Spatial aspects of MRSA epidemiology:A case study using stochastic simulation, kernel estimation and SaTScan

The identification of disease clusters in space or space-time is of vital importance for public health policy and action. In the case of methicillin-resistant Staphylococcus aureus (MRSA), it is particularly important to distinguish between community and health care-associated infections, and to identify reservoirs of infection. 832 cases of MRSA in the West Midlands (UK) were tested for clustering and evidence of community transmission, after being geo-located to the centroids of UK unit postcodes (postal areas roughly equivalent to Zip+4 zip code areas). An age-stratified analysis was also carried out at the coarser spatial resolution of UK Census Output Areas. Stochastic simulation and kernel density estimation were combined to identify significant local clusters of MRSA (p<0.025), which were supported by SaTScan spatial and spatio-temporal scan. In order to investigate local sampling effort, a spatial 'random labelling' approach was used, with MRSA as cases and MSSA (methicillin-sensitive S. aureus) as controls. Heavy sampling in general was a response to MRSA outbreaks, which in turn appeared to be associated with medical care environments. The significance of clusters identified by kernel estimation was independently supported by information on the locations and client groups of nursing homes, and by preliminary molecular typing of isolates. In the absence of occupational/ lifestyle data on patients, the assumption was made that an individual's location and consequent risk is adequately represented by their residential postcode. The problems of this assumption are discussed, with recommendations for future data collection.

Cost-based pricing in the NHS internal market : accounting choices and the achievement of economic efficiency

Since 1988, quasi-markets have been introduced into many areas of social policy in the UK, the NHS internal market is one example. Markets operate by price signals. The NHS Internal Market, if it is to operate efficiently, requires purchasers and providers to respond to price signals. The research hypothesis is - cost accounting methods can be developed to enable healthcare contracts to be priced on a cost-basis in a manner which will facilitate the achievement of economic efficiency in the NHS internal market. Surveys of hospitals in 1991 and 1994 established the cost methods adopted in deriving the prices for healthcare contracts in the first year of the market and three years on. An in-depth view of the costing for pricing process was gained through case studies. Hospitals had inadequate cost information on which to price healthcare contracts at the inception of the internal market: prices did not reflect the relative performance of healthcare providers sufficiently closely to enable the market's espoused efficiency aims to be achieved. Price variations were often due to differing costing approaches rather than efficiency. Furthermore, price comparisons were often meaningless because of inadequate definition of the services (products). In April 1993, the NHS Executive issued guidance on costing for contracting to all NHS providers in an attempt to improve the validity of price comparisons between alternative providers. The case studies and the 1994 survey show that although price comparison has improved, considerable problems remain. Consistency is not assured, and the problem of adequate product definition is still to be solved. Moreover, the case studies clearly highlight the mismatch of rigid, full-cost pricing rules with both the financial management considerations at local level and the emerging internal market(s). Incentives exist to cost-shift, and healthcare prices can easily be manipulated. In the search for a new health policy paradigm to replace traditional bureaucratic provision, cost-based pricing cannot be used to ensure a more efficient allocation of healthcare resources.

Influences on general practitioner prescribing with particular reference to community pharmacy

Influences on general practitioner prescribing of drugs continue to be of interest and importance as cost containment becomes central to Government health policy. This thesis employs a plurality of research methods including quantitative and qualitative survey techniques for example, questionnaires, interviews and prescription analyses to investigate some of the factors which may influence GP prescribing such as information sources, hospital consultants and in particular the community pharmacist. When the use and influence of drug information sources by GPs was examined, the community pharmacist was given a relatively low rating as a source but a high rating, similar to that of the consultant, for helpfulness. Influences are needed to improve prescribing and reduce the incidence of iatrogenic disease for the benefit of the patient. The education and expertise of pharmacists and their familiarity with local prescribing habits places them in a unique position to meet the needs of local GPs. As 96.5% of the public always or nearly always take their prescriptions to the same pharmacy, patient medication records, now kept by 77.5% of pharmacies, provide a valuable check on the appropriateness and safety of patients' medication. The barriers to the pharmacist's greater involvement were shown to be suspicion by GPs of pharmacists' motivation, isolation of many community pharmacists, difficulties in leaving the pharmacy for domiciliary visits, residential home care and GP practice meetings. These barriers must be lowered if the pharmacist is to have a greater influence and involvement. It was concluded that changes are necessary in pharmaceutical education, staff training, organisation and remuneration. Some changes in the targeting of remuneration to the pharmaceutical care services provided and registration of patients with pharmacies would contribute greatly to these aims.

