The SPHERE Study: Secondary prevention of heart disease in general practice: protocol of a randomised controlled trial of tailored practice and patient care plans with parallel qualitative, economic and policy analyses. [ISRCTN24081411]

Background: The aim of the SPHERE study is to design, implement and evaluate tailored practice and personal care plans to improve the process of care and objective clinical outcomes for patients with established coronary heart disease (CHD) in general practice across two different health systems on the island of Ireland.CHD is a common cause of death and a significant cause of morbidity in Ireland. Secondary prevention has been recommended as a key strategy for reducing levels of CHD mortality and general practice has been highlighted as an ideal setting for secondary prevention initiatives. Current indications suggest that there is considerable room for improvement in the provision of secondary prevention for patients with established heart disease on the island of Ireland. The review literature recommends structured programmes with continued support and follow-up of patients; the provision of training, tailored to practice needs of access to evidence of effectiveness of secondary prevention; structured recall programmes that also take account of individual practice needs; and patient-centred consultations accompanied by attention to disease management guidelines.

Methods: SPHERE is a cluster randomised controlled trial, with practice-level randomisation to intervention and control groups, recruiting 960 patients from 48 practices in three study centres (Belfast, Dublin and Galway). Primary outcomes are blood pressure, total cholesterol, physical and mental health status (SF-12) and hospital re-admissions. The intervention takes place over two years and data is collected at baseline, one-year and two-year follow-up. Data is obtained from medical charts, consultations with practitioners, and patient postal questionnaires. The SPHERE intervention involves the implementation of a structured systematic programme of care for patients with CHD attending general practice. It is a multi-faceted intervention that has been developed to respond to barriers and solutions to optimal secondary prevention identified in preliminary qualitative research with practitioners and patients. General practitioners and practice nurses attend training sessions in facilitating behaviour change and medication prescribing guidelines for secondary prevention of CHD. Patients are invited to attend regular four-monthly consultations over two years, during which targets and goals for secondary prevention are set and reviewed. The analysis will be strengthened by economic, policy and qualitative components.

Impact of Government Intervention on Employment Change and Plant Closure in Northern Ireland, 1983-97

Harris R. and Trainor M. (2007) Impact of government intervention on employment change and plant closure in Northern Ireland, 1983-97, Regional Studies 41, 51-63. Financial assistance to manufacturing industry is an important element of the industrial development policy in Northern Ireland. This paper uses the individual plant-level records of the Annual Respondents Database (ARD) for the Northern Ireland manufacturing sector (1983-97) matched to the plant-level details of financial support provided by the Industrial Development Board to examine the effect of selective financial assistance (SFA) on employment change and plant closure. It is found that SFA concentrated on protecting existing, rather than new, enterprises in terms of employment change. Using a hazard model, it is found that the receipt of SFA significantly reduced the probability of plant closure by, on average, between 15 and 24%.

Shaping the Future of Mental Health Policy and Legislation in Northern Ireland: The Impact of Service User and Professional Social Work Discourses

This paper explores the complex interrelationship between service user and professional social work discourses and provides a critical commentary on their respective contributions to the recent review of mental health policy and legislation in Northern Ireland. The analysis indicates that dominant trends in mental health care, as mediated through service structures and institutional identities, have tended to prioritize the more coercive aspects of the social work role and reinforce existing power inequalities with service users. It is argued that such developments underline the need for a ‘refocusing’ debate in mental health social work to consider how a more appropriate balance can be achieved between its participatory/empowering and regulatory/coercive functions. Whilst highlighting both congruence and dissonance between respective discourses, the paper concludes that opportunities exist within the current change process for service users and social workers to build closer alliances in working together to reconstruct practice, safeguard human rights and develop innovative alternatives to a traditional bio-medical model of treatment.

'Surfacing' Micropolitics as a Potential Management Change Frame

This paper considers the findings of a small-scale survey undertaken in a university department. Against a background of massification and commodification, the the increased level of responsibility and accountability has intensified political activity in general but at the micro level in particular. The conclusions of this research demonstrate that staff perceived power in the form of workload, appointment's and promotions were all contingent on the micro politics within the department and the affiliation to senior staff.

Retrospective assessment of dryland soil stability in relation to grazing and climate change

Accelerated soil erosion is an aspect of dryland degradation that is affected by repeated intense drought events and land management activities such as commercial livestock grazing. A soil stability index (SSI) that detects the erosion status and susceptibility of a landscape at the pixel level, i.e., stable, erosional, or depositional pixels, was derived from the spectral properties of an archived time series (from 1972 to 1997) of Landsat satellite data of a commercial ranch in northeastern Utah. The SSI was retrospectively validated with contemporary field measures of soil organic matter and erosion status that was surveyed by US federal land management agencies. Catastrophe theory provided the conceptual framework for retrospective assessment of the impact of commercial grazing and soil water availability on the SSI. The overall SSI trend was from an eroding landscape in the early drier 1970s towards stable conditions in the wetter mid-1980s and late 1990s. The landscape catastrophically shifted towards an extreme eroding state that was coincident with the “The Great North American Drought of 1988”. Periods of landscape stability and trajectories toward stability were coincident with extremely wet El Niño events. Commercial grazing had less correlation with soil stability than drought conditions. However, the landscape became more susceptible to erosion events under multiple droughts and grazing. Land managers now have nearly a year warning of El Niño and La Niña events and can adjust their management decisions according to predicted landscape erosion conditions.

