Editorial

Full text: There are phrases in daily use today which were not so common a decade or so back, such as ‘ageing population’ or ‘climate changes’ or ‘emerging markets’ or even ‘social networking’. How do these things affect our lives is certainly interesting but for us as eye care practitioners how these changes affect our clinical work may be also relevant and sometimes more interesting. A recent advertisement for recruitment to the Royal Marine Corps of the British Army ended with a comment ‘find us on Facebook!’ The BCLA, IACLE and other organisations as well as many manufacturers have their own Facebook groups. In 2011 Chandni Thakkar was awarded the BCLA summer studentship and her project was based around increasing the contact lens business of a small independent optometric practice where contact lens sales were minimal. The practice typically recruited one new wearer per month. Chandni was able to increase the number of new patient fits with various strategies (her work was presented as poster at the 2012 BCLA conference in Birmingham). One of her strategies was to start a Facebook group and 655 joined the special group she started in just over a month. Interestingly she found that the largest single factor in convincing patients to trial contact lenses was recommendation by the eye care practitioner at the end of the examination, but nonetheless it is interesting that so many people used the social networking site to find out more information regarding contact lenses in her study. Moreover, we already see the use, by some practitioners, of smart phone ‘apps’ or electronic diaries or text messages when coordinating patient check-ups. Climate change has affected the way we think and act; we now leave out special recycle bins and we hope that the items that are recyclable are actually recycled and do not just join our other refuse somewhere down the track! How environmentally friendly are contact lenses? This was discussed by various speakers at this year's BCLA conference in Birmingham. Daily disposable lenses surely produce more contact lens waste but do not involve solutions in plastic bottles like monthly lenses. It is certainly something that manufacturers are taking seriously and of course there are environmental benefits but the cynic in each of us sees the marketing potential too. The way the ageing population is certainly something that will impact all healthcare providers. In the case of eye care with people living longer they will need refractive corrections for longer. Furthermore, since presbyopes are not resigning themselves to only gentle hobbies like knitting and gardening, but instead want to continue playing tennis or skiing or whatever, their visual demands are becoming more complex. This is certainly an area that contact lens manufacturers are focussing on (pun not intended!). Again the BCLA conference in Birmingham saw the launch of various new products by different companies to help us deal with our presbyopic contact lens wearers. It is great to have such choice and now with fitting methods becoming easier too we have no excuse not to try them out with our clients. Finally to emerging markets – well there was not a specific session at the BCLA conference in May discussing this but this most certainly would have been discussed by professional services managers and marketing directors of most of the contact lens companies. ‘How will we conquer China?’ ‘How can we increase our market share in Russia?’ Or ‘How should we spend our marketing budget in India?’ These topics as well as others would certainly have cropped up in backroom discussions. Certainly groups like IACLE (International Association of CL Educators) have increasing numbers of members and activities in developing markets to ensure that educators educate, to that practitioners can practice successfully and in turn patients can become successful contact lenses wearers. Companies also wish to increase their market share in these developing markets and from the point of view of CLAE we are certainly seeing more papers being submitted from these parts of the world. The traditional centres of knowledge are being challenged, I suppose as they have been throughout history, and this can only be a good thing for the pursuit of science. The BCLA conference in Birmingham welcomed more international visitors than ever, and from more countries, and long may that continue. Similarly, CLAE looks forward to a wider audience in years to come and a wider network of authors too.

It's not just for boys

Against an historical background of sexual inequality in the workplace engineering persists as a bastion of inequality in the 21st century. This research examines the perceptions of engineering of 86 students, who chose to study the new Level 2 Engineering Diploma at age 14. The students were based in the South West of Birmingham, close to the MG Rover Longbridge plant that closed in 2005. The results have been compared with the results of the EngineeringUK survey (EngineeringUK,2012) on perceptions of Engineering. The survey involved 5 schools - one all girls' school. Nearly a third of the students were girls. The study provides an insight into how these students acquired their perceptions of Engineering and provides clarity as to why they were attracted to join the programme at age 14. A key aspect of this study is to understand why these girls did choose and stay with the study of engineering, whilst most do not despite performing as well as boys in Maths and Science at GCSE level. Informed by the outcomes of this study the paper identifies key areas where work can be done to change teachers, parents and pupils perceptions and enable more females to recognise the possibility of both studying and working in an engineering field.