Strategies for agricultural change and the UK balance of payments

The world food crisis, Britain's reliance on imported food and feedstuffs and balance of payments difficulties were some of the factors which lent weight to the call for increased self-sufficiency in Britain's agriculture in the 1970s. This project considers two main areas: an investigation of the impact of radical agricultural change, designed to increase self-sufficiency, on the balance of payments; and, an appraisal of the potential role of the food industry within a radically different food system. The study proceeded by: an examination of the principles of agricultural policy and its development in Britain; an overview of the mechanism and meaning of the balance of payments; a consideration of the debate on agricultural import saving; the construction of radical agricultural strategies; the estimation of effects of the strategies, particularly to the balance of. payments; the role of the food industry and possible innovations within the strategies; a case study of textured vegetable proteins; and, the wider implications of implementation of radical agricultural alternatives. Two strategies were considered: a vegan system, involving no livestock; and, an intermediate system, including some livestock and dairy cattle. The study concludes that although agricultural change could in principle make a contribution to the balance of payments, implementation of agricultural change cannot be justified for this purpose alone. First, balance of payments problems can be solved by more appropriate methods. Second, the UK' s balance of payments problem has disappeared for the time being owing to North Sea oil and economic recession. Third, the political and social consequences of the changes investigated would be unacceptable. Progress in UK food policy is likely to be in the form of an integrated food and health policy.

Medication -related adverse events in older people with dementia:causes and possible solutions

This submission for a PhD by previously published work is based upon six publications in peer reviewed journals, reflecting a 9-year research programme. My research has shown, in a coherent and original way, the difficulty in treating people with dementia with safe and effective medication whilst providing research-founded guidance to develop mechanisms to optimise medication choice and minimise iatrogenic events. A wide range of methods, including systematic reviews, meta-analysis, randomised controlled trials (RCTs), quantitative research and mixed methods were used to generate the data, which supported the exploration of three themes. The first theme, to understand the incidence and causes of medication errors in dementia services, identified that people with dementia may be more susceptible to medication-related iatrogenic disease partly due to inherent disease-related characteristics. One particular area of concern is the use of anti-psychotics to treat the Behavioural and Psychological Symptoms of Dementia (BPSD). The second and third themes, respectively, investigated a novel pharmacological and health services intervention to limit anti-psychotic usage. The second phase found that whilst the glutamate receptor blocker memantine showed some promise, further research was clearly required. The third phase found that anti-psychotic usage in dementia may be higher than official figures suggest and that medication review linking primary and secondary care can limit such usage. My work has been widely cited, reflecting a substantial contribution to the field, in terms of our understanding of the causes of, and possible solutions to limit, medication-related adverse events in people with dementia. More importantly, this work has already informed clinical practice, patients, carers and policy makers by its demonstrable impact on health policy. In particular my research has identified key lines of enquiry for future work and for the development of my own personal research programme to reduce the risk associated with medication in this vulnerable population.

Revolution or evolution:the challenges of conceptualizing patient and public involvement in a consumerist world

Background Changing the relationship between citizens and the state is at the heart of current policy reforms. Across England and the developed world, from Oslo to Ontario, Newcastle to Newquay, giving the public a more direct say in shaping the organization and delivery of healthcare services is central to the current health reform agenda. Realigning public services around those they serve, based on evidence from service user's experiences, and designed with and by the people rather than simply on their behalf, is challenging the dominance of managerialism, marketization and bureaucratic expertise. Despite this attention there is limited conceptual and theoretical work to underpin policy and practice. Objective This article proposes a conceptual framework for patient and public involvement (PPI) and goes on to explore the different justifications for involvement and the implications of a rights-based rather than a regulatory approach. These issues are highlighted through exploring the particular evolution of English health policy in relation to PPI on the one hand and patient choice on the other before turning to similar patterns apparent in the United States and more broadly. Conclusions A framework for conceptualizing PPI is presented that differentiates between the different types and aims of involvement and their potential impact. Approaches to involvement are different in those countries that adopt a rights-based rather than a regulatory approach. I conclude with a discussion of the tension and interaction apparent in the globalization of both involvement and patient choice in both policy and practice. © 2009 Blackwell Publishing Ltd.

The snakes and ladders of user involvement:moving beyond Arnstein

For 35 years, Arnstein's ladder of citizen participation has been a touchstone for policy makers and practitioners promoting user involvement. This article critically assesses Arnstein's writing in relation to user involvement in health drawing on evidence from the United Kingdom, the Netherlands, Finland, Sweden and Canada. Arnstein's model, however, by solely emphasizing power, limits effective responses to the challenge of involving users in services and undermines the potential of the user involvement process. Such an emphasis on power assumes that it has a common basis for users, providers and policymakers and ignores the existence of different relevant forms of knowledge and expertise. It also fails to recognise that for some users, participation itself may be a goal. We propose a new model to replace the static image of a ladder and argue that for user involvement to improve health services it must acknowledge the value of the process and the diversity of knowledge and experience of both health professionals and lay people.