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ROI IN PUBLIC HEALTH

POLICY

Supporting Decision Making

Subhash Pokhrel, Lesley Owen, Kathryn Coyle and Doug Coyle

ROI in Public Health Policy

Subhash Pokhrel • Lesley Owen Kathryn Coyle • Doug Coyle

ROI in Public Health Policy

Supporting Decision Making

Subhash Pokhrel

Health Economics Research Group (HERG), Division of Health Sciences

Brunel University London Uxbridge, UK

Kathryn Coyle

Health Economics Research Group (HERG)

Brunel University London Uxbridge, UK

Lesley Owen Centre for Guidelines

National Institute for Health and Care Excellence

London, UK

Doug Coyle School of Epidemiology and Public Health

University of Ottawa Ottawa, ON, Canada

ISBN 978-3-319-68896-1 ISBN 978-3-319-68897-8 (eBook) https://doi.org/10.1007/978-3-319-68897-8

Library of Congress Control Number: 2017956107

© The Editor(s) (if applicable) and The Author(s) 2017

This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed.

The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Cover illustration: Abstract Bricks and Shadows © Stephen Bonk/Fotolia.co.uk

Printed on acid-free paper

This Palgrave Pivot imprint is published by Springer Nature

The registered company is Springer International Publishing AG

The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Dedicated to colleagues and stakeholders from whom we have learnt a great deal.

Preface

It was a mere coincidence that brought four of us together—several years ago we needed to contribute to an exciting National Institute for Health and Care Excellence (NICE) project that looked at the possibility of developing a decision support tool to help local policymakers build their business cases for tobacco control. At the time, each of us was at different career paths, and none of us realised this collaboration would eventually lead to a book of this nature. We believe that return on investment (ROI) analyses can be useful in supporting public health decisions, but more needs to be written to make them accessible to readers.

As the use of economic evidence in policymaking increased, thanks to the work persistently done by national health watchdogs like NICE in England, this development required health researchers, including health economists, to take more responsibility to find ways in which evidence is produced and communicated to decision makers: in more iterative, engaging and meaningful ways than ever before. This process made the task of engaging with stakeholders (that included decision makers alongside other colleagues) in the buildup to, during and in the aftermath of a “research project” a desired goal within our professional circles. We soon discovered the trajectory between what we as the researchers find (knowledge) and what end users will use (translation) is not always linear; in fact it seldom is. This is the discovery (at least on our part) around “knowledge translation” that has inspired us in writing this book. We hope a health economic book of this kind would be a nice addition to the contemporary market.

Our approach to writing this book has been somewhat different from many other books that are written on similar topics. We always had end users—policy/decision makers, academics and researchers, service commissioners and providers, health advocates, patient groups, service users, and so on—in mind and we hope we have made the book accessible to all types of audience. We also hope that the book offers a nifty balance between theoretical details and pragmatic considerations as one wants to learn, and potentially design and conduct, ROI analyses. Chapter 5 is relatively more technical as it introduces the concepts around economic modelling that underlie the NICE Tobacco Control ROI tool and Chap. 7 is a step-by-step guide that we hope will enable the readers to use the NICE ROI tools. Issues related to decision making and wider than economics are featured throughout but can be found mostly in Chaps. 8 and 9. We start the book with a fictional story to set the scene so that readers can appreciate the challenging context of public health decision making. In the last chapter, this fictional story is revisited to enable readers to appreciate how ROI analyses can actually be useful. We look forward to hearing readers’ feedback on our endeavour.

Throughout the book, we have provided several case studies where a core concept needed to be illustrated, many of which are based on our own work around public health ROI tools. We hope our storytelling approach will be valuable to the readers, particularly those for whom the ROI concepts are relatively new. Although the book revolves around mainly the UK context (where most of our own work in this area is located), attempts have been made to make the book as relevant as possible to a wider audience by drawing on some European and global evidence/examples.

Many people have helped us in this undertaking, directly and indirectly. Indirect inputs came from several stakeholders and colleagues particularly the research advisors and collaborators of the EQUIPT study (http:// equipt.eu). Glenn Stewart contributed to writing up Chap. 2. Derek Ward and Tessa Lindfield’s helpful contribution to Chap. 1 in understanding the use of cost-effectiveness/ROI evidence in policymaking is gratefully acknowledged, and so are the constructive comments from Robert West, Adam Lester-George, Stephen Hanney, Annette Boaz and Nana Anokye. Several institutions—NICE, the European Commission, Tobacco Free Futures, Smokefree SouthWest and Fresh NorthEast—supported our ROI work at various stages. Needless to say, the incredible support received

from our respective families in the form of their “forgone evenings and weekends” (with us) deserves a special mention here.

Uxbridge, UK

London, UK

Uxbridge, UK

Ottawa, ON, Canada

Subhash Pokhrel

Lesley Owen

Kathryn Coyle

Doug Coyle

Doug Coyle is a health economist and professor in the School of Epidemiology and Public Health, University of Ottawa, and in the Health Economics Research Group, Brunel University London. He has taught graduate courses in health economics for over 20 years and authored over 200 research papers.

Kathryn Coyle has 15 years of experience as an academic health economist originally at the University of Ottawa. In addition to being the principal economic modeller for the EQUIPT ROI tool, she has conducted numerous economic evaluations for multiple funders, including the National Institute for Health and Care Excellence.

Lesley Owen is a technical adviser in health economics in the Centre for Guidelines at the National Institute for Health and Care Excellence London. Owen’s main responsibilities are to provide advice and leadership on the health economic analyses underpinning the development of public health guidelines and more recently social care guidelines. Owen has led the development of five return on investment tools for NICE.

Subhash Pokhrel PhD, is a reader in health economics and Director, Division of Health Sciences in the College of Health and Life Sciences at Brunel University London. He led the development of NICE Tobacco Control ROI tool in England and its roll out into other European jurisdictions via the EQUIPT study. He has authored several research articles on

behavioural health issues including tobacco control, physical activity, breastfeeding and medical care utilisation.

Glenn Stewart FFPH is a Consultant in Public Health and the Assistant Director of Public Health at the London Borough of Enfield. He has an MSc in Exercise and Health from St. Mary’s University, Twickenham, and an MPH from the University of London, UK. He was awarded the Brunel University London Vice Chancellor’s prize for doctoral research for his DrPH study.

List of figures

Fig. 2.1 Trend in smoking prevalence in the UK [12]

17

Fig. 2.2 Economic cost of tobacco use in selected European jurisdictions [22] 19

Fig. 2.3 Breastfeeding behaviour in a cross section of countries [81] 28

Fig. 2.4 Breastfeeding initiation and cessation in the UK and home countries [82] 29

Fig. 3.1 Challenges in conducting economic evaluations in public health [10]. Based on: Edwards et al. (2013), BMC Public Health, 13:1001

Fig. 3.2 The ROI of a cross section of interventions reported in a recent systematic review [8]

Fig. 5.1 Segmentation of population for the ROI analysis [2]

46

50

79

Fig. 5.2 The three states considered in the Markov model 80

Fig. 6.1 The PICO framework for defining a decision problem [6]. Based on NICE PMG4 (2012)

97

Fig. 7.1 Tobacco Control ROI Tool screenshot 1 108

Fig. 7.2 Tobacco Control ROI Tool screenshot 2 109

Fig. 7.3 Tobacco Control ROI Tool screenshot 3 110

Fig. 7.4 Tobacco Control ROI Tool screenshot 4 112

Fig. 7.5 Tobacco Control ROI Tool screenshot 5 113

Fig. 7.6 Tobacco Control ROI Tool screenshot 6 114

Fig. 7.7 Tobacco Control ROI Tool screenshot 7

Fig. 7.8 Physical Activity ROI Tool screenshot 1 119

Fig. 7.9 Physical Activity ROI Tool screenshot 2

Fig. 7.10 Physical Activity ROI Tool screenshot 3

Fig. 7.11 Physical Activity ROI Tool screenshot 4

Fig. 7.12 Physical Activity ROI Tool screenshot 5

Fig. 7.13 Physical Activity ROI Tool screenshot 6

Fig. 7.14 Alcohol use ROI Tool screenshot 1

Fig. 7.15 Alcohol use ROI Tool screenshot 2

Fig. 7.16 Alcohol use ROI Tool screenshot 3

Fig. 7.17 Alcohol use ROI Tool screenshot 4

Fig. 7.18 Alcohol use ROI Tool screenshot 5

Fig. 7.19 Alcohol use ROI Tool screenshot 6 135

Fig. 8.1 Proportion of respondents agreeing to specific facilitator of evidence uptake in the EQUIPT study [16]

