Costs and cost-minimisation analysis.

Whatever kind of economic evaluation you plan to undertake, the costs must be assessed. In health care these are first of all divided into costs borne by the NHS (like drugs), by patients and their families (like travel), and by the rest of society (like health education). Next the costs have to be valued in monetary terms; direct costs, like wages, pose little problem, but indirect costs (like time spent in hospital) have to have values imputed to them. And that is not all: costs must be further subdivided into average, marginal, and joint costs, which help decisions on how much of a service should be provided. Capital costs (investments in plant, buildings, and machinery) are also important, as are discounting and inflation. In this second article in the series Ray Robinson defines the types of costs, their measurement, and how they should be valued in monetary terms.     

Equity in the NHS. Monitoring and promoting equity in primary and secondary care.

Although need is often assumed to be the most important factor in determining the use of health services, there are many inequities in the provision and use of NHS services in both primary and secondary care. For example, existing data from district child health information services have been combined with census data for small areas to show wide variations in immunisation rates between affluent and deprived areas. Purchasers of health care are already responsible for assessing health needs and evaluating services, and the process of monitoring equity is a logical extension of these activities. Routine data sources used to collect activity data in both primary and secondary care can be used to assess needs for care and monitor how well these needs are met. Purchasers and providers should collaborate to improve the usefulness of these routine data and to develop a framework for monitoring and promoting equity more systematically.     

Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente

ObjectiveTo compare the costs and performance of the NHS with those of an integrated system for financing and delivery health services (Kaiser Permanente) in California.MethodsThe adjusted costs of the two systems and their performance were compared with respect to inputs, use, access to services, responsiveness, and limited quality indicators.ResultsThe per capita costs of the two systems, adjusted for differences in benefits, special activities, population characteristics, and the cost environment, were similar to within 10%. Some aspects of performance differed. In particular, Kaiser members experience more comprehensive and convenient primary care services and much more rapid access to specialist services and hospital admissions. Age adjusted rates of use of acute hospital services in Kaiser were one third of those in the NHS.ConclusionsThe widely held beliefs that the NHS is efficient and that poor performance in certain areas is largely explained by underinvestment are not supported by this analysis. Kaiser achieved better performance at roughly the same cost as the NHS because of integration throughout the system, efficient management of hospital use, the benefits of competition, and greater investment in information technology.

What is already known on this topic

Comparisons of healthcare systems in different countries have to be undertaken with great care but can be instructiveThe overall healthcare system in the United States is more expensive than the NHS and population health outcomes are no betterThe US healthcare system comprises many discrete and unique subsystems, including the health maintenance organisations

What this paper adds

An integrated, non-profit health maintenance organisation in California (Kaiser Permanente), with over six million members, costs about the same as the NHS but performs considerably betterKaiser''s superior performance is mainly in prompt and appropriate diagnosis and treatmentThese findings challenge the widely held view that the NHS is efficient and that its inadequacies are mainly due to underinvestment     

Career pathways and destinations 18 years on among doctors who qualified in the United Kingdom in 1977: postal questionnaire survey

ObjectiveTo determine the career destinations, by 1995, of doctors who qualified in the United Kingdom in 1977; the relation between their destinations and early career choice; and their intentions regarding retirement age.DesignPostal questionnaire.SettingUnited Kingdom.SubjectsAll (n=3135) medical qualifiers of 1977.ResultsAfter about 12 years the distribution of respondents by type of employment, and, for women, the percentage of doctors in part time rather than full time medical work, had stabilised. Of all 2997 qualifiers from medical schools in Great Britain, 2399 (80.0% (95% confidence interval 79.5% to 80.6%)) were working in medicine in the NHS in Great Britain 18 years after qualifying. Almost half the women (318/656) worked in the NHS part time. Of 1714 doctors in the NHS, 1125 intended to work in the NHS until normal retirement age, 392 did not, and 197 were undecided. Of the 1548 doctors for whom we had sufficient information, career destinations at 18 years matched the choices made at 1, 3, and 5 years in 58.9% (912), 78.2% (1211), and 86.6% (1341) of cases respectively.ConclusionsPlanning for the medical workforce needs to be supported by information about doctors’ career plans, destinations, and whole time equivalent years of work. Postgraduate training needs to take account of doctors’ eventual choice of specialty (and the timing of this choice).

