Analysis Of England Research Articles

Associations of type 1 and type 2 diabetes with COVID-19-related mortality in England: a whole-population study

BackgroundAlthough diabetes has been associated with COVID-19-related mortality, the absolute and relative risks for type 1 and type 2 diabetes are unknown. We assessed the independent effects of diabetes status, by type, on in-hospital death in England in patients with COVID-19 during the period from March 1 to May 11, 2020.MethodsWe did a whole-population study assessing risks of in-hospital death with COVID-19 between March 1 and May 11, 2020. We included all individuals registered with a general practice in England who were alive on Feb 16, 2020. We used multivariable logistic regression to examine the effect of diabetes status, by type, on in-hospital death with COVID-19, adjusting for demographic factors and cardiovascular comorbidities. Because of the absence of data on total numbers of people infected with COVID-19 during the observation period, we calculated mortality rates for the population as a whole, rather than the population who were infected.FindingsOf the 61 414 470 individuals who were alive and registered with a general practice on Feb 16, 2020, 263 830 (0·4%) had a recorded diagnosis of type 1 diabetes, 2 864 670 (4·7%) had a diagnosis of type 2 diabetes, 41 750 (0·1%) had other types of diabetes, and 58 244 220 (94·8%) had no diabetes. 23 698 in-hospital COVID-19-related deaths occurred during the study period. A third occurred in people with diabetes: 7434 (31·4%) in people with type 2 diabetes, 364 (1·5%) in those with type 1 diabetes, and 69 (0·3%) in people with other types of diabetes. Unadjusted mortality rates per 100 000 people over the 72-day period were 27 (95% CI 27–28) for those without diabetes, 138 (124–153) for those with type 1 diabetes, and 260 (254–265) for those with type 2 diabetes. Adjusted for age, sex, deprivation, ethnicity, and geographical region, compared with people without diabetes, the odds ratios (ORs) for in-hospital COVID-19-related death were 3·51 (95% CI 3·16–3·90) in people with type 1 diabetes and 2·03 (1·97–2·09) in people with type 2 diabetes. These effects were attenuated to ORs of 2·86 (2·58–3·18) for type 1 diabetes and 1·80 (1·75–1·86) for type 2 diabetes when also adjusted for previous hospital admissions with coronary heart disease, cerebrovascular disease, or heart failure.InterpretationThe results of this nationwide analysis in England show that type 1 and type 2 diabetes were both independently associated with a significant increased odds of in-hospital death with COVID-19.FundingNone.

SAT352 - Clinical and economic consequences of antiviral treatment for hepatitis C chronic infection in Europe: analysis of England, Italy, Romania and Spain data

SAT352 - Clinical and economic consequences of antiviral treatment for hepatitis C chronic infection in Europe: analysis of England, Italy, Romania and Spain data

The economic impact of violence perpetration in severe mental illness: a retrospective, prevalence-based analysis in England and Wales

SummaryBackgroundCalls for increased funding for mental health services require many lines of evidence in support, including estimates of economic impact. One understudied source of cost is violence perpetrated by individuals with severe mental illness. Estimating this economic impact can inform budget planning across several government sectors and emphasise the importance of violence prevention. Therefore, we aimed to provide a comprehensive estimate of the economic costs of violence perpetrated by people with severe mental illness.MethodsFor this retrospective analysis, we used a prevalence-based modelling approach to estimate the annual economic cost of violent incidents committed by people with severe mental illness in England and Wales during 2015–16. The model was based on secondary data, including the association between violence and severe mental illness, illness prevalence, recidivism, absolute numbers of violent incidents in 2015–16, and costs to society per violent crime, by area of spending. Uncertainty was addressed with probabilistic and deterministic sensitivity analyses that tested the effect of underreporting of domestic violence and distributions of crime types in individuals with severe mental illness.OutcomesThe estimated annual economic impact of violence perpetrated by people with severe mental illness was £2·5 (95% CI 1·4–4·5) billion in England and Wales in 2015–16, or 5·3% of the total estimated societal cost of violence. The largest contributors to the cost of violent crime perpetrated by individuals with severe mental illness were the cost of physical and emotional harm to victims (£1·4 [95% CI 0·8–2·5] billion), followed by lost productivity of victims (£348.0 [190·0–628·8] million), while the combined cost to the police and criminal justice system was £561·3 (305·9–1009·2) million and the cost to health services was £136·7 [74·3–246·3] million. The additional cost to secure forensic care was estimated to be £487·7 (302·0–709·1) million.InterpretationThe economic impact of violence perpetrated by individuals with severe mental illness is potentially important. Preventing violence, especially through services for individuals with comorbid substance misuse, and reducing recidivism might lead to cost savings at a governmental and individual level, in addition to the clinical and societal benefits.FundingWellcome Trust, National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, and NIHR Applied Research Collaboration Oxford and Thames Valley.