Fig. 8.2 Excess weight in adults (16+ years), London, 2013–2015 [21]

Fig. 8.3 The EQUIPT model of stakeholder engagement [23]

Fig. 8.4 An infographic showing the economic case for investing in smoking cessation, based on EQUIPT study [27]

Fig. 8.5 An infographic showing the ROI of increased rates of GP brief advice uptake, based on the EQUIPT study [27]

145

147

150

154

154

List of tabLes

Table 2.1 Costs of suboptimal breastfeeding reported in the literature [78, 83–96] 31

Table 4.1 A guide to questions to understand the audience and their needs for ROI analyses 61

Table 7.1 Southwark Local Stop Smoking Services 116

Table 7.2 Liverpool—business case for pedometers: original versus new evidence 127

Table 7.3 Cost and impact at one year of three school-based interventions to prevent or reduce alcohol use 136

Table 9.1 Current limitations and agenda for research—NICE Tobacco Control ROI tool 163

Table 9.2 Some unanswered questions from the EQUIPT study: setting future research agenda on transferability of evidence 165

Box 3.1

List of boxes

CHAPTER

1

Diary of a Policymaker

Abstract Policymakers are in search of evidence that resonates to their local needs (real-world practice). Often what is available is not in the format desired. This is particularly the case for economic evidence, where the traditional metric (cost/QALY (quality adjusted life year)) is seen as “abstract” in the context of real-world decision making by many. This chapter introduces return on investment (ROI) analyses that offer information on the costs and benefits of alternative policy actions. ROI information should usually be presented as a single, simplified metric making it easy for decision makers to relate it to their local contexts.

Keywords Decision making • Return on investment • ROI • Cost • QALY

“Tomorrow’s a DH funding meeting, George. You are expected to present your business case for the ‘Bio’ programme”, read the new email that had just landed in George’s inbox. This was from his secretary, Elaine, who always preferred to send a “gentle” reminder to her boss what she thought needed George’s careful attention and probably some focused time preparing for.

Elaine had been George’s secretary for the last five years and he was used to her gentle reminders. However, on this occasion, the “gentle” reminder did not sound “gentle” in any way as despite Elaine’s and other

© The Author(s) 2017

S. Pokhrel et al., ROI in Public Health Policy, https://doi.org/10.1007/978-3-319-68897-8_1

1

colleagues’ best efforts, he had not been able to collect the sort of information he was after for the next day’s meeting. Besides, he was just coming back from chairing a local strategy meeting, had another meeting scheduled for late afternoon and, above all, he and his team had been very busy for the last few months working out efficiency savings that they needed to deliver next year. Thanks to the current austere climate, his job had never been this hard!

“This meeting might turn out to be fiercely competitive, who knows?” thought George looking at the meeting agenda and the list of attendees, “without robust data, and more importantly, without showing economic returns in the short to medium terms, our plan is unlikely to get funded”.

George always liked his role as the Director of Public Health for the New Maryland local authority (LA). New Maryland is characterised by its beautiful woods, several small but stunning lakes and lovely residents. The population health status was better than the national average, thanks to the abundance of small and medium enterprises (SMEs) that served as the backbone of the local economy.

One public health problem that George and his team were trying to address, however, was the extremely low breastfeeding rates in their local authority, much worse than the national average. Less than 0.1% of new mothers were breastfeeding at four months despite about 60% of all postpartum women in the local authority initiating breastfeeding post birth. The breastfeeding cessation curve for the borough looked odd: most mothers who initiated breastfeeding would turn to breastfeeding substitutes by the 6th week, and by the 12th week, less than 0.1% would be exclusively breastfeeding their babies.

George and colleagues wanted to do something meaningful to improve this situation. They realised that because of the strong local economy in the borough, most women were working in the SMEs. They loved their job and the income it provided. The borough has almost 90% home ownership and most working women hold full-time jobs. Thus, women were more likely to return to work immediately after six weeks of maternity leave. At that point, breastfeeding ceased and breast milk substitutes kicked in.

Having understood the root of the problem, George and his team consulted with women about how the local authority could help continue breastfeeding their babies for (at least) four months or longer. The consultation pointed to a couple of possible interventions George and his team could offer to women: a nursery/childcare closer to the workplace where

they can visit their babies and breastfeed and a workplace facility where the working women were able to express breast milk during working hours and safely store it. Having further consulted with the employers and after scrutiny of relevant literature around the possible health gains of continued breastfeeding, George and his team had come up with a plausible intervention, the “Bio”. The acronym “Bio” stood for “Breastfeeding in Offices”, and it was on George’s list of new programmes that needed funding to start this year.

“We have worked so hard and worked together with women and employers to develop this intervention”, George got nostalgic for a while but soon recovered, “it would be a shame if we were not able to build an economic case for it. I have just a few hours now…”.

George gave a second thought on what had been a problem in relation to the economic case. “The evidence on the health benefits of exclusive breastfeeding for four months or longer is pretty strong”, he consoled himself. “But the evidence on the cost-effectiveness of interventions is rather sparse and where those evidence exist it is hard for us to translate that to our own contexts”, he seemed to be in two minds. “It’s the ‘format’ in which the information appears that seems to be problematic here”, he concluded.

Soon, his fingers were on the telephone. “Paul, would you like to pop in to my office, please? We need to discuss ‘Bio’”. On such anxious occasions, it was not uncommon for George to count on Paul, his public health analyst.

“You know George, I found a very interesting new report this morning when you were in the local strategy meeting”, announced Paul after taking a seat at the round meeting table in George’s office. “They talk about the scale of cost savings to the NHS … if breastfeeding rates in the UK were to increase” he said as he passed the report on to George.

“I think it does the trick for us”, declared Paul. “Our new intervention ‘Bio’ would increase breast milk feeding and given this new evidence, we could calculate how much cost savings it would generate under different assumptions of breastfeeding rates. If we then compared the cost savings with the extra costs to us of implementing ‘Bio’, we would be able to present our business case, wouldn’t we?”

Paul’s suggestion based on this new evidence punched George. “Eureka!” he exclaimed as he struggled to push himself back in to his chair.

The next hour was perhaps the most productive time they spent together working out the business case for the “Bio”. Once they realised

that the evidence was in the format they needed, it was not hard for them to estimate likely returns from the investment they would require to run the “Bio” under different assumptions across New Maryland.

When Elaine came to remind George of his next meeting in 15 minutes, George seemed very confident that he would be able to present a strong business case for “Bio” the next day.

“This meeting might turn out to be fiercely competitive but I may get the funding, who knows?” he said smiling at Elaine as he left his office.

Elaine knew her boss had got all the information in the format that he needed them.

Why is George’s story relevant here?

Evidence-based approaches to decision making have been on the forefront of public policy for a long time. What works, in what population and with what consequences are the three questions underlying the quest for evidence prior to or during the decision-making process. In the medical sector, the dominance of evidence-based medicine (EBM) as a supplement to traditional medical practice is well known. Clinical (micro-level) decision making is often heavily based on EBM approaches whilst reimbursement (macro-level) decision making involves EBM as just one component. EBM can be defined as “the conscientious, explicit, judicious and reasonable use of modern, best evidence in making decisions about the care of individual patients” [1]. This definition lends itself to a simple interpretation—in order to make evidence-based medical decisions, one has to rely on better (than what is used traditionally), high-quality research information that can be integrated into or with one’s clinical experience and patient values. Judgement is inevitable in such decisions but that is expected to have been informed by reasonable use of “best evidence”. Any evidencebased decision would then bring about the maximal benefit to a patient.

The principles of EBM have extended to public health policymaking too. However, there is one fundamental distinction between the two. Unlike in the world of medicine, the aim of public health is to move the interventional benefits from one patient to a large number of people (the population). Unlike a clinician’s focus on improving health of a patient, public health professionals work towards achieving better health outcomes at the population level. How would best available evidence such as the effect size of an intervention coming out from an adequately powered randomised control trial (RCT) translate to public health decision making then?