Key messages

• A large scale national study in the United Kingdom followed doctors from qualification to mid-career and beyond
• Most doctors had made their choice of eventual career—at least in terms of broadly defined specialty—within 5 years of qualifying
• Eighteen years on, 80% of the doctors were working in the NHS and nearly half of women doctors were working part time
• Almost a quarter of NHS doctors planned to retire early

     

Connexin channel permeability to cytoplasmic molecules

Connexin channels are known to be permeable to a variety of cytoplasmic molecules. The first observation of second messenger junctional permeability, made approximately 30 years ago, sparked broad interest in gap junction channels as mediators of intercellular molecular signaling. Since then, much has been learned about the diversity of connexin channels with regard to isoform diversity, tissue and developmental distribution, modes of channel regulation, assembly, expression, biochemical modification and permeability, all of which appear to be dynamically regulated. This information has expanded the potential roles of connexin channels in development, physiology and disease, and made their elucidation much more complex--30 years ago such an orchestra of junctional dynamics was unanticipated. Only recently, however, have investigators been able to directly address, in this more complex framework, the key issue: what specific biological molecules, second messengers and others, are able to permeate the various types of connexin channels, and how well? An important related issue, given the ever-growing list of connexin-related pathologies, is how these permeabilities are altered by disease-causing connexin mutations. Together, many studies show that a variety of cytoplasmic molecules can permeate the different types of connexin channels. A few studies reveal differences in permeation by different molecules through a particular type of connexin channel, and differences in permeation by a particular molecule through different types of connexin channels. This article describes and evaluates the various methods used to obtain these data, presents an annotated compilation of the results, and discusses the findings in the context of what can be inferred about mechanism of selectivity and potential relevance to signaling. The data strongly suggest that highly specific interactions take place between connexin pores and specific biological molecular permeants, and that those interactions determine which cytoplasmic molecules can permeate and how well. At this time, the nature of those interactions is unclear. One hopes that with more detailed permeability and structural information, the specific molecular mechanisms of the selectivity can be elucidated.     

Conducting clinical research in the new NHS: the model of cancer. United Kingdom Coordinating Committee on Cancer Research.

The United Kingdom Coordinating Committee on Cancer Research represents the major organizations funding cancer research in the United Kingdom. The deliberations of a working party convened by the committee to evaluate recently expressed concerns that the changes in the NHS threaten research, especially clinical trials to evaluate new treatments, are reported. A survey of contributors to trials coordinated by the committee showed that half are now experiencing difficulties in continuing to participate in clinical trials. The two major problems identified were lack of time and of staff, especially for NHS staff in non-teaching hospitals. Recent changes in junior doctors'' hours and proposed reductions in the length of time for training will exacerbate this. It is possible to identify the direct and indirect excess costs of conducting research in the NHS, but currently the mechanism does not exist to designate funds specifically for this purpose. Consultation with the regional directors of research and development confirmed that the service increment for teaching and research is not the solution for this. Proposals are made to secure future clinical research in the NHS, including finance, indemnity, the licensing of new drugs, the greater use of nurse counsellors, and the value of cancer registries.     

Age structure: an indicator to monitor populations of large herbivores

Most populations of large herbivores are hunted over much of their distribution. The size of these populations over time must be monitored to detect responses to management actions and environmental changes. Here, I first review the limits in precision and accuracy of most methods used to estimate population size in wild herbivores. I then show how density-dependence of age structure can be used to monitor harvested populations, using simulated and empirical data. Accurate estimates of population size are difficult, costly in time and effort, and mostly impracticable at a large scale. Indices are widely used to monitor population size at a large scale, but are rarely tested, and assumptions of constant detection rates over years are questionable. In a recent approach, the effects of population density on habitat quality and individual performance were used as ecological indicators to infer changes in population size over time. Populations of large mammals are strongly age structured. In harvested populations, density-dependence and harvest affect age structure through changes in age-specific vital rates. Because age- and sex-specific vital rates are density-dependent, changes over time in age structure should reflect the response of population to changes in environmental conditions such as density and harvest rate. Time series of age-structure may be used as an ecological indicator to monitor harvested populations, and to infer their demographic trajectory, especially when used within a set of ecological indicators. However, attention needs to be paid in the use of ecological indicators because of the potential bias introduced in data collection by hunter selectivity.     

