicating worsening mental health. Amongst subcategories of CEP spending, cuts to planning and development services impacted mental health trends the most, with a 15% reduction in spend associated with a 0.018 (95% CI: 0.005, 0.031) increase in the SAMHI score. The association between cuts in CEP and deteriorating mental health was greater in more affluent areas.
Cuts to spending on cultural, environmental, planning and development services were associated with worsening population mental health in England. Impacts were driven by cuts to planning and development services in particular. Reinvesting in these services may contribute to improved public mental health.

UNASSIGNED: Population health has stagnated or is declining in many high-income countries. We analysed whether nationally administered austerity cuts in England were associated with prevalence of multimorbidity (individuals with two or more long-term conditions) and health-related quality of life.
UNASSIGNED: We conducted an observational, longitudinal study on 147 local authorities in England. We examined associations of changes in spending over time (2009/10-2017/18), in total and by budget line, with (i) prevalence of multimorbidity, 2+ conditions (2011/12-2017/18), and (ii) health-related quality of life (EQ-5D-5L) score (2012/13-2016/17). We estimated linear, log-log regression models, incorporating local authority fixed-effects, time-varying demographic and socio-economic confounders, and time trends.
UNASSIGNED: All local authorities experienced real spending cuts, varying from 42% (Barking and Dagenham) to 0·3% (Sefton). A 1% cut in per capita total service expenditure was associated with a 0·10% (95% CI 0·03 to 0·16) increase in prevalence of multimorbidity. We found no association (0·003%; 95% CI -0·01 to 0·01) with health-related quality of life. By budget line, after controlling for other spending, a 1% cut in public health expenditure was associated with a 0·15% (95% CI 0·11 to 0·20) increase in prevalence of multimorbidity, and a 1% cut in adult social care expenditure was associated with a 0·01% (95% CI 0·002 to 0·02) decrease in average health-related quality of life.
UNASSIGNED: Fiscal austerity is associated with worse multimorbidity and health-related quality of life. Policymakers should consider the potential health consequences of local government expenditure cuts and knock-on effects for health systems.
UNASSIGNED: Medical Research Council.

This paper provides a longitudinal examination of local inequalities in health behaviours during a period of austerity, exploring the role of \'place\' in explaining these inequalities. Data from the Stockton-on-Tees prospective cohort study of 836 individuals were analysed and followed over 18 months (37% follow-up). Generalised estimating equation models estimated the deprivation gap in health behaviours (smoking status, alcohol use, fruit and vegetable consumption and physical activity practices) between the 20% most- and least-deprived neighborhoods (LSOAs), explored any temporal changes during austerity, and examined the underpinning role of compositional and contextual determinants. All health behaviours, except for frequent physical activity, varied significantly by deprivation (p ≤ 0.001). Smoking was lower in the least-deprived areas (OR 0.21, CI 0.14 to 0.30), while alcohol use (OR 2.75, CI 1.98 to 3.82) and fruit and vegetable consumption (OR 2.55, CI 1.80 to 3.62) were higher in the least-deprived areas. The inequalities were relatively stable throughout the study period. Material factors (such as employment, education and housing tenure) were the most-important and environmental factors the least-important explanatory factors. This study suggests that material factors are the most important \'place\' determinants of health behaviours. Health promotion activities should better reflect these drivers.

Infant regulatory disturbances are common and stable over time and can compromise infant outcomes across a range of developmental domains. Many such problems have their origins within the parent-infant relationship and specialized parent-infant relationship teams provide support and intervention that is explicitly aimed at addressing such relationship difficulties. However, there are currently only around 27 such teams across the United Kingdom, and just under half of CAMHS do not accept referrals of children under 2 years of age.
The current research aimed to examine the views of commissioners of children\'s services regarding the reasons for commissioning (or not) infant mental health services.
Fourteen in-depth interviews were conducted with a range of stakeholders involved in commissioning children\'s services across 14 areas of England, half of which were commissioning specialized infant mental health services. A thematic analysis was undertaken.
A total of five themes emerged from the data as being key factors in the commissioning of infant mental health services: pressure from local practitioners, policy transfer through policy networks, opportunity for long-term cost reduction, potential to embed the service model within existing services and perinatal mental health funding.
As with commissioning more widely, the commissioning of infant mental health services is a complex process, with a range of factors influencing whether such services are commissioned or not, and data to suggest that the process is currently driven by informal and contingent factors, as much as by the evidence regarding what works.