A slight adaptation is needed to apply EBM approaches to public health. Moving away from individuals to populations, from diagnosis to prevention, from treatment to health promotion and from whole patient to whole community is necessary [2]. Medical care is thus no more the only policy goal; it extends beyond that to include interventions that could mitigate the underlying causes of the low levels of population health such as poor sanitation, environmental pollution, certain lifestyles and behaviours. Is the sort of research information that is needed for evidence-based public health essentially different from the ones needed to practice EBM? The following view articulated by Cairney and Oliver [3] may help answer this question:

Evidence-based policymaking is not just about the need for policymakers to understand how evidence is produced and should be used. It is also about the need for academics to reflect on the assumptions they make about the best ways to gather evidence and put the results into practice, in a political environment where other people may not share, or even know about, their understanding of the world; and the difference between the identification of evidence on the success of an intervention, in one place and one point in time (or several such instances), and the political choice to roll it out, based on the assumption that national governments are best placed to spread that success throughout the country. [3]

Understanding what research information is helpful to make public health policymaking is therefore crucial. As the EBM principles suggest, the evidence should be robust, usually coming from more than a single study (e.g. from systematic reviews, meta-analyses and economic evaluations) and presented in a critical way to guide users to choose what is known as the “best available evidence”. The Cochrane initiative uses stringent criteria to “gather and summarize the best evidence from research” [4] to aid the decision-making process. The evolution over time of national guideline development bodies, such as the National Institute for Health and Care Excellence (NICE) in England, has clarified the attributes of best available evidence [5]. The Health Technology Assessment (HTA) programme that aims to combine clinical effectiveness/health outcomes information with costs provides a framework upon which evidence needs to be developed, scrutinised and presented [6].

Increasingly, cost-effectiveness evidence, most of which is presented in the form of incremental cost per QALY (quality adjusted life year) gained— to reflect the additional cost of generating one extra year of full health at the population level—is being used to make treatment choices in the NHS and beyond, including public health interventions. NICE considers an intervention would provide good value for money if the cost per QALY is

preferably under £20,000 but not above £30,000. Health economists argue that presenting research information as explicitly as incremental cost per QALY is useful for decision makers because it helps them consider whether the benefits of a new treatment are worth the health displaced elsewhere by their decision to fund that treatment.

If this was that straightforward, what would explain the struggle for obtaining the right information in George’s story?

That question has haunted us for the last seven years!

In 2010, we started to look at the economic impact of tobacco use in local areas in England (the then Primary Care Trusts). The timing couldn’t have been more interesting as the localism agenda had just started to show up high on the recently elected Coalition Government’s White Paper [7]. As a result, the Health and Social Care Act 2012 later entrusted the local authorities (LAs) to provide public health provisions such as Stop Smoking Services [8]. Austerity being high on the agenda, service commissioners started to look for relevant “data” supporting their business cases, be it for continued or new investment or even disinvestment from existing services.

As practising public health economists, we didn’t see any problem with that as we were convinced—based on the hard data—that most public health interventions actually provide good value for money. In fact, Lesley and her colleagues at NICE evaluated over 20 economic evaluation studies (comprising 200 cost-effectiveness estimates) underpinning the NICE Public Health Guidance published between 2006 and 2010. They found that in 15% of the cases, the intervention was more effective and cheaper than comparator and a whopping 85% of the 200 estimates were cost-effective at a threshold of £20,000 per QALY. On that basis, they confidently concluded: “the majority of public health interventions assessed are highly cost-effective” [9].

As we kept on engaging with key stakeholders in this area, the “resonance” issue started to pop up: that most evidence in public health was created to aid national-level decision making that may not necessarily resonate to the local needs. “Local population is different” (questioning whether national population averages were the best measure to make policies where “we as the LA are so different”); “local data for local decision making”; and “I want to know what economic returns this investment gives me in two years” were some of the concerns we heard consistently. Even the NICE guidance (cost/QALY) wasn’t considered enough by some. It seemed to us that decision makers were in need of something different, something that is meaningful to them (not just meaningful to us as the researchers).

S. POKHREL

It was the time, we realised, for us to abandon our respective ivory towers of academia and go to the ground to understand what stakeholders actually needed.

Soon, some of us started engaging with a number of stakeholders as part of a study [10]. Of the 12 stakeholders with whom we interacted, 8 were from health institutions (4 with public health, 2 with primary care and 3 with finance roles) and 3 from local authorities. The feedback reasonably represented the viewpoint of an important cross section of the professionals who were engaged in tobacco control at the time.

By this time, we had completed an evidence review to establish the feasibility and underlying methods of an economic tool aimed to help local decision makers build their business cases for tobacco control. The variation that we found in both methods and resulting estimates across different published studies led to a clear conclusion: if we wanted to be helpful to local decision makers, we needed to ask them what types of impact from their investments they would like to see in the tool. Not being sensitive to their needs would only risk poor uptake and receptivity of the tool when rolled out.

The findings of our engagement with the 12 stakeholders representing an important cross section of professionals were very interesting (summarised in Box 1.1). The stakeholders felt that published economic tools at the time were somewhat disjointed from local decision-making frameworks; they did not provide estimates of cash-releasing cost savings, and they had very long time horizons which might be entirely appropriate for national-level policy debates but not for the context in which local public finance operated. Of particular note was the idea that the tool should be able to capture proxies of progress, for example, changes in prevalence, changes in the rates of new smokers (particularly in young people), hospital admissions by type (e.g. by lung cancer or coronary heart disease) and incidence of smoking-related diseases.

The stakeholders also felt that it was important to include productivity and employment losses to businesses due to smoking. Importantly, they felt that the economic tool should be populated with local authority data as default and include short-term impacts, typically proxies at one to two years and the medium-term (up to ten years) costs and benefits. Long-term benefits, usually the lifetime costs and benefits, were of less interest to stakeholders. This reflected the current austerity climate in which public finance operated. There was a very clear message regarding how the tool should be presented. They strongly preferred an economic tool presented as simple and user-friendly, allowing real-time analysis of

“what-if” scenarios. Graphical illustration of results would make it more attractive. The economic tool needed to be able to address different populations and include micro-level analyses.

Box 1.1 Summary Findings from Stakeholder Engagement Activities

• There is a demand for a well-designed economic analysis of smoking cessation and tobacco control, in particular for an economic tool that would help local service commissioners and tobacco control managers make their business cases.

• Focus of such tools should be on current smokers, uptake and passive smoking.

• Such tools need to reflect the needs of local decision makers. Identifying “cash-releasing” savings through reduced number of hospital admissions is an example.

• Important impacts to include in the models are short-term (twoyear) impacts such as primary care visits, hospital admissions and productivity losses and medium term (ten-year) impacts such as treatment costs of new diseases caused by smoking.

• Productivity losses, extent of passive smoking, particularly in children, and uptake of smoking in young people are other impacts that need to be included for both short and medium terms.

• Long-term impacts such as QALYs may be less relevant to local decision making.

• Balancing robustness with transparency and ease of use is important; in particular ensure that the model has a short run time to allow for “what-if” analyses.

Much of our work in developing public health return on investment (ROI) tools, analyses and evidence particularly for tobacco control has since been informed by stakeholder feedback. Initially, we conducted this work for NICE, but together with other European colleagues we endeavoured to roll the NICE Tobacco ROI tool to other European countries through the Europeanstudy on Quantifying Utility of Investment in Protection from Tobacco, (EQUIPT) study [11]. This book is largely based on this experience.

Stakeholder engagement became a part of our study design by default. We just could not ignore George’s story and his busy diary anymore. The two boxed items (Boxes 1.2 and 1.3) are reflections from real-world decision makers and serve to highlight some of the challenges in this area.

Box 1.2 Understanding Decision Contexts for ROI Analyses

Professor Derek Ward, Public Health Advisor to Derbyshire Clinical Commissioning Group (CCG).

Interview excerpts:

The vast majority of policy/ decision making still relies on historical decisions. Most often commissioning decisions require savings made through recommissioning contracts; look at the contract details and change them if possible by following NICE guidance. However, where there is a significant problem or where a new service is believed to provide benefits (or harms), looking for details about the area, its effectiveness and efficiency data such as ROI evidence is more common practice. This is rather a pragmatic approach. Also, since the Health and Social Care Act 2012, organisational structures have changed and decision making often cuts across NHS England, Public Health England (PHE), local authorities and clinical commissioning groups. At times, it is driven by how much money is available and considering the budget line by line.