On the fraction of habitat allocated to marine reserves

The case for marine reserves is strengthening, and both deterministic and stochastic calculations show that fisheries management using reserves may achieve harvests comparable with management without reserves. Thus, depending upon the metric used, reserves need not disadvantage harvest. Reserves provide a buffer that increases the chances of sustainability of the stock, and thus the fishery. In this paper, I develop methods (deterministic and stochastic) that allow one to determine how much habitat needs to be set aside as reserve, once societal decisions concerning the goals of reserves are made. The answer to the question: "how much habitat needs to be allocated to reserves" is not a simple single number. Rather, it is a procedure that can be employed once biological, operational and social information are provided. The methods also apply to reserves used to aid stock recovery.     

Commentary: educational initiatives deserve randomised controlled trials.

The media have been full of reports of crisis in the NHS. Although national analyses suggest that the NHS should be able to cope within the increases in spending it has been given, local pressures can leave parts of the service struggling. Firstly, the change to allocation of funds on the basis of population needs has meant that some authorities and trusts have had effective cuts in their budgets, requiring them to trim services. Secondly, the government''s insistence on an annual 3% increase in efficiency may have resulted in authorities taking short term measures that actually decrease efficiency in the long term. Thirdly, health authorities have had to bear the costs of national targets such as reducing waiting lists and junior doctors'' hours as well as local problems such as higher numbers of mentally disordered offenders. However, all these factors can be controlled by national or local management and so their impact is not inevitable.     

Appointment systems: feasibility study of a new approach.

Patients in a semirural dispensing practice were asked to determine how much time they required when booking an appointment. A comparison was made between their estimates and the actual time taken. Patients'' estimates proved sufficiently accurate to produce a system that worked well.     

The rationing agenda in the NHS. Rationing Agenda Group.

The Rationing Agenda Group has been founded to deepen the British debate on rationing health care. It believes that rationing in health care is inevitable and that the public must be involved in the debate about issues relating to rationing. The group comprises people from all parts of health care, none of whom represent either their group or their institutions. RAG has begun by producing this document, which attempts to set an agenda of all the issues that need to be considered when debating the rationing of health care. We hope for responses to the document. The next stage will be to incorporate the responses into the agenda. Then RAG will divide the agenda into manageable chunks and commission expert, detailed commentaries. From this material a final paper will be published and used to prompt public debate. This stage should be reached early in 1997. While these papers are being prepared RAG is developing ways to involve the public in the debate and evaluate the whole process. We present as neutrally as possible all the issues related to rationing and priority setting in the NHS. We focus on the NHS for two reasons. Firstly, for those of us resident in the United Kingdom the NHS is the health care system with which we are most familiar and most concerned. Secondly, focusing on one system alone allows more coherent analysis than would be possible if issues in other systems were included as well. Our concern is with the delivery of health care, not its finance, though we discuss the possible effects of changing the financing system of the NHS. Finally, though our position is neutral, we hold two substantive views--namely, that rationing is unavoidable and that there should be more explicit debate about the principles and issues concerned. We consider the issues under four headings: preliminaries, ethics, democracy, and empirical questions. Preliminaries deal with the semantics of rationing, whether rationing is necessary, and with the range of services to which rationing relates. Under ethics and democracy are the substantive issues of principle and theory. The final section deals with empirical questions and those relating to the practicality of various strategies.     

Regulation of the cutaneous circulation

In this symposium, a diversity of perspectives was focused on how blood flow to the skin is controlled. Thus, control of the cutaneous circulation by reflexes aimed at body temperature regulation, blood pressure regulation, and the reflexes attending muscular exercise was discussed in detail, as were the similarities and differences between control of cutaneous arterioles and arteriovenous anastomoses. A mechanistic treatment of interaction between adrenergic control of cutaneous blood vessels and their temperature brought physical factors and pharmacological approaches to the consideration of reflex control. Finally, the more slowly developing changes in the control of the skin circulation that accompany circadian rhythms, changes in blood volume or its distribution, physical training, and acclimatization were discussed. Because the cutaneous circulation has potentially large vascular conductance, blood flow, and blood volume, control of the resistance and compliance vessels within the skin has an importance well beyond that of tissue nutrition. Indeed, overall hemodynamics are dependent on how much blood flow and how much blood volume are distributed to skin. Consequently, reflex factors, physical factors, and their interaction all have roles of importance with respect to exchange of heat with environment as well as maintenance of blood pressure, cardiac output, and blood flow to other tissues.     