Transgressing community:the case of Muslims in a twenty-first-century British city

This paper draws on ethnographic research carried out in Birmingham, UK – a city significant for its sizeable Muslim population and its iconic role in the history of minority ethnic settlement in Britain – to consider how associations of place and ethnicity work in different ways to inform ideas about ‘Muslim community’ in twenty-first-century Britain. The paper charts happenings around a local event in an area of majority Asian settlement and how representations of the area as a place of Muslim community were used to implicate it in the ‘war on terror’. The paper goes on to show how this sensibility is disrupted by Muslims themselves through alternative engagements with space and ethnicity. The paper argues that these offer a ground for making Muslim community in ways that actively engage with histories and patterns of ethnic settlement in the city rather than being determined by them.

Editorial

The year so far has been a slow start for many businesses, but at least we have not seen the collapse of as many businesses that we were seeing around two years ago. We are, however, still well and truly in the midst of a global recession. Interest rates are still at an all time low, UK house prices seem to be showing little signs of increase (except in London where everyone still seems to want to live!) and for the ardent shopper there are bargains to be had everywhere. It seems strange that prices on the high street do not seem to have increased in over ten years. Mobile phones, DVD players even furniture seems to be cheaper than they used to be. Whist much of this is down to cheaper manufacturing and the rest could probably be explained by competition within the market place. Does this mean that quality suffered too? Now that we live in a world when if a television is not working it is thrown away and replaced. There was a time when you would take it to some odd looking man that your father would know who could fix it for you. (I remember our local television fix-it man, with his thick rimmed bifocal spectacles and a poor comb-over; he had cardboard boxes full of resistors and electrical wires on the floor of his front room that smelt of soldering irons!) Is this consumerism at an extreme or has this move to disposability made us a better society? Before you think these are just ramblings there is a point to this. According to latest global figures of contact lens sales the vast majority of contact lenses fitted around the world are daily, fortnightly or monthly disposable hydrogel lenses. Certainly in the UK over 90% of lenses are disposable (with daily disposables being the most popular, having a market share of over 50%). This begs the question – is this a good thing? Maybe more importantly, do our patients benefit? I think it is worth reminding ourselves why we went down the disposability route with contact lenses in the first place, and unlike electrical goods it was not just so we did not have to take them for repair! There are the obvious advantages of overcoming problems of breakage and tearing of lenses and the lens deterioration with age. The lenses are less likely to be contaminated and the disinfection is either easier or not required at all (in the case of daily disposable lenses). Probably the landmark paper in the field was the work more commonly known as the ‘Gothenburg Study’. The paper, entitled ‘Strategies for minimizing the Ocular Effects of Extended Contact Lens Wear’ published in the American Journal of Optometry in 1987 (volume 64, pages 781-789) by Holden, B.A., Swarbrick, H.A., Sweeney, D.F., Ho, A., Efron, N., Vannas, A., Nilsson, K.T. They suggested that contact lens induced ocular effects were minimised by: •More frequently removed contact lenses •More regularly replaced contact lenses •A lens that was more mobile on the eye (to allow better removal of debris) •Better flow of oxygen through the lens All of these issues seem to be solved with disposability, except the oxygen issue which has been solved with the advent of silicone hydrogel materials. Newer issues have arisen and most can be solved in practice by the eye care practitioner. The emphasis now seems to be on making lenses more comfortable. The problems of contact lens related dry eyes symptoms seem to be ever present and maybe this would explain why in the UK we have a pretty constant contact lens wearing population of just over three million but every year we have over a million dropouts! That means we must be attracting a million new wearers every year (well done to the marketing departments!) but we are also losing a million wearers every year. We certainly are not losing them all to the refractive surgery clinics. We know that almost anyone can now wear a contact lens and we know that some lenses will solve problems of sharper vision, some will aid comfort, and some will be useful for patients with dry eyes. So if we still have so many dropouts then we must be doing something wrong! I think the take home message has to be ‘must try harder’! I must end with an apology for two errors in my editorial of issue 1 earlier this year. Firstly there was a typo in the first sentence; I meant to state that it was 40 years not 30 years since the first commercial soft lens was available in the UK. The second error was one that I was unaware of until colleagues Geoff Wilson (Birmingham, UK) and Tim Bowden (London, UK) wrote to me to explain that soft lenses were actually available in the UK before 1971 (please see their ‘Letters to the Editor’ in this issue). I am grateful to both of them for correcting the mistake.