It is hard to say how much of decision making would involve looking for cost-effectiveness (CE)/ROI evidence, mainly due to the complexity of service commissioning. Core packages involving individual clinical interventions need to be commissioned. Sometimes, one could look at things on a case-by-case basis, but the middle ground would be to have ad hoc conversations with the local clinical decision-making team and decide what would be the best thing to do. However, when different funding scenarios are worked out, it is useful to have cost-effectiveness/ROI evidence to hand.

Looking for cost-effectiveness/ROI evidence when there is a need for it is really a “hit-and-miss”. Where an intervention is safe or harmful, or it has no or significant clinical benefit or its cost is very high or very low, one would be required to look for evidence. The starting point would be the evidence hierarchy—look for NICE

guidelines and meta-analyses and then bring in clinical expertise. Consideration of cost is always important. However, consideration of CE or ROI is secondary to whether the intervention has been commissioned in the past and whether there is an expectation it should continue, for example, grommets. We needed strong clinical evidence and guidelines to stop doing lots of grommets! Also, costs/ QALY is not obvious for CCGs and they often follow the “we just pay it” approach. However, all CCGs have a commissioning procedure that they follow. In the case of very high-cost or high-volume interventions, guidelines from the NHS England and/or NICE would (normally) be followed.

In order to use CE/ROI information more effectively, we need to move away from single-risk behaviour to more complex multiple behaviour/conditions to an integrated model of care. In relation to public health, a behaviour change package involving different aspects such as smoking, nutrition, cancer prevention, and so on, would be useful to think about. Then, various scenarios with different effects could be worked out and ROI analysis would be very helpful there.

Cost/QALY does not resonate very well in a local commissioning context. Rather, if that information is broken down to benefits in terms of actual savings (e.g. avoidable numbers of hospitalisations and GP visits or averted numbers of falls) as the result of interventions, that would make much more sense. Likewise, working out how many accidents and emergenices (A&E) repeat attenders or episodes of serious mental illnesses admissions that a package of interventions could avoid gives a real impetus to the local decision-making process. Here, the point is about avoided costs rather than ROI— unless the ROI can be demonstrated over a very short timeline— preferably in a year!

Granularity of information is vital as that can be applied locally more readily than the cost/QALY information. Public finance works with a very short time horizon. What can we do this year to reduce the incidence of major conditions to deliver cost savings for this or next year? This is what most commissioners ask. There is common acceptance that benefits, usually the morbidity and mortality benefits in terms of QALYs, from interventions accrue over a long period of time. However, there is also an acknowledgement that we need to balance the books. Therefore, showing any benefits that would accrue in the short to medium term is very helpful.

Box 1.3 Understanding the Use of Cost-Effectiveness Evidence in Local Policymaking

Tessa Lindfield, Director of Public Health at London Borough of Enfield

Interview excerpts:

Cost-effectiveness and ROI are one element of decision making alongside other elements including risk and practicalities. There are many elements in decision making, particularly in organisations with many stakeholders and working across and between sectors and organisational boundaries. CE/ROI is obviously important but they have to be balanced against other considerations. There is not enough CE/ROI evidence for local authorities. This is less of problem for the NHS where there is more evidence, but this is still not enough. In local authorities, evidence is sparse. About 10% of decision making currently involves looking for CE/ ROI evidence.

We use different sources of evidence when there is a need for it; first we’d go to recognised sources such as Public Health England, the York Consortium, Sheffield, and so on. If evidence could not be found we’d go online and look for grey evidence. NICE evidence can be useful, but as noted above particularly in local authorities, there may be insufficient evidence.

Consideration of costs usually kick in at the beginning of the decision-making process. Clearly there are a number of considerations to any decision but costs are a pretty fundamental one and if the costs begin to mount without any foreseeable benefits the decision begins to be made for you.

We could improve the uptake of CE/ROI evidence in decision making by making the evidence more relevant to the decisions and organisations we are working for. Also, there is a very big gap in how much evidence there is. Evidence also needs to be made as accessible as possible so that it can be understood and therefore influential.

Key Points

• Public health policymakers are expected to apply evidence-based decision-making principles, similar to those of evidence-based medicine (EBM).

• In order to make evidence-based decisions, one has to rely on high-quality research information integrating clinical benefits with population values.

• In applying evidence to decision making, some form of judgement becomes necessary but such judgement should be informed by reasonable use of “best evidence”.

• Policymakers are in search of evidence that resonates to their local needs (real-world practice). Often what is available is not in the format desired. This is particularly the case for economic evidence, where the traditional metric (cost/QALY) is seen as “abstract” in the context of real-world decision making by many.

• Return on investment (ROI) analyses could help real-world decision makers by offering information on the costs and benefits of alternative policy actions. ROI information should usually be presented as a single, simplified metric making it easy for decision makers to relate it to their local contexts.

RefeRences

1. Masic I, Miokovic M, Muhamedagic B. Evidence based medicine – new approaches and challenges. Acta Inform Med. 2008;16(4):219–25.

2. The Public Health Information and Data Tutorial. From evidence-based medicine to evidence-based public health. 2017. https://phpartners.org/ tutorial/04-ebph/2-keyConcepts/4.2.1.html

3. Cairney P, Oliver K. Evidence-based policymaking is not like evidence-based medicine, so how far should you go to bridge the divide between evidence and policy? Health Res Policy Syst. 2017;15(1):35.

4. Cochrane Collaboration. What do we do? 2017. http://www.cochrane.org/ about-us

5. National Institute for Health and Care Excellence (NICE). Guide to the methods of technology appraisal 2013 [PMG9]. London: National Institute for Health and Care Excellence; 2013.

6. National Institute for Health Research (NIHR). Health technology assessment. 2017. https://www.nihr.ac.uk/funding-and-support/funding-forresearch-studies/funding-programmes/health-technology-assessment/

7. NHS. Equity and excellence: liberating the NHS. London: Secretary for Health, 2010 to 2015 Conservative and Liberal Democrat Coalition Government; 2010.

8. UK Government. Health and Social Care Act 2012. London: Lesiglation.gov. uk; 2012.

9. Owen L, Morgan A, Fischer A, Ellis S, Hoy A, Kelly MP. The cost-effectiveness of public health interventions. J Public Health (Oxf). 2012;34(1):37–45.

10. Trapero-Bertran M, Pokhrel S, Trueman P. Building the business case for Tobacco Control: a toolkit to estimate the economic impact of tobacco. Brunel Univeristy in asosciation with Tobacco Free Futures, Fresh Smoke Free North East & Smokefree South West, 2011. https://www.brunel. ac.uk/__data/assets/file/0017/144710/Technical-Report-16-Dec-2011. pdf

11. EQUIPT. European-study on Quantifying Utility of Investment in Protection from Tobacco. 2016. http://www.equipt.eu/

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H I S T O R I C A L R E C O R D

OF THE

EIGHTY-SIXTH, OR

THE ROYAL COUNTY DOWN REGIMENT OF F O O T .

The last twelve years of the eighteenth century form a period, remarkable in the annals of Europe, for the efforts made to overthrow the governments of Christendom, and to establish the destructive domination of atheism and democracy, upon the ruins of institutions which had elevated the inhabitants of this quarter of the globe to an height of knowledge, refinement, wealth, and power, unknown in other parts of the earth. France was the great theatre of commotion: there the war of hostile principles produced the most sanguinary results;—the cry of “equality” was raised,—the blood of princes, nobles, and citizens was shed, and democracy appeared to triumph over the rights of society. In other countries, republican principles were spreading to an alarming extent; the sovereigns of Europe were forced to engage in war to oppose the progress of destruction, and to Great Britain pertains the honour of having persevered in this contest, for twenty years, when

On the commencement of hostilities in 1793, the British army was augmented: upwards of fifty regiments of foot were raised, and one of the first corps embodied, on this occasion, was the regiment which now bears the title of the E-, R C D R.