Deaths of Despair and Brexit Votes: Cross-Local Authority Statistical Analysis in England and Wales.

Objectives. To test the hypothesis that deaths of despair, a marker of social suffering, were associated with greater support for Brexit in the United Kingdom's 2016 European Union referendum.Methods. We used cross-local authority regression models of Brexit vote shares on changes in suicide and drug-related death rates before (2005-2007) and after the recession (2014-2016), adjusting for sociodemographic factors. The population comprised 345 local authorities in England and Wales.Results. Mortality rates were associated with voting patterns. An increase of 10 drug-related deaths per 100 000 was associated with a 15.25-percentage-point increase in Brexit votes (95% confidence interval [CI] = 10.27, 20.24), while an increase of 10 suicides per 100 000 was associated with a 9.97-percentage-point increase in vote shares for Brexit (95% CI = 6.25, 13.70). These results were substantially attenuated after we adjusted for education, and reduced to nonsignificance for drug mortality (b = 2.18; 95% CI = -0.21, 4.57) and suicide (b = 0.94; 95% CI = -0.32, 2.21) upon inclusion of other sociodemographic factors.Conclusions. Worsening mortality correlated with Brexit votes. These phenomena appear to share similar antecedents. A rise in such deaths may point to deeper social problems that could have political consequences.

Deaths of despair and Brexit votes: cross-local authority statistical analysis in England and Wales

Abstract Objectives To test the hypothesis that ‘deaths of despair’, a marker of social suffering, was associated with greater support for Brexit in the UK’s 2016 EU referendum. Methods Cross local authority regression models of 2016 Brexit referendum vote shares for each local authority in England and Wales on changes in rates of suicide and drug-related deaths pre- (2005-2007) and post-recession (2014-2016), adjusting for several socioeconomic and demographic factors. Survey population: 345 local authorities in England and Wales. Results Greater mortality rates from deaths of despair were significantly associated with higher Brexit vote shares. In unadjusted models, an increase of 10 drug-related deaths per 100 000 associated with a 13.20 percentage point increase in Brexit votes (95% CI: 7.09 to 19.31), while an increase of 10 suicides per 100 000 was associated with a 9.93 percentage point increase in vote shares for Brexit (95% confidence interval 6.21 to 13.65). These associations are explained by local area-level economic and education factors. Conclusions Worsening external causes of death correlate with Brexit voting. Such deaths may serve as an early warning indicator for political instability. Key messages Prior research has shown correlations between deaths of despair and votes shares for Trump in the 2016 US presidential election. We extend this research to the UK, showing that greater mortality rates from deaths of despair were significantly associated with higher Brexit vote shares.

Impact of cancer service centralisation on the radical treatment of men with high-risk and locally advanced prostate cancer: A national cross-sectional analysis in England.

In many countries, specialist cancer services are centralised to improve outcomes. We explored how centralisation affects the radical treatment of high‐risk and locally advanced prostate cancer in the English NHS. 79,085 patients diagnosed with high‐risk and locally advanced prostate cancer in England (April 2014 to March 2016) were identified in the National Prostate Cancer Audit database. Poisson models were used to estimate risk ratios (RR) for undergoing radical treatment by whether men were diagnosed at a regional co‐ordinating centre (‘hub’), for having surgery by the presence of surgical services on‐site, and for receiving high dose‐rate brachytherapy (HDR‐BT) in addition to external beam radiotherapy by its regional availability. Men were equally likely to receive radical treatment, irrespective of whether they were diagnosed in a hub (RR 0.99, 95% CI 0.91–1.08). Men were more likely to have surgery if they were diagnosed at a hospital with surgical services on site (RR 1.24, 1.10–1.40), and more likely to receive additional HDR‐BT if they were diagnosed at a hospital with direct regional access to this service (RR 6.16, 2.94–12.92). Centralisation of specialist cancer services does not affect whether men receive radical treatment, but it does affect treatment modality. Centralisation may have a negative impact on access to specific treatment modalities.