Asymmetric price transmission in EU petroleum markets

This research investigates the determinants of asymmetric price transmission (APT) in European petroleum markets. APT is the faster response of retail prices to cost increases than to cost decreases; resulting in a welfare transfer from consumers to fuel retailers. I investigate APT at 3 different levels: the EU, the UK and at the Birmingham level. First, I examine the incidence of asymmetries in the retail markets of six major EU countries; significant asymmetries are found in all countries except from the UK. The market share data suggest that asymmetries are more important in more concentrated markets; this finding supports the collusion theory. I extend the investigation to 12 EU countries and note that APT is greater in diesel markets. The cross-country analysis suggests that vertical and horizontal concentration at least partly explains the degree of asymmetry. I provide evidence justifying scrutiny over retail markets’ pricing and structure. Second daily data unveil the presence of APT in the UK fuel markets. I use break tests to identify segments with different pricing regimes. Two main types of periods are identified: periods of rising oil price exhibit significant asymmetries whilst periods of recession do not. Our results suggest that oligopolistic coordination between retailers generate excess rents during periods of rising oil price whilst the coordination fails due to price wars when oil prices are going downwards. Finally I investigate the pricing behaviour of petroleum retailers in the Birmingham (UK) area for 2008. Whilst the market structure data reveals that the horizontal concentration is higher than the national UK average, I find no evidence of APT. In contrast, I find that retail prices are sticky upwards and downwards and that firms with market power (majors and supermarkets) adjust their prices slower than other firms.

Diagnosis of retinopathy in children younger than 12 years of age:implications for the diabetic eye screening guidelines in the UK

Aim: To assess whether the current starting age of 12 is suitable for diabetic retinopathy (DR) screening and whether diabetes duration should be taken into account when deciding at what age to start screening patients. Materials and methods: A retrospective analysis of 143 patients aged 12 years or younger who attended diabetic eye screening for the first time in the Birmingham, Solihull and Black Country Diabetic Eye Screening Programme was performed. Results: The mean age of the patients was 10.7 (7-12) years with 73 out of 143 aged below 12 years and 70 were 12 years of age. 98% had type 1 diabetes and mean diabetes duration was 5 (1 month-11 years) years. For those younger than 12 years, 7/73 (9.6%) had background DR (BDR), of these mean diabetes duration was 7 years (6-8). The youngest patient to present with DR was aged 8 years. In those aged 12 years, 5/70 (7.1%) had BDR; of these mean diabetes duration was 8 years (6-11). No patient developed DR before 6 years duration in either group. Conclusions: The results show that no patient younger than the age of 12 had sight-threatening DR (STDR), but BDR was identified. Based on the current mission statement of the Diabetic Eye Screening Programme to identify STDR, 12 years of age is confirmed as the right age to start screening, but if it is important to diabetic management to identify first development of DR, then screening should begin after 6 years of diabetes diagnosis.

Potential causes of ethnic group disparities in infertility:a hospital database study