This corps was raised by Major-General Cornelius Cuyler, who had served with reputation in North America, and also in the West Indies, where he had performed the duties of commander-in-chief; its general rendezvous was at Shrewsbury, and its designation was “G C’ S V;” but its ranks were completed with men, principally from Yorkshire, Lancashire, and Cheshire,—counties which have furnished many excellent soldiers. Major-General Cuyler’s appointment was dated the 30th of October, 1793, and the royal warrants for raising recruits were issued on the following day[1] .

1794 the overthrow of that tyrannical power which sprung out of the French revolution, was accomplished.

In February, 1794, the following officers were holding commissions in the regiment:—

Colonel, M-G C C

Lieut.-Colonel, G S.

Major, R. M. D.

Captains. Lieutenants. Ensigns.

T. C. Hardy

W H Digby

Thomas Neilson Willm. Murray

Hugh Houstown Thos Thornhill

Charles Byne W S Curry Thomas Symes

Edward Robinson

Edward Barnes W. C. Williams

Alexander Campbell Thos. Pickering James Burke

Rowland Hill[2] Charles Dod Danl. McNeill

Robert Bell

Geo Middlemore Edward Fox

Chas E Jolley Wm St Clair

Captain-Lieutenant Daniel Gavey

George Cuyler. Wm. Semple

J. C. Tuffnell.

Chaplain, Chas. Austen; Adjutant, Daniel Coleman; Quarter-Master, Richard Jackson; Surgeon, Hugh Dean

From Shrewsbury, the regiment proceeded to Park-gate, where it embarked, in April, for Ireland, and after landing at Cork, marched to Kilkenny.

At this period the newly-raised corps were numbered, and this regiment received the designation of the E-, or S V.

On the 20th of June, 1794, Major-General Cuyler was appointed to the Sixty-ninth Regiment, and was succeeded in the colonelcy of the E-, by Lieutenant-General Russell Manners.

After remaining in Ireland ten weeks, the regiment embarked at Cork, and was held in readiness for active service; but it landed at Frome, in Somersetshire, in September, and proceeded from thence to the Isle of Wight.

The regiment having been brought into a state of discipline and efficiency, was selected to serve on board the fleet as marines; eight officers, and four hundred and fourteen noncommissioned officers and soldiers, embarked in January, 1795, on board the “Prince of Wales,” “Triumph,” “Brunswick,” and “Hector,” line-of-battle ships, and in February, seven officers, and two hundred and seventy-six non-commissioned officers and soldiers, embarked on board the “Prince,” “Saturn,” and “Boyne.” The “Boyne” caught fire at Spithead, and was destroyed, when the grenadier company of the regiment lost its arms, accoutrements, and baggage.

1795

Lieut.-General Russell Manners was removed to the Twenty-sixth Light Dragoons, in March, 1795, and was succeeded by MajorGeneral William Grinfield, from Lieut.-Colonel in the Third Foot Guards.

The head-quarters of the regiment were at Newport, in the Isle of Wight, where they were inspected by His Royal Highness the Duke of York, who expressed his approbation of their appearance; and in October the establishment was augmented to one hundred rank and file per company, its numbers being completed by drafts from the 118th and 121st Regiments; the men of the last-mentioned corps

were then recently liberated from French prison. In December, the regiment was stationed at Portsmouth and Hilsea.

In the beginning of 1796, the establishment was augmented to twelve companies,—the eleventh and twelfth being recruiting companies; and as the ships of war came into port, the officers and soldiers of the E- landed and joined the regiment; they had served in several engagements in which the ships they were embarked in had taken part, during that eventful period. In April, the regiment proceeded to Guildford, and in June it returned to the Isle of Wight.

Meanwhile, Flanders and Holland had embraced the republican principles of France, and the British government resolved to deprive the Dutch of the settlement of the Cape of Good Hope; the E embarked for the Cape, where they landed on the 22nd of September, six days after the Dutch governor had surrendered the colony to the forces under General Sir Alured Clarke.

The regiment was stationed at the Cape of Good Hope during the years 1797 and 1798, and received drafts from the 95th, and other corps. In February, 1799, it embarked for the East Indies, and landed, on the 10th of May, at Madras, upwards of thirteen hundred strong,—a splendid body of men, whose appearance excited much admiration.

The capture of Seringapatam had rendered the services of the regiment at this station unnecessary, and after a month’s repose at Madras, it embarked for Bombay, where it arrived on the 22nd of July, and sent detachments by sea, under Major Bell, and Captain James Richardson, to Tannah and Surat: these detachments returned to Bombay, in December following.

From Bombay, three companies sailed, towards the end of 1800, for Ceylon, in the expectation of taking part in the reduction of the Isle of France[3]; but orders had, in the meantime, arrived for an army from India, to co-operate with a body of troops from Europe, in the expulsion of the French “A E” from Egypt, and the detachment returned, in January, 1801, to

Bombay, where Major-General Baird assumed the command, and the expedition sailed for the Red Sea.

It was originally designed, that the army from India should land at Suez, a city of Egypt, situate at the head of the Red Sea, on the borders of Arabia; and a small squadron under Admiral Blanquett, having on board three companies of the E- (the grenadier, light, and colonel’s companies) under Lieut.-Colonel Lloyd, a detachment of Bombay artillery, a battalion of sepoys, with other detachments, sailed some time before the main body of the expedition, to attack Suez, and interrupt the formation of any establishment there by the French. This small force left Bombay in December 1800, arrived at Mocha in the middle of January 1801, where the fleet remained two days to procure provisions, when it sailed for Jedda, where one of the ships was lost on a bank. The navigation of the Red Sea, from Jedda to Suez, proved particularly difficult and tedious, on account of the want of a sufficient depth of water, the fleet having to anchor daily, and take advantage of the tides. On reaching Suez, the French had evacuated the place in consequence of the arrival of the army from Europe, under General Sir Ralph Abercromby, on the Mediterranean shores of Egypt, and the success of the British arms near Alexandria, where Sir Ralph Abercromby was killed.

The troops landed at Suez, and Lieut.-Colonel Lloyd, in reporting his arrival, solicited permission to cross the Desert and share in the dangers and honours of the army, which was advancing up the Nile, and approaching Cairo, the modern capital of Egypt, which it was expected the French would defend. Lieut.-General Hutchinson acquiesced in Lieut.-Colonel Lloyd’s wishes, and preparations were accordingly made to pass the Desert.

At six o’clock, on the evening of the 6th of June, the three companies of the E- commenced their march, with only three pints of water per man; the distance in a straight line, was only fifty-eight miles; but the Arab Sheiks, furnished for guides by the Vizier, and made responsible for the safe passage of the detachment, represented that a detour of ten or twelve miles would be necessary to prevent the French intercepting the detachment.

After marching two hours over a hard sandy country, Captain Cuyler, Lieutenant Morse, and Lieutenant Goodfellow, were taken so ill as to be unable to proceed. At eleven the troops halted for two hours, then resumed the march until seven in the morning, when they again halted, having performed twenty-six miles of the journey. The day became so intolerably hot, that Lieut.-Colonel Lloyd ordered the tents to be pitched to shelter the men from the sun; but at ten o’clock the guides stated it was necessary to march, as the camels would be so debilitated by the heat, if they rested on the sand, as to require water before they could move again; but if kept in motion they would not be affected in so fatal a degree; adding, if the soldiers slept, the camel drivers might steal the water, which they feared would be found scarcely sufficient. The guides being responsible for the safety of the detachment, Lieut.-Colonel Lloyd acceded to their wishes; the tents were struck at eleven, and the march resumed; the thermometer being at 109. Captain Cuyler soon fainted again, and fell from his horse, and a camel and two men were left to attend him and bring him forward. The men beginning to drop fast in the rear, Lieut.-Colonel Lloyd halted about one o’clock, cut his own baggage from the camels, which example was followed by all the officers, as many men as could be carried were then mounted on the camels, and the whole proceeded. At two o’clock a camseen, or south wind began to blow, the thermometer rose to 116, and afterwards much higher; the officers and soldiers were seized with dreadful sensations:—some were affected with giddiness and loss of sight, and others fell down gasping for breath, and calling for drink. At four o’clock, Lieut.-Colonel Lloyd was forced to halt. The skins had been cracked by the sun, and the water had become of a thick consistence; the men who drank it were seized with vomiting and violent pains. The officers had brought with them some Madeira wine, which they divided among the soldiers; a proportion of spirits were mixed with the remaining water, which was issued to the men, accompanied with the warning, that every drop was in their own possession, half the journey had not been performed, and on their own prudence, in reserving a portion in their canteens, must depend whether or not they should be enabled to accomplish the remainder of the distance.