Biological constraints in algal biotechnology

In the past decade, considerable progress has been made in developing the appropriate biotechnology for microalgal mass cultivation aimed at establishing a new agro-industry. This review points out the main biological constraints affecting algal biotechnology outdoors and the requirements for making this biotechnology economically viable. One of them is the availability of a wide variety of algal species and improved strains that favorably respond to varying environmental conditions existing outdoors. It is thus just a matter of time and effort before a new methodology like genetic engineering can and will be applied in this field as well. The study of stress physiology and adaptation of microalgae has also an important application in further development of the biotechnology for mass culturing of microalgae. In outdoor cultures, cells are exposed to severe changes in light and temperature much faster than the time scale required for the cells to acclimate. A better understanding of those parameters and the ability to rapidly monitor those conditions will provide the growers with a better knowledge on how to optimize growth and productivity. Induction of accumulation of high value products is associated with stress conditions. Understanding the physiological response may help in providing a better production system for the desired product and, at a later stage, give an insight of the potential for genetic modification of desired strains. The potential use of microalgae as part of a biological system for bioremediation/detoxification and wastewater treatment is also associated with growing the cells under stress conditions. Important developments in monitoring and feedback control of the culture behavior through application of on-line chlorophyll fluorescence technique are in progress. Understanding the process associated with those unique environmental conditions may help in choosing the right culture conditions as well as selecting strains in order to improve the efficiency of the biological process.     

Managing the Myth of Ecotourism: A Queensland Case Study

Although social anthropologists are taking an increased interest in tourism in Australia, not much attention has been paid thus far to the sites from which visitors take off into the bush, wilderness or nature. Tourist resorts and lodges are not simply the locations in which basic needs are met before more energetic activities begin. Especially in ecotourist settings, important ideological claims are made about their built environments as well as the everyday practices and localised activities which are ongoing in these discursive sites. This paper provides an ethnographic analysis of one such ecotourist resort. It aims to detail the myths which are manufactured about its relation to the island environment in which it is situated, and to the world beyond.     

CHINA AS A CENTER FOR EARLY ANIMAL DOMESTICATION

The paleontological as well as the archeological record in China is unique in that there is adequate evidence of hominid association with most of the animals that we know today as domesticates beginning at very early dates. During the last few years advances have been made with studies of the dog, horse, camel,water buffalo, cattle,yak,sheep, goat, pig, and chicken in China. One drawback is that by the time most domestic animals can be dated by recorded history they are quite advanced as domesticates and are quite similar osteologicaly to their modern counterparts.     

What value do computers provide to NHS hospitals?

As the NHS spends around pond 220 million a year on information technology for use by acute hospitals that are hard pressed for resources, it is reasonable to ask what value is provided. A review of rigorous scientific evidence for the value of information technology to NHS hospitals found that published evidence is scarce and far from conclusive. Information technology in NHS hospitals needs further assessment so that future decisions on such necessary and important investments are based on clear, well documented experience and research.     

Discretizing the cellular bases of plant morphogenesis: Emerging properties from subcellular and noisy patterning

A fundamental question in biology is how multicellular organisms robustly shape their organs. In the past decade, much progress has been made not just in identifying biochemical and biophysical factors underpinning morphogenesis, but also in analyzing their spatio-temporal dynamics. A remarkable outcome of such analyses is that morphogenesis involves high levels of heterogeneity and fluctuations at local scales. Although this could be considered as white noise to be averaged over time, there is increasing evidence that these heterogeneities and fluctuations are instructive cues for development. In this review, we highlight some of the new questions that such heterogeneities raise for plant morphogenesis. We also investigate their effects across scales, focusing on how subcellular heterogeneities contribute to organ shape robustness and evolvability.     

Nutrient control of neural stem cells

The physiological status of an organism is able to influence stem cell behaviour to ensure that stem cells meet the needs of the organism during growth, and in response to injury and environmental changes. In particular, the brain is sensitive to metabolic fluctuations. Here we discuss how nutritional status is able to regulate systemic and local insulin/IGF signalling so as to control aspects of neural stem behaviour. Recent results have begun to reveal how systemic signals are relayed to neural stem cells through local interactions with a glial niche. Although much still remains to be discovered, emerging parallels between the regulation of Drosophila and mammalian stem cells suggest a conserved mechanism for how the brain responds to changes in nutritional state.