Introduction - Lower success rates of in vitro fertilisation (IVF) in South East Asian countries compared to Western countries in informal studies and surveys was considered a reflection of variations in methodology and expertise. However, recent studies on the effects of ethnicity on success rates of infertility procedures in western countries have suggested other inherent contributing factors to the ethnic disparity but the evidence evaluating these is lacking. In our study we aim to investigate some of the comorbidities that might cause ethnic disparity to infertility and related procedures from hospital admissions data. Methods - Anonymous hospital admissions data on patients of various ethnic groups with infertility, comorbidities and infertility procedures from multiple hospitals in Birmingham andManchester, UK between 2000 and 2013 were obtained from the local health authority computerised hospital activity analysis register using ICD-10 and OPCS coding systems. Statistical analysis was performed using SPSS version 20.Results Of 522 223 female patients aged 18 and over, there were44 758 (8.4%) patients from South Asian (SA) community. 1156(13.4%) of the 8653 patients coded for infertility were SA, whichis a considerably higher proportion of the background SA population. For IVF procedures, the percentage of SA increased to15.4% (233 of the total 1479 patients). The mean age of SA codedfor infertility (30.6 ± 4.7 SD years versus 32.8 ± 4.9 SD years)and IVF (30.4 ± 4.3 SD years versus 32.7 ± 4.4 SD years) was significantly lower than caucasian patien ts (P < 0.001). A multivariate logistic regression model looking at patients with infertility, accounting for variations in age, showed that SA have significantly higher prevalence of hypothyroidism, obesity andiron-deficiency anaemia compared to caucasians but lower prevalence of endometriosis. Interestingly, psychiatric and psychological conditions diagnoses were seldom registered in infertility patients. Conclusion - Other studies suggest that various cultural, lifestyles, psychosocial and socio-economic factors may explain the disparities in IVF success rates between South Asians and caucasians. The fact that SA infertility and IVF patients, in ou rstudy, were significantly younger than caucasians and that their proportion is considerably higher than the background South Asian population suggests the influence of these factors. A significant psychiatric disease burden in other conditions and low numbers in our data suggest under diagnosis in this group.Despite the limitations of the coding data, from our study, we propose that hypothyroidism, obesity and/or iron-deficiency anaemia should be considered for the ethnic disparity. Further research in this topic is essential to fully investigate the reasons for such ethnic disparities.

Diabetes management in care homes:steps in the right direction?

Aims: Previous research has identified several inadequacies in management of diabetes within care homes many of which were highlighted in Diabetes UK’s report Diabetes in care homes:awareness, screening, training. The aim of this study was to see if this was still the case and to identify specific areas for improvement. Methods: Thirty care homes in Birmingham were invited to participate in the study. Data were collected using a standard questionnaire based on the Diabetes UK national survey of care homes comprising questions relating to screening, self-management, care planning and local authority support. All returned responses were analysed. Results: Responses were received from 20 of the 30 care homes approached. The mean percentage of residents with diabetes in the care homes sampled was 13.7%. None of the homes screened for diabetes on admission and only 5% screened residents annually.80% of homes acknowledged providing diabetes-specific training to staff. Residents in 95% of homes had a medical review in the last 12 months: 70% with a GP, 20% with a diabetes specialist nurse/nurse. 65% of homes provided support for self-management.45% of care homes did not have individualised care plans for residents with diabetes. 35% of managers reported poor support and guidance from their local authority.Conclusions: Improvements were noted in the care provided to individuals with diabetes living in care homes in Birmingham. Aspects relating to screening, individualised care plans and support to care home staff still need attention.

The possibilities and limits of contestation in times of 'urban austerity'

This paper seeks to provide a conceptual framework in which to examine the social practices of contemporary austerity programmes in urban areas, including how these relate to different conceptions of crisis. Of current theoretical interest is the apparent ease with which these austerity measures have been accepted by urban governing agents. In order to advance these understandings we follow the recent post-structuralist discourse theory ‘logics’ approach of Glynos and Howarth (2007), focusing on the relationship between hegemony, political and social logics, and the subject whose identificatory practices are key to understanding the form, nature and stability of discursive settlements. In such thinking it is not only the formation of discourses and the mobilisation of rhetoric that are of interest, but also the manner in which the subjects of austerity identify with these. Through such an approach we examine the case of the regeneration/economic development and planning policy area in the city government of Birmingham (UK). In conclusion, we argue that the logics approach is a useful framework through which to examine how austerity has been uncontested in a city government, and the dynamics of acquiescence in relation to broader hegemonic discursive formations.