Between six and seven o’clock the wind ceased; as the sun declined, the air became more temperate, and the detachment being a little refreshed, though still a languor pervaded the whole, the order for marching was given at seven o’clock. Seventeen men, unable to travel, were left on the ground, and camels were left to bring them forward as soon as they could be moved.

During the march several officers and soldiers experienced an extraordinary sensation of seeing horses, camels, and all kinds of animals, moving with rapid transition before them, which false perception their judgment could not correct. At eleven the detachment halted; the night was excessively dark, and the officers and soldiers were so exhausted, that unconquerable sleep seized upon all.

At four o’clock the guides awoke Lieut.-Colonel Lloyd, and the soldiers formed in order of march with difficulty, a heavy dew having fallen upon them, and their limbs being benumbed with cold. The march was, however, resumed; the south wind began to blow at the same hour as on the preceding day, but the men were not affected in the same severe degree; and by strenuous exertions the detachment arrived at the springs of Elhanka, between four and five o’clock in the evening of the same day, when the joy experienced by every one was very great. By eight o’clock all the camels had come up, and the men, who, from giddiness had fallen from their backs, joined during the night. Eight of the seventeen men left behind, joined on the 9th of June, and the other nine perished in the Desert.

No man had partaken of food after quitting Suez, as it would have increased the thirst, and the rations of salt pork were thrown away on the first morning. On arriving at the springs, the soldiers partook of the water with caution; but two officers’ horses having broke loose drank till they died on the spot. During the march of seventy miles, no vegetation, bird, or beast, had been seen.

After halting at the springs of Elhanka until the evening of the 9th of June, the detachment commenced its march in the dark, to prevent being discovered by the enemy, and at eleven o’clock on the following day, it joined the Turkish army, encamped at Chobra, under

the Grand Vizier; the British, under Lieut.-General Hutchinson, being encamped on the other side of the river Nile. The E- pitched their tents with Colonel Stuart’s division, which was with the Vizier’s army; the soldiers had suffered the loss of their uniforms, which had been burnt in consequence of the plague, and they had been forced to abandon their knapsacks on the march; being very fine men, their appearance excited great interest. On the 16th, the three officers left behind on the march, joined; they had returned to Suez, and afterwards passed the Desert with a caravan.

Advancing towards the metropolis of modern Egypt, the army made preparations for investing that extensive fortress; but on the 22nd of June a flag of truce arrived from the French Commandant, General Belliard, who agreed to surrender Cairo, on condition of himself and garrison being sent back to France.

On the surrender of Cairo, the three companies of the E marched into the citadel, which the French had evacuated a few hours previously. On the same day they took possession of Fort Ibrahim.

In the mean time, the other three companies of the regiment which had returned from Ceylon to join the expedition, had been delayed by the difficult navigation of the Red Sea, and had landed at Cosseir, from whence a march of above one hundred and twenty miles had to be performed across the Desert to Kenna on the Nile. This distance was divided into stages, stores were formed at several points, relays of camels were placed to convey water, wells were found, and others digged, and the march was performed by the army with much less suffering than was experienced by the three companies under Lieut.Colonel Lloyd, in the passage of the Desert from Suez to the springs of Elhanka. At the third stage, called Moilah, some soldiers of the E- dug a well at the foot of a hill, under the direction of Captain Middlemore, and found an excellent spring, for which they received the thanks of the commander of the forces.

Arriving on the banks of the Nile, the troops embarked in boats and proceeded down the river to the island of Rhonda, where they encamped, while the forces from Europe were engaged in the siege

of Alexandria At Rhonda the six companies of the E- were united; four companies remaining in India.

In the beginning of September, Alexandria surrendered; Egypt was thus delivered from the power of the French “A E,” and Europe saw the dawn of liberty in the horizon. The E- received, in common with the other corps which served in this enterprise, the approbation of their Sovereign, the thanks of Parliament, and the royal authority to bear on their colours the S, with the word “E,” to commemorate the share taken by the regiment in this splendid achievement.

To perpetuate the remembrance of the services rendered to the Ottoman Empire, the Grand Seignor established an order of knighthood, which he named the order of the C, of which the superior officers of the army and navy were constituted members. The officers of the E-, and other corps, had gold medals presented to them by the Grand Seignor, which they were permitted by King George III., to accept and wear.

The object of the expedition having been accomplished, the E- sailed up the Nile in boats, in order to return to India; they arrived at El Hamed on the 14th of October, and on the 30th proceeded to Gheeza, where they remained several months.

In April of this year, one of the four companies left in India, proceeded from Bombay to Surat, a town situate on the south bank of the river Taptee, in the province of Guzerat; and in November, two companies sailed for Dieu in the same province.

The two companies at Dieu returned to Bombay in February, 1802, and in March they sailed to Cambay, under the command of Captain Richardson, and joined the company from Surat, which had arrived there a short time previously. They encamped at Cambay, with part of the Seventy-fifth, five companies of the Eighty-fourth, a battalion of native infantry, and some artillery, under Colonel Sir William Clarke.

1802

The jealousy of the native chiefs at the accession of territory acquired by the British in India, often produced hostilities, and

circumstances occurred which occasioned a detachment of the E-, under Lieutenant William Purcell Creagh, to take part in an attempt to surprise the hostile fortress of Kareah, one hundred and twenty miles from Cambay, on the night of the 17th of March. The soldiers were advancing to storm the place with the greatest gallantry, when their progress was arrested by a deep ditch, cut through the rock a short time previously, and the Arabs in garrison being numerous and prepared, opened a heavy fire. Lieutenant Creagh was killed by a cannon ball, while in the act of leading the soldiers to the attack; Lieutenant Lovell was also killed, and many officers and soldiers were wounded; soon after day-break the troops were obliged to retire.

In consequence of this repulse, the three companies of the E-, with the other detachments encamped at Cambay, were ordered to advance upon Kareah. The enemy having formed for battle a short distance from the fort, with a numerous force, were routed by the British on the 30th of April; and immediately afterwards the town was captured, also some out-works, in one of which an explosion took place, killing an officer and twenty-five soldiers.

The siege of the fort was commenced; but when the batteries opened their fire, the garrison surrendered. The chief, Mulhar Rao, was sent a prisoner to Bombay. After placing a garrison in the fort, the troops marched for Surat, (170 miles,) where they arrived on the 12th of June, having captured Tarrapore, and other small places, while on the march.

The six companies of the regiment in Egypt remained at Gheeza until May, when they traversed the Desert to Suez, and from thence to “Moses’ Well,” or the “Font of Moses,” on the Arabian side of the Gulf of Suez. While at Gheeza they received two hundred and seven volunteers from the Twentieth, Thirty-fifth, Forty-eighth, and Sixtythird Regiments; Major Henry Torrens joined at that station.

While at Moses’ Well, several soldiers died of the plague, when the men’s clothing, bedding, and tents were burnt, and the six companies embarked for India; no other cases of the plague occurring, the companies landed at Bombay on the 4th of July. In

November, the three companies arrived from the province of Guzerat, and the regiment was once more united at Bombay.

The E- were only permitted to enjoy a short repose at Bombay: the hostile demonstrations of some of the predatory states composing the Mahratta power, rendering it necessary for the British forces to be held in readiness for active operations, and assembled on the verge of the British territory. The Mahratta states were united by a sentiment of interest founded upon their common origin, civil and religious usages, and habits of conquest and depredation; the chiefs acted as independent sovereigns, but nominally acknowledged the supreme authority of the Peishwah. They, however, viewed with jealousy the treaties between the British and the Peishwah, as tending to restrain their predatory habits, and prevent their acquisition of power; and this acknowledged head of the Mahratta states found his independence controlled, and the existence of his government menaced by the violence and ambition of his feudatory chieftains; at the same time he was unable to fulfil his engagements with the British, the safety of whose possessions was endangered. In consequence of these events, connected with other causes, the E- left Bombay in the middle of November, for the province of Guzerat, and landed at Cambay, from whence they marched towards the hostile fortress of Baroda, in the vicinity of which place they encamped, with several other corps, on the 3rd of December. An enemy’s force was assembled to protect the fortress, and on the 18th of December the British advanced, leaving their tents standing, and engaged their opponents. During the fight the garrison made a sally; but the English proved victorious, routing their adversaries with great slaughter, and capturing a pair of Arab colours and many prisoners.

