Mathers Jonathan, Taylor Rebecca, Parry Jayne
School of Health and Population Sciences, University of Birmingham.
Milbank Q. 2014 Dec;92(4):725-53. doi: 10.1111/1468-0009.12090.
Policy Points: In 2004, England's National Health Service introduced health trainer services to help individuals adopt healthier lifestyles and to redress national health inequalities. Over time these anticipated community-focused services became more NHS-focused, delivering "downstream" lifestyle interventions. At the same time, individuals' lifestyle choices were abstracted from the wider social determinants of health and the potential to address inequalities was diminished. While different service models are needed to engage hard-to-reach populations, the long-term sustainability of any new service model depends on its aligning with the established medical system's characteristics.
In 2004, the English Public Health White Paper Choosing Health introduced "health trainers" as new members of the National Health Service (NHS) workforce. Health trainers would offer one-to-one peer-support to anyone who wished to adopt and maintain a healthier lifestyle. Choosing Health implicitly envisaged health trainers working in community settings in order to engage "hard-to-reach" individuals and other groups who often have the poorest health but who engage the least with traditional health promotion and other NHS services.
During longitudinal case studies of 6 local health trainer services, we conducted in-depth interviews with key stakeholders and analyzed service activity data.
Rather than an unproblematic and stable implementation of community-focused services according to the vision in Choosing Health, we observed substantial shifts in the case studies' configuration and delivery as the services embedded themselves in the local NHS systems. To explain these observations, we drew on a recently proposed conceptual framework to examine and understand the adoption and diffusion of innovations in health care systems.
The health trainer services have become more "medicalized" over time, and in doing so, the original theory underpinning the program has been threatened. The paradox is that policymakers and practitioners recognize the need to have a different service model for traditional NHS services if they want hard-to-reach populations to engage in preventive actions as a first step to redress health inequalities. The long-term sustainability of any new service model, however, depends on its aligning with the established medical system's (ie, the NHS's) characteristics.
政策要点：2004年，英国国家医疗服务体系引入了健康培训师服务，以帮助个人采用更健康的生活方式，并纠正国家健康不平等问题。随着时间的推移，这些预期的以社区为重点的服务变得更加以国家医疗服务体系为中心，提供“下游”生活方式干预措施。与此同时，个人的生活方式选择脱离了更广泛的健康社会决定因素，解决不平等问题的潜力也被削弱了。虽然需要不同的服务模式来接触难以触及的人群，但任何新服务模式的长期可持续性都取决于其与既定医疗系统特征的一致性。
2004年，英国公共卫生白皮书《选择健康》引入了“健康培训师”作为国家医疗服务体系（NHS）工作人员的新成员。健康培训师将为任何希望采用并维持更健康生活方式的人提供一对一的同伴支持。《选择健康》含蓄地设想健康培训师在社区环境中工作，以接触那些“难以触及”的个人和其他群体，这些人往往健康状况最差，但与传统健康促进和其他国家医疗服务体系服务的接触最少。
在对6个地方健康培训师服务进行纵向案例研究期间，我们对关键利益相关者进行了深入访谈，并分析了服务活动数据。
我们观察到，与《选择健康》中设想的以社区为重点的服务顺利且稳定地实施不同，随着这些服务融入当地国家医疗服务体系，案例研究中的配置和提供方式发生了重大转变。为了解释这些观察结果，我们借鉴了最近提出的一个概念框架，以研究和理解医疗保健系统中创新的采用和传播情况。
随着时间的推移，健康培训师服务变得更加“医学化”，这样一来，该项目最初的理论受到了威胁。矛盾之处在于，政策制定者和从业者认识到，如果他们希望难以触及的人群参与预防行动，以此作为纠正健康不平等的第一步，那么就需要有一个与传统国家医疗服务体系服务不同的服务模式。然而，任何新服务模式的长期可持续性都取决于其与既定医疗系统（即国家医疗服务体系）特征的一致性。