Editorial Comment

Prostate biopsy is one of the most common procedures performed by urologists with an estimated >2 million performed in the United States and Europe every year, 1 Borghesi M. Ahmed H. Nam R. et al. Complications after systematic, random, and image-guided prostate biopsy. Eur Urol. 2017; 71: 353-365 Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar , 2 Loeb S. Carter H.B. Berndt S.I. et al. Complications after prostate biopsy: data from SEER-Medicare. J Urol. 2011; 186: 1830-1834 Abstract Full Text Full Text PDF PubMed Scopus (451) Google Scholar and is the gold standard for the diagnosis of prostate cancer. The majority of prostate biopsies in the United States are done in the office setting using the ultrasound probe through a transrectal approach. The proximity of the posterior prostate to the anterior rectal wall provides easy access the peripheral zone which is known to harbor >70% of malignancies. 3 McNeal J.E. Normal histology of the prostate. Am J Surg Pathol. 1988; 12: 619-633 Crossref PubMed Scopus (421) Google Scholar However, this approach is associated with a significant risk of infectious complications, with rates ranging from 1 to 17.5% in the literature. Furthermore, the risk of serious infectious complications requiring hospitalization has been shown to be increasing over time, 4 Anastasiadis E. van der Meulen J. Emberton M. Hospital admissions after transrectal ultrasound-guided biopsy of the prostate in men diagnosed with prostate cancer: a database analysis in England. Int J Urol. 2015; 22: 181-186 Crossref PubMed Scopus (35) Google Scholar likely as a result of the increased prevalence of fluoroquinolone-resistant Escherichia coli. 5 Tukenmez Tigen E. Tandogdu Z. Ergonul O. et al. Outcomes of fecal carriage of extended-spectrum beta-lactamase after transrectal ultrasound-guided biopsy of the prostate. Urology. 2014; 84: 1008-1015 Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Partly in response to this, several centers are increasingly using the transperineal (TP) approach to prostate biopsy. Rather than using broad-spectrum prophylaxis, which contributes to antibiotic resistance, TP biopsies are often performed after a single prophylactic dose of first generation cephalosporin. Large series using this approach have reported sepsis rates approaching zero. 1 Borghesi M. Ahmed H. Nam R. et al. Complications after systematic, random, and image-guided prostate biopsy. Eur Urol. 2017; 71: 353-365 Abstract Full Text Full Text PDF PubMed Scopus (180) Google Scholar To date, TP biopsy has been mostly performed under general anesthesia, having important implications on health care resources, cost and time. Although the TP approach has been more widely adopted in other countries, in the United States it has been mostly reserved for special situations where the transrectal approach is either not possible or is unsafe. In recent years, several devices have been developed allowing TP prostate biopsies to be performed in the office, under local anesthesia, without the need for bulky, cumbersome, expensive equipment. The authors of this manuscript present their initial experience using 1 such device, and demonstrate the safety and feasibility of office TP prostate biopsy in a small number of men. What is now needed are studies in larger cohorts of patients demonstrating safety on a large scale using standardized reporting, patient tolerability using validated pain questionnaires and confirmation of the diagnostic accuracy for prostate cancer. Advances in prostate imaging (eg magnetic resonance imaging) aim to decrease the overuse of prostate biopsy, similarly modifications of the approach and instrumentation for prostate biopsy aim to decrease the morbidity of the procedure. These efforts will continue to shift the balance in favor of screening and diagnosis of prostate cancer, and will thus benefit the population on a large scale.

Are survival and mortality rates associated with recruitment to clinical trials in teenage and young adult patients with acute lymphoblastic leukaemia? A retrospective observational analysis in England

ObjectiveParticipation rates in clinical trials are low in teenagers and young adults (TYA) with cancer. Whilst the importance of clinical trials in informing best practice is well established, data regarding...

The Reliability of Free School Meal Eligibility as a Measure of Socio-Economic Disadvantage: Evidence from the Millennium Cohort Study in Wales

ABSTRACTOver the last 20 years, the use of administrative data has become central to understanding pupil attainment and school performance. Of most importance has been its use to robustly demonstrate the impact of socio-economic status (SES) on pupil attainment. Much of this analysis in England and Wales has relied on whether pupils are eligible for free school meals (eFSM). However, very little is known about the validity of this measure as a proxy for SES. Using a recent major birth cohort study, this paper examines the relationship between pupils’ eFSM and their more detailed socio-economic circumstances.