Implementing a resuscitation policy for patients at the end of life in an acute hospital setting: qualitative study

Objective : To explore attitudes and experiences of doctors and nurses regarding cardiopulmonary resuscitation for patients with end stage illness in an acute hospital. Design : Qualitative study; thematic analysis of two audio-taped focus groups and four semi-structured interviews. Setting : Acute district hospital, Northern Ireland. Participants : Seven nurses and nine doctors; varying nationality, gender and years of professional experience; involved in cardiopulmonary resuscitation decision-making. Results : Participants reported different interpretations of resuscitation policy and of what do not attempt to resuscitate (DNAR) decisions meant in relation to practical care for patients. This confusion in translating policy into practice contributed to communication difficulties in initiating, documenting and implementing cardiopulmonary resuscitation decisions. Participants were aware of how clinical conditions could change and reported uncertainty in determining end stage illness; they expressed fears of potential consequences of DNAR decisions for patients' care. The more disease-centred approach of doctors to patients' management, compared to nurses' more patient-centred approach, contributed to inter-professional conflict within teams. Doctors identified training needs in applying resuscitation policy and ethical principles in `real life' and nurses identified a need for ongoing professional support, which was perceived as being less available to junior doctors. Personal relationships between staff and patients, cultural reluctance to address sensitive issues and local community expectations of relatives being involved in decisions added to policy implementation difficulties. Conclusions : The findings indicate a need for ongoing staff support and training in applying resuscitation policy to decisions for patients with end stage illness in an acute hospital. They support suggestions that reviews of local resuscitation policy and of national guidelines should be undertaken with openness and honesty regarding the goals, opportunities and difficulties involved in trying to deliver good end of life care in local settings. Palliative Medicine 2007; 21 : 305—312 Key Words: do not attempt resuscitation (DNAR) • end stage illness • inter-professional • policy • resuscitation decisions

Where there is smoke, there is (the potential for) fire: soft indicators of research and policy impact

There is a growing literature examining the impact of research on informing policy, and of research and policy on practice. Research and policy do not have the same types of impact on practice but can be evaluated using similar approaches. Sometimes the literature provides a platform for methodological debate but mostly it is concerned with how research can link to improvements in the process and outcomes of education, how it can promote innovative policies and practice, and how it may be successfully disseminated. Whether research-informed or research-based, policy and its implementation is often assessed on such 'hard' indicators of impact as changes in the number of students gaining five or more A to C grades in national examinations or a percentage fall in the number of exclusions in inner city schools. Such measures are necessarily crude, with large samples smoothing out errors and disguising instances of significant success or failure. Even when 'measurable' in such a fashion, however, the impact of any educational change or intervention may require a period of years to become observable. This paper considers circumstances in which short-term change may be implausible or difficult to observe. It explores how impact is currently theorized and researched and promotes the concept of 'soft' indicators of impact in circumstances in which the pursuit of conventional quantitative and qualitative evidence is rendered impractical within a reasonable cost and timeframe. Such indicators are characterized by their avowedly subjective, anecdotal and impressionistic provenance and have particular importance in the context of complex community education issues where the assessment of any impact often faces considerable problems of access. These indicators include the testimonies of those on whom the research intervention or policy focuses (for example, students, adult learners), the formative effects that are often reported (for example, by head teachers, community leaders) and media coverage. The collation and convergence of a wide variety of soft indicators (Where there is smoke …) is argued to offer a credible means of identifying subtle processes that are often neglected as evidence of potential and actual impact (… there is fire).

UN 2006 Climate Change Conference: a confidence building step?

An analysis of the UN 2006 COP.

Restraing Regulatory Capture? Anglo America, Crisis Politics and Trajectories of Change in Global Financial Governance

A growing number of respected commentators now argue that regulatory capture of public agencies and public policy by leading banks was one of the main causal factors behind the financial crisis of 2007–2009, resulting in a permissive regulatory environment. This regulatory environment placed a faith in banks own internal risk models, contributed to pro-cyclical behaviour and turned a blind eye to excessive risk taking. The article argues that a form of ‘multi-level regulatory capture’ characterized the global financial architecture prior to the crisis. Simultaneously, regulatory capture fed off, but also nourished the financial boom, in a fashion that mirrored the life cycle of the boom itself. Minimizing future financial booms and crises will require continuous, conscious and explicit efforts to restrain financial regulatory capture now and into the future. The article assesses the extent to which this has been achieved in current global financial governance reform efforts and highlights some of the persistent difficulties that will continue to hamper efforts to restrain regulatory capture. The evidence concerning the extent to which regulatory capture is being effectively restrained is somewhat mixed, and where it is happening it is largely unintentional and accidental. Recent reforms have overlooked the political causes of the crisis and have failed to focus explicitly or systematically on regulatory capture.