This paper examines trends in mental health among adults in England during the period of economic recovery and austerity following the 2008 \'great recession\'. We report analysis of data on 17,212 individuals living in England, from the longitudinal Understanding Society Survey (USS). We examined how individual\'s self-reported mental health over time (2011-2017), related to their changing socio-geographical status. Self-reported mental health is reported in the USS using version 2 of the SF12 Mental Component Summary. Trends in this score (across 5 observations per subject) were categorised into Mental Health Trajectory Groups (MHTGs) using Group Based Trajectory Modelling. We used maximum-likelihood multinomial logit models to estimate for individuals the relative likelihood of belonging to different Mental Health Trajectory categories as compared with a \'base\' category, for whom mental health was good and stable throughout the period. We focus on likelihood of belonging to a group showing \'declining\' mental health. Predictor variables included individuals\' attributes and area conditions in their places of residence (including Office of National Statistics indicators of local employment deprivation and data on average income loss within districts due to welfare benefit reforms, published by the Centre of Regional Economic and Social Research at Sheffield Hallam University, UK). Our results emphasise the multiple socio-geographical \'determinants\' likely to be operating on individual mental health. Declining mental health was associated both with conditions at the start of the study period and with social and socio-geographical mobility by the end of the study period. Risks of declining mental health were significantly greater for more deprived individuals and also (controlling for individual attributes) among those living in English neighbourhoods that were already economically disadvantaged at the beginning of the \'great recession\' and located in districts where average incomes were most severely impacted by the effects of governmental austerity programmes on welfare benefits.

UNASSIGNED: Organizational reform has been commonplace in the response to global socio-economic changes. Rising managerialism, consumerism and marketization has accelerated reforms; providing challenges for the healthcare professions. The latest socio-economic challenge, austerity, and its professional implications have scarcely been researched. This study aims to explore the lived reality of austerity as experienced by physiotherapists working on the frontline of the National Health Service (NHS) in the UK.
UNASSIGNED: Ethical approval was granted by the University of Nottingham; the study was advertised via the Chartered Society of Physiotherapy online network. Two participants took part; semi-structured interviews were completed, audio recorded, and transcribed. Data was analyzed using thematic analysis.
UNASSIGNED: Three themes arose from the data: (1) Fulfilling professional responsibilities; (2) Changing organizational landscape; and (3) Professional reality of rationalizing and accommodating austerity. The clinical implications of austerity included increased length of hospital stay, insufficient community services, constrained resources, and understaffing. Participants demonstrated attempts to preserve their professional status and services through restratification throughout the intra-professional hierarchy, changing division of labor, and re-professionalization.
UNASSIGNED: Despite claims that austerity is coming to an end, it remained a reality for these clinicians in the NHS. Physiotherapists in this study used similar methods to preserve practice when faced with exogenous constraints as seen in medicine, such as re-professionalization and restratification. However, this attempt to defend professionalism by a non-medical healthcare profession was met with both successes and losses and has implications for the wider healthcare profession ecology, identifying an area for future research.

The economic crisis posed various challenges to policy-makers who had to decide on which health policy measures to focus on and on which to refrain from. The aim of this research was to assess the relevance of ethics and to highlight ethical dimensions in decision-taking by policy-makers with regard to policy and priority-setting in health systems posed by the economic crisis.
Semi-structured qualitative interviews were conducted with eight European policy-makers from six countries.
All interviewees recalled difficult and strenuous situations where they had to prioritise between distinct areas to focus on and invest in, for example around choices between prioritising medications, health professional staffing, care specific equipment, or urgent infrastructure issues. Values could be identified which they deemed as important within the policy-making process, such as trust and responsibility. They explicitly expressed the need for ethical tools and assistance in terms of policy advice for reaching morally sustainable decisions in health policy matters.
The study showed that ethical concepts and values frequently come into play in health policy-making, and that ethics is highly relevant in policy-makers\' daily decision-taking, yet that they lack ethical guidance on what to base their decisions. The study is of relevance since it can provide future decisions on austerity-related issues with an ethical underpinning and could identify areas of moral concern.

BACKGROUND: Prisons offer the state the opportunity to gain access to a population that is at particularly high risk of ill-health. Despite the supportive legal and policy structures surrounding prison rehabilitation, the oppressive nature of the austerity policy in England threatens its advanced improvement.
METHODS: Using grounded theory methodology, this is the first interdisciplinary qualitative study to explore the impact of macroeconomic austerity on prison health in England from the perspective of 29 international prison policymakers.
RESULTS: The far-reaching impact of austerity in England has established a regressive political system that shapes the societal attitude towards social issues, which has exacerbated the existing poor health of the prisoners. Austerity has undermined the notion of social collectivism, imposed a culture of acceptance among prison bureaucrats and the wider community, and normalised the devastating impacts of prison instability. These developments are evidenced by the increasing levels of suicide, violence, radicalisation and prison gangs among prisoners, as well as the imposition of long working hours and the high levels of absenteeism among prison staff.
CONCLUSIONS: This study underscores an important and yet unarticulated phenomenon that despite being the fifth largest economy in the world, England\'s poorest, marginalised and excluded population continues to bear the brunt of austerity. Reducing the prison population, using international obligations as minimum standards to protect prisoners\' right to health and providing greater resources would create a more positive and inclusive system, in line with England\'s international and domestic commitments to the humane treatment of all people.