Has the NHS 111 urgent care telephone service been a success? Case study and secondary data analysis in England

ObjectivesTo explore the success of the introduction of the National Health Service (NHS) 111 urgent care service and describe service activity in the period 2014–2016.DesignComparative mixed method case study of...

The impact of car ownership and public transport usage on cancer screening coverage: Empirical evidence using a spatial analysis in England

A spatial analysis has been conducted in England, with the aim to examine the impact of car ownership and public transport usage on breast and cervical cancer screening coverage. District-level cancer screening coverage data (in proportions) and UK census data have been collected and linked. Their effects on cancer screening coverage were modelled by using both non-spatial and spatial models to control for spatial correlation.Significant spatial correlation has been observed and thus spatial model is preferred. It is found that increased car ownership is significantly associated with improved breast and cervical cancer screening coverage. Public transport usage is inversely associated with breast cancer screening coverage; but positively associated with cervical cancer screening. An area with higher median age is associated with higher screening coverage. The effects of other socio-economic factors such as deprivation and economic activity have also been explored with expected results. Some regional differences have been observed, possibly due to unobserved factors.Relevant transport and public health policies are thus required for improved coverage. While restricting access to cars may lead to various benefits in public health, it may also result in worse cancer screening uptake. It is thus recommended that careful consideration should be taken before implementing policy interventions.

High lung cancer surgical procedure volume is associated with shorter length of stay and lower risks of re-admission and death: National cohort analysis in England

It is debated whether treating cancer patients in high-volume surgical centres can lead to improvement in outcomes, such as shorter length of hospital stay, decreased frequency and severity of post-operative complications, decreased re-admission, and decreased mortality.The dataset for this analysis was based on cancer registration and hospital discharge data and comprised information on 15,738 non-small-cell lung cancer patients resident and diagnosed in England in 2006–2010 and treated by surgical resection. The number of lung cancer resections was computed for each hospital in each calendar year, and patients were assigned to a hospital volume quintile on the basis of the volume of their hospital.Hospitals with large lung cancer surgical resection volumes were less restrictive in their selection of patients for surgical management and provided a higher resection rate to their geographical population. Higher volume hospitals had shorter length of stay and the odds of re-admission were 15% lower in the highest hospital volume quintile compared with the lowest quintile. Mortality risks were 1% after 30 d and 3% after 90 d. Patients from hospitals in the highest volume quintile had about half the odds of death within 30 d than patients from the lowest quintile.Variations in outcomes were generally small, but in the same direction, with consistently better outcomes in the larger hospitals. This gives support to the ongoing trend towards centralisation of clinical services, but service re-organisation needs to take account of not only the size of hospitals but also referral routes and patient access.

Bailey Stone.The Anatomy of Revolution Revisited: A Comparative Analysis of England, France, and Russia.

Bailey Stone.<i>The Anatomy of Revolution Revisited: A Comparative Analysis of England, France, and Russia</i>.

Incidental prostate cancer diagnosed following a transurethral resection of the prostate: A national database analysis in England

Objectives: The aim was to compare prostate cancer and all-cause mortality in patients diagnosed with prostate cancer following a transurethral resection of the prostate (TURP) (incidental prostate cancer, IPC), to men diagnosed with localised non-incidental prostate cancer (NIPC). Patients and methods: Men diagnosed with localised prostate cancer between 2000 and 2008 were identified from the English national cancer registry. Their records were linked to the Hospital Episode Statistics (HES) database of hospital admissions in England to identify men who had a TURP. Men were considered to have IPC if prostate cancer was diagnosed less than 60 days after TURP. Mortality rates were calculated using the Kaplan–Meier method. Mortality rate ratios (RR) comparing IPC and NIPC were calculated with multivariable Poisson regression adjusting for age group, co-morbidities, year of diagnosis and radical treatment. Results: A total of 192,960 men were included. Of these, 6666 (3.5%) had IPC and 186,294 (96.5%) NIPC. Median follow-up was 4.7 years (0.5–11.0). Ten-year prostate cancer mortality was 17.1% in IPC, 19.0% in NIPC. With adjustment, the prostate cancer-specific mortality in IPC was 30% lower than NIPC (RR 0.70, 95% CI 0.65–0.75, p&lt;0.001), with no difference in all-cause mortality. Conclusion: Ten-year prostate cancer mortality in IPC was 17%. Men with IPC had lower prostate cancer-specific mortality than other prostate cancer patients.