GPs' perspectives on managing the NHS Health Check in primary care:a qualitative evaluation of implementation in one area of England

OBJECTIVES: To evaluate the implementation of the National Health Service (NHS) Health Check programme in one area of England from the perspective of general practitioners (GPs). DESIGN: A qualitative exploratory study was conducted with GPs and other healthcare professionals involved in delivering the NHS Health Check and with patients. This paper reports the experience of GPs and focuses on the management of the Heath Check programme in primary care. SETTING: Primary care surgeries in the Heart of Birmingham region (now under the auspices of the Birmingham Cross City Clinical Commissioning Group) were invited to take part in the larger scale evaluation. This study focuses on a subset of those surgeries whose GPs were willing to participate. PARTICIPANTS: 9 GPs from different practices volunteered. GPs served an ethnically diverse region with areas of socioeconomic deprivation. Ethnicities of participant GPs included South Asian, South Asian British, white, black British and Chinese. METHODS: Individual semistructured interviews were conducted with GPs face to face or via telephone. Thematic analysis was used to analyse verbatim transcripts. RESULTS: Themes were generated which represent GPs' experiences of managing the NHS Health Check: primary care as a commercial enterprise; 'buy in' to concordance in preventive healthcare; following protocol and support provision. These themes represent the key issues raised by GPs. They reveal variability in the implementation of NHS Health Checks. GPs also need support in allocating resources to the Health Check including training on how to conduct checks in a concordant (or collaborative) way. CONCLUSIONS: The variability observed in this small-scale evaluation corroborates existing findings suggesting a need for more standardisation. Further large-scale research is needed to determine how that could be achieved. Work needs to be done to further develop a concordant approach to lifestyle advice which involves tailored individual goal setting rather than a paternalistic advice-giving model.

The MG Rover closure and policy response: an evaluation of the Task Force model in the UK

In recent years there have been a number of high-profile plant closures in the UK. In several cases, the policy response has included setting up a task force to deal with the impacts of the closure. It can be hypothesised that task force involving multi-level working across territorial boundaries and tiers of government is crucial to devising a policy response tailored to people's needs and to ensuring success in dealing with the immediate impacts of a closure. This suggests that leadership, and vision, partnership working and community engagement, and delivery of high quality services are important. This paper looks at the case of the MG Rover closure in 2005, to examine the extent to which the policy response to the closure at the national, regional and local levels dealt effectively with the immediate impacts of the closure, and the lessons that can be learned from the experience. Such lessons are of particular relevance given the closure of the LDV van plant in Birmingham in 2009 and more broadly – such as in the case of the downsizing of the Opel operation in Europe following its takeover by Magna.

Clinical significance of medication reconciliation in children admitted to a UK pediatric hospital:observational study of neurosurgical patients

Background: In December 2007, the National Institute for Health and Clinical Excellence and the National Patient Safety Agency in the UK (NICE-NPSA) published guidance that recommends all adults admitted to hospital receive medication reconciliation, usually by pharmacy staff. A costing and report tool was provided indicating a resource requirement of d12.9 million for England per year. Pediatric patients are excluded from this guidance. Objective: To determine the clinical significance of medication reconciliation in children on admission to hospital. Methods: A prospective observational study included pediatric patients admitted to a neurosurgical ward at Birmingham Childrens Hospital, Birmingham, England, between September 2006 and March 2007. Medication reconciliation was conducted by a pharmacist after the admission of each of 100 consecutive eligible patients aged 4 months to 16 years. The clinical significance of prescribing disparities between pre-admission medications and initial admission medication orders was determined by an expert multidisciplinary panel and quantified using an analog scale. The main outcome measure was the clinical signficance of unintentional variations between hospital admission medication orders and physician-prescribed pre-admission medication for repeat (continuing) medications. Results: Initial admission medication orders for children differed from prescribed pre-admission medication in 39%of cases. Half of all resulting prescribing variations in this setting had the potential to cause moderate or severe discomfort or clinical deterioration. These results mirror findings for adults. Conclusions: The introduction of medication reconciliation in children on admission to hospital has the potential to reduce discomfort or clinical deterioration by reducing unintentional changes to repeat prescribed medication. Consequently, there is no justification for the omission of children from the NICENPSA guidance concerning medication reconciliation in hospitals, and costing tools should include pediatric patients. © 2010 Adis Data Information BV. All rights reserved.