During the night the erection of batteries commenced; on the 21st of December the fire of the artillery was opened, and the flank companies of the E- stormed an outwork, defended by Arabs, who refused quarter, and were nearly all destroyed, very few escaping. In four days the breach was practicable, and the storming parties were ready; but the garrison surrendered. The E- had seven men killed, and twenty-three wounded in these services.

Captain John Grant distinguished himself during the siege, and at the storming of the outwork.

Towards the end of this year, the usurpations of Jeswunt Rao Holkar, one of the Mahratta chiefs, forced the Peishwah to abandon his capital, and to seek British aid, when a treaty was concluded with him; and the refractory chiefs persisting in aggression, hostilities were commenced to reinstate the deposed chieftain.

On the third of February, 1803, three companies of the E-, under Captain James Richardson, were detached, with other forces, the whole commanded by Major Holmes, of the Bombay army, in pursuit of the Mahratta chieftain, Canojee Rao Guickwar, who had taken the field with a considerable force.

1803

While in quest of the enemy, the advance-guard of the Seventyfifth Regiment was suddenly attacked, when emerging from a defile, on the 6th of February, and overpowered, with a loss of many men and a gun. The three companies of the E-, being at the head of the column of march, moved forward, encountered the enemy, and, by a determined charge, routed the hostile forces, chasing them across the bed of a river into the jungle, where they dispersed, leaving their tents, baggage, camels, horses, and the captured gun behind. The regiment lost very few men in this gallant exploit.

On the same day five companies of the regiment, under Captain Cuyler, marched from Baroda to reinforce Major Holmes’ detachment, leaving two companies behind under Captain Grant.

The Chief Canojee was at the head of a considerable force, but he avoided an engagement, which occasioned many harassing marches in endeavouring to come up with him. On the 25th of February, a party of the E- was detached against the fort of Kirrella, which was captured without experiencing serious opposition.

On the 1st of March, when near Copperbund, information was received that Canojee’s force was not far distant; and by

extraordinary exertions, the detachment came up with the hostile bands, which were in full retreat. The Mahratta horse, attached to the British detachment, did not act with spirit; but the E-, though nearly exhausted with the march, made a gallant effort, and encountered the enemy, who was in the act of passing the bed of a river. The adverse bands being nearly all cavalry, and the British nearly all infantry, the enemy escaped with little loss. The E had two men killed; Lieutenant Alexander Grant, and a few men wounded.

The forces of Canojee Rao Guickwar having been, in a great measure, dispersed, the E- were allowed a short period of repose; and these districts were annexed to the British possessions in India.

Operations having commenced for the restoration of the Peishwah, the E- were stationed a short time in Guzerat, where a force was detained to afford security to that valuable and important province, and also a reserve disposable for active operations. The regiment formed part of the disposable force stationed in front of Brodera, the residence of the Guickwar, and to the northward of the Nerbudda river.

In May, the regiment advanced and pitched its tents before the fortress of Keira, belonging to one of Doulat Rao Scindia’s chiefs, where some native infantry and battering guns also arrived; but the garrison surrendered without waiting for a breach having been made in the works.

From Keira the regiment marched to Nerriade, where it was joined by two companies left at Baroda under Captain Grant; but the rains setting in, the operations were suspended.

Information having been received that a body of the enemy was levying contributions about thirty miles from the quarters of the regiment, Captain Grant performed a forced march with four companies and some sepoys, and making a night attack with great success, killed and took prisoners many of the enemy, and captured some horses, &c. Lieutenant Procter and a few men of the regiment were wounded on this occasion.

A body of Canojee’s troops threatening to cross the river about fifteen miles above Baroach, and plunder the country, four hundred rank and file of the regiment, with a battalion of sepoys, and four guns, under Captain James Richardson, advanced, on the 14th of July, during the heavy rains, in search of the enemy. The gunbullocks failed, and the country being inundated by the rains, the soldiers had to drag the guns, up to their waists in water; but by extraordinary efforts they arrived at the bank of the river on the 16th of July, and attacking a number of Canojee’s troops which had crossed the stream, routed them, and forced them into the water, where many lost their lives, the river being full and rapid.

The river having fallen considerably during the night, the soldiers passed the stream on the following day, under cover of the fire of the guns, and assaulting the breast-works of the main body of Canojee’s legions, carried them at the point of the bayonet, and pursued the routed enemy two miles with great slaughter. A body of Arabs disdaining to seek their safety in flight, fought with great desperation until overpowered.

Captain Richardson and Lieutenant Lanphier distinguished themselves on this occasion; and the enterprise being accomplished with the loss of a few men killed and wounded, the troops returned to Baroda.

In pursuance of the plan suggested to the Governor-General by Major-General Hon. Arthur Wellesley, five hundred men of the E-, a small detachment of the Sixty-fifth, a proportion of European artillery, and a battalion of Sepoys, advanced, under Lieut.-Colonel Woodington, to besiege the strong fortress of Baroach. On the 23rd of August, this small body of troops encamped on the bank of the river within a few miles of the fortress, expecting the arrival of the battering train in boats. The baggage of the regiment was this day attacked by a numerous body of the enemy’s horse, when nearly every soldier and follower was killed or wounded, and the baggage captured and plundered.

A schooner and gun-boat having arrived with cannon and ammunition, the troops advanced on the 25th of August, and arriving

within two miles of the fortress, discovered a numerous body of hostile cavalry, infantry, and Arabs, in order of battle on the plain. These opponents were speedily routed with the loss of their flag and a number of killed and wounded; and the armament soon afterwards attacked, and carried, the pettah with great gallantry; Ensign D’Aguilar distinguished himself on this occasion.

The siege of the fort was commenced, and a breach was reported practicable; at one o’clock on the 29th of August, the storming parties assembled in the streets under the command of Major Cuyler; the bayonets were firmly fixed by the introduction of a piece of cotton cloth, to prevent the Arab swordsmen disengaging them, and the soldiers proceeded quietly to their post behind the battery. At three the signal to attack was fired, and the forlorn hope, consisting of Serjeant John Moore and twelve soldiers of the E-, sprang forward; a hundred soldiers of the E-, and a hundred Sepoy grenadiers, under Captain Richardson, rushed towards the breach, followed by three hundred men under Major Cuyler, and a reserve of two hundred under Captain Bethune.

Passing the ditch knee-deep in mud, and climbing the long steep and difficult ascent to the breach, the soldiers encountered the Arab and Scindian defenders, who made a desperate resistance. Hand to hand the combatants strove for mastery, and amidst the clash of steel and turmoil of deadly contest, many feats of valour were performed. Captain Maclaurin, who evinced great ardour, was wounded and made prisoner, but he was rescued from the Arabs, by Private John Brierly. Captain Richardson and Captain Grant signalized themselves, and Serjeant Bills was conspicuous for the heroic courage with which he fought. At length British valour proved triumphant, and the breach was won, when the E- crowned the rampart, the Scindian colours were pulled down, and the British standard planted in their place, by Serjeant Moore.

Having overpowered all resistance at the breach, Captain Richardson’s party swept the works to the Cuttoopore gate; Major Cuyler led his detachment at a running pace to the Jaraseer gate, and firing upon the Scindians and Arabs who were escaping by that avenue, wounded one of the elephants in the passage. The Arabs

threw down their matchlocks, drew their creesis, and rushing upon their assailants with deadly fury, refused to give or receive quarter. The contest was of short duration; British discipline and prowess were again victorious; two hundred Arab horsemen and foot lay on the ground, and the E- stood triumphant on the scene of conflict. Among the trophies of the day, were fifteen stand of Scindian and Arab colours, which were sent to head-quarters, excepting two, retained by the E- regiment, as trophies of the valour displayed by the corps on this occasion.

Thus was captured a fortress of great importance to the commercial interests of Britain, with a territory yielding a considerable revenue, which were added to the British dominions. In his public despatch, Lieut.-Colonel Woodington highly commended the conduct of Major Cuyler and Captain Richardson, and added, —“The whole of the officers and men employed on this service have conducted themselves so much to my satisfaction, that I cannot express myself too strongly in their commendation.”