Transgressing community:the case of Muslims in a twenty-first-century British city

This paper draws on ethnographic research carried out in Birmingham, UK - a city significant for its sizeable Muslim population and its iconic role in the history of minority ethnic settlement in Britain - to consider how associations of place and ethnicity work in different ways to inform ideas about 'Muslim community' in twenty-first-century Britain. The paper charts happenings around a local event in an area of majority Asian settlement and how representations of the area as a place of Muslim community were used to implicate it in the 'war on terror'. The paper goes on to show how this sensibility is disrupted by Muslims themselves through alternative engagements with space and ethnicity. The paper argues that these offer a ground for making Muslim community in ways that actively engage with histories and patterns of ethnic settlement in the city rather than being determined by them.

Magic City Gospel

Magic City Gospel is a collection of poems that explores themes of race and identity with a special focus on racism in the American South. Many of the poems deal directly with the author’s upbringing in Birmingham, Alabama, the Magic City, and the ways in which the history of that geographical place informs the present. Magic City Gospel confronts race and identity through pop culture, history, and the author’s personal experiences as a black, Alabama-born woman. Magic City Gospel is, in part, influenced by the biting, but softly rendered truth and historical commentary of Lucille Clifton, the laid-back and inventive poetry of Terrance Hayes, the biting and unapologetically feminist poetry of Audre Lorde, and the syncopated, exact, musical poetry of Kevin Young. These and other authors like Tim Siebles, Gwendolyn Brooks, and Major Jackson influence poems as they approach the complicated racial and national identity of the author.

The clinical significance of medicines reconciliation in children admitted to hospital

Aims and Objectives: The NICE/NPSA guidance on Medicines Reconciliation in adults upon hospital admission excludes children under the age of 16.1 Hence the primary aim and objective of this study was to use medicines reconciliation to primarily identify if discrepancies occur upon hospital admission. Secondary objectives were to clinically assess for harm discrepancies that were identified in paediatric patients on long term medications at four hospitals across the UK. Method: Medicines reconciliation is a procedure where the current medication history of a patient prior to hospital admission would be taken and verifying the medication orders made at hospital admission against this history, addressing any discrepancies identified. Medicines reconciliation was carried out prospectively for 244 paediatric patients on chronic medication across four UK hospitals (Birmingham, London, Leeds and North Staffordshire) between January – May 2011. Medicines reconciliation was conducted by a clinical pharmacist using the following sources of information: 1) the patient's Pre-Admission Medication (PAM) from the patient's general practitioner 2) examination of the Patient's Own Medications brought into hospital, 3) a semi-structured interview with the parent-carers and 4) identification of admission medication orders written on the drug chart prior to clinical pharmacy input (Drug Chart). Discrepancies between the PAM and Drug Chart were documented and classified as intentional or unintentional. Intentional discrepancies were defined as changes that were made knowingly by the prescriber and confirmed. Unintentional discrepancies were assessed for clinical significance by an expert panel and assigned a significance score based on the likelihood of causing potential discomfort or clinical deterioration: class 1 unlikely, class 2 moderate and class 3 severe.2 Results: 1004 medication regimens were included from the 244 patients across the four sites. 588 of the 1004 (59%) medicines, had discrepancies between the PAM and Drug Chart; of these 36% (n = 209) were unintentional and included for clinically assessment. 189 drug discrepancies 30% were classified as class 1, 47% were class 2 and 23% were class 3 discrepancies. The remaining 20 discrepancies were cases where deviating from the PAM would have been the right thing to do, which might suggest that an intentional but undocumented discrepancy by the prescriber writing up the admission order may have occurred. Conclusion: The results suggest that medication discrepancies in paediatric patients do occur upon hospital admission, which do have a potential to cause harm and that medicines reconciliation is a potential solution to preventing such discrepancies. References: 1. National Institute for Health and Clinical Excellence. National Patient Safety Agency. PSG001. Technical patient safety solutions for medicines reconciliation on admission of adults to hospital. London: NICE; 2007. 2. Cornish, P. L., Knowles, S. R., Marchesano, et al. Unintended Medication Discrepancies at the Time of Hospital Admission. Archives of Internal Medicine 2005; 165:424–429