The Governor-General in Council, also, signified in general orders, —“his particular approbation of the valour and judgment manifested by Major Cuyler, of His Majesty’s E- regiment, throughout the service at Baroach, and in commanding the storm of the fort, and by Captain Richardson of the same corps, leading the assault. His Excellency in Council, also, observes with particular satisfaction the conduct of Captain Cliffe, of the Engineers of Bombay. To all the officers and troops, European and Native, employed on this honorable occasion, His Excellency in Council signifies his high commendation.”

Serjeant Bills was rewarded with the appointment of serjeantmajor; Serjeant Moore received a donation of five hundred rupees from the Government for his gallantry, and Private Brierly was promoted corporal, and afterwards serjeant.

The loss of the regiment was Captain William Semple, killed in the breaching battery on the 25th of August—an excellent officer, whose fall was much regretted; also two serjeants and ten rank and file

killed; Major Cuyler, Captain Richardson, Captain Maclaurin, and twenty-three rank and file wounded.

From Baroach the regiment proceeded to Baroda, from whence five hundred rank and file of the E-, a battalion of Sepoys, some irregular horse, and a battering train, marched to attack the fort of Powanghur, situated on a stupendous rock of extraordinary height and of difficult ascent. Arriving before this place on the 14th of September, and the garrison refusing to surrender, the walls were battered until the 17th, when orders were issued to prepare to attack the lower fort by storm. The garrison was intimidated by the knowledge of the fact, that if they defended the breach, their communication with the fort on the top of the mountain would be cut off, and their escape rendered impossible; they therefore surrendered. Thus a fort of great strength by nature and art fell into the hands of the British.

The district of Champaneer, the only territory remaining to Scindia, in the province of Guzerat, had thus been reduced, and annexed to the British dominions. Lieut.-Colonel Murray, of the Eighty-fourth regiment, assumed the command of the troops at Baroda, and advanced towards Scindia’s territories, in the province of Malwa, in quest of Holkar’s forces, but it was found impossible to bring the armed bands of that chieftain to action. On the 18th of October the city and fortress of Godera was taken possession of, the enemy retiring as the British approached. At this place information was received of the victory of Assaye, gained by the troops under MajorGeneral the Hon. Arthur Wellesley, on the 23rd of September, which was followed by the submission of two of the hostile chiefs, Scindia and the Rajah of Berar, leaving Holkar, Canojee, and some minor chiefs in the field.

Leaving Godera, the troops took possession of Balinsanere in the beginning of November; and advanced towards Lunawarrah. On the march, the rearguard, consisting of five companies of Sepoys, and some native cavalry, was suddenly attacked, while passing through an extensive jungle, by a numerous body of the enemy in ambush.

The hostile bands did not venture to attack the Europeans of the advance-guard, nor the column, but rushed with great fury upon the native troops in the rear, occasioning the loss of many Sepoys and camp followers, with some baggage, before assistance could arrive from the column. The E- had several men killed and wounded on this occasion.

Lunawarrah was evacuated by the enemy, and Dhowd was taken, about six weeks afterwards, with little opposition.

In this part of the country, the E-, and other corps, with Lieut.-Colonel Murray, remained about two months[4] , watching Holkar, who had power to concentrate an overwhelming force, which rendered vigilance particularly necessary.

On the death of Lieut.-General Grinfield, King George III. conferred the colonelcy of the regiment on Lieut.-General Sir James Henry Craig, K.B., from the Forty-sixth Foot, by commission dated the 5th of January, 1804.

1804

From Dhowd, the E-, and other corps under Lieut.Colonel Murray, retired to Godera, and from thence to Jerode, in order to obtain supplies, and protect the province of Guzerat. At this period a dreadful famine raged in the Deccan, and other parts of the country hitherto the seat of war.

After three weeks’ repose at Jerode, the E-, Sixty-fifth, Sepoys and native cavalry, advanced once more into the province of Malwa, under Lieut.-Colonel Murray, and arrived at Dhowd on the 12th of June, having lost many men from the excessive heat. On the march Major Stuart, of the Sixty-fifth, died and was buried, (9th June,) under the colours of the E-, on which day twentyone men of the Sixty-fifth, and eleven of the E-, died from the effects of the hot winds.

From Dhowd, the troops advanced to Ongein, the capital of Scindia, from whence the E-, three battalions of Sepoys, a train of artillery, and a body of Scindia’s cavalry, were immediately pushed on to Indore, the capital of Holkar’s dominions, where they

arrived on the 14th of August; the city having been evacuated on the previous evening.

From Indore, the flank companies of the regiment, and a battalion of Sepoys, advanced with scaling ladders, under Captain Richardson, twenty miles, to surprise a fort, which was reported to be full of troops and provisions; but when the soldiers scaled the walls, they found the place empty; the enemy having fled a few hours previously.

Having penetrated so far beyond the boundaries of Guzerat, the troops under Lieut.-Colonel Murray found their communication with that country cut off, and Holkar threatening to enter and lay waste the province; their supplies were nearly exhausted; they were in a territory devastated by famine and disease; the rainy season was approaching, and a small force, under Lieut.-Colonel Monson, sent by General Lord Lake to effect a junction with Lieut.-Col. Murray, was pursued by Holkar’s numerous legions, and forced to make a precipitate flight, abandoning its cannon and baggage. Under these circumstances, a sudden advance was made, of two marches, to deceive the enemy, and on the third march the troops faced about and retreated. The rain set in with such violence as to destroy the tents;—the artillery and baggage oxen and camels died in great numbers;—much of the baggage was abandoned;—the soldiers had to drag the guns through the cotton-grounds waist-deep in water;— no cover or shelter for officers or soldiers;—the inhabitants dying in great numbers from famine;—the European soldiers dying also from excessive fatigue, the inclemency of the weather and privation;—the native troops and followers also perishing in great numbers: such were the distressing circumstances under which this retrograde movement was executed, but, by the perseverance of the Europeans, the guns were preserved, and the troops arrived at Ongein, where the Sixty-fifth, E-, and artillery, were accommodated with a building in the fort. This force had been reduced by its sufferings, from six to three thousand men.

Exertions were made to re-equip this diminished force for the field, and orders being received to advance, it was again in motion in the middle of October, advancing in the direction of Kota and

Rhampoorae, and capturing, on the route, the hill fort of Inglehur by escalade, also several other small forts.

The army of Holkar was routed and dispersed by the troops under General Lord Lake; but the war was protracted by the defection of the Rajah of Bhurtpore, and the E- were destined to transfer their services to the rajah’s dominions.

Reinforcements having arrived from Bombay, Major-General Jones assumed the command, and marched towards the city of Bhurtpore, the capital of the hostile rajah’s territory[5] After a long and harassing march, the troops approached that fortress on the 10th of February, 1805, when a large body of hostile horsemen surrounded the column and impeded its movements across a level country. Half the force was employed in protecting the baggage, and the guns were repeatedly unlimbered, to keep the adverse cavalry at a distance. On the following day, Major-General Jones’s division joined the army before Bhurtpore, and was inspected by Lord Lake, who expressed his satisfaction at the bearing of the troops. The soldiers of the Sixty-fifth and E- presented a motley appearance: their worn-out uniforms were patched with various colours, or replaced by red cotton jackets; many of the men wore sandals in the place of shoes, and turbans instead of hats; but beneath this outward war-worn appearance, the innate courage of Britons still glowed.

1805

The siege of Bhurtpore had unfortunately been undertaken without a battering train of sufficient weight, and necessary to insure the reduction of so strong a fortress; the siege was, however, persevered in. At three o’clock, on the 20th of February, two hundred and fifty men of the E-, and two companies of Sepoys, commanded by Captain Grant, of the E-, stormed an outwork, covering one of the principal gates, with the bayonet, driving the Arabs, who fought with their usual determination, into the city, and capturing eleven brass guns; in which service Lieutenants Lanphier and D’Aguilar distinguished themselves, the former receiving a spear wound in the neck. As the Arabs fled to the gate, Captain Grant followed, in the hope of being able to enter with them, but he found it closed, and, after destroying the fugitives, who were

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