Older people's exercising of choice in long-term care: a comparative analysis of England and Japan

ABSTRACTThere has been an increasing emphasis on choice for older people in long-term care in both England and Japan. However, despite the emphasis on the importance of choice, the perspectives of older people have been given little attention. Considering national and local policies in Bristol, England and Kyoto, Japan, the article explores how older people are exercising (and not exercising) choice in care practice through examining the perspectives of the older people themselves, as well as key informants in the field. Empirical data were collected from interviews with older people and key informants in the two countries, and were analysed using qualitative and comparative approaches. Choice in policy is regarded as a mechanism of the market with an assumption of the independent autonomous individual who can exercise ‘rational choice’. However, the findings have reflected older people's relational decision-making, which does not conform to the rational model of decision-making, and illustrates the value of ‘interdependence’. The findings from care practice have shown that choice was considered an important value in involving older people's views and ensuring their needs are met sensitively and respectfully. The findings also suggested that consideration of the psychological aspects of choice is an important aspect of ‘care’, facilitating the inclusion of older people's views in the process of making judgements, in order to meet their needs.

Sociodemographic determinants of place of death in dementia: whole population cross-sectional analysis in England, 2001–10

BackgroundThe in-hospital death rate from dementia in England is among the highest in Europe. The personal, regional, and temporal factors influencing place of death in dementia are unknown. MethodsOffice for National Statistics mortality data were used for whole population cross-sectional analysis of deaths from dementia in England, 2001–10. Place of death (home, hospice, care home, hospital) was the outcome variable. Explanatory variables included demographic, social, and regional factors. Multivariable Poisson regression analysis was used to provide an independent relative risk of place of death for each of the variables studied. The change in place of death over time was studied using linear regression. Findings387 004 deaths were included. Most patients died in care homes (55·3%) or hospital (39·6%). Home deaths (4·8%) and hospice deaths (0·3%) were rare. Hospital deaths were less likely with increasing affluence (relative risk [RR] 0·83, 95% CI 0·81–0·85), and increasing provision of a care-home bed (0·61, 95% CI 0·58–0·63). Lack of social support (marital status) reduced home deaths (RRs 0·45–0·60). Hospice deaths were increased in areas with greater hospice bed provision (RR 4·23, 95% CI 2·14–8·35) and in patients whose underlying cause of death was cancer (19·0, 95% CI 16·2–22·3). Deaths in care homes were more common with increasing affluence (RR 1·28, 95% CI 1·24–1·32) and increased provision of a care-home bed (2·02, 95% CI 1·97–2·08). Time-trend analysis showed a recent decrease in hospital deaths and reciprocal increase in care-home deaths. InterpretationGovernments and policy makers recognise the urgent need for public health planning in dementia. Reducing the number of deaths in hospital, and increasing those at home, in dementia has both societal and economic benefits. Social support, deprivation, and service provision are key targets for policy. FundingNational Institute for Health Research.

Adult Social Care Workforce Analysis in England

Changes in demographic and regulations in social care in England are expected to alter the social care landscape and increase pressure on people working in the adult social care sector, especially those who deliver direct care services. While significant work has been done to understand the demand side of the adult social care system, work on the supply side is considerably limited and analysis has been dominated by methods such as macro- and micro-simulation. This paper demonstrates that system dynamics modelling can be used to understand the dynamics of the social care workforce who deliver direct care services in the formal sector, specifically, to identify the main feedback loops that govern the dynamics of the system, to identify sensitive and influential factors, and to show non-linearity in the system. Therefore, system dynamics should play a more important role in the analysis of adult social care system.

Acquisitive Crime, Sentencing and Detection: An Analysis of England and Wales

We provide the first detailed econometric analysis of the impact of sentencing on various types of acquisitive crime in England and Wales. We examine (a) whether sentencing reduces crime and (b) whether short sentences are more effective than long sentences. Detection is an important explanatory variable whose effect needs to be controlled in order to identify the impact of sentencing. To address the potential endogeneity of detection, we instrument using lagged values of police expenditure and detection. Our results show that detection is significant and negatively affects all crime types while the impact of sentences is negative and significant for all crime except robbery in a linear specification. A quadratic specification shows that the linear term is positive while the square term is negative suggesting short sentences may be counterproductive in reducing robbery. We also control for a number of socio economic variables whose effects significantly affect crime.

Vernacularity in England and Wales, c. 1300-1550 ed. by Elisabeth Salter and Helen Wicker (review)

Reviewed by: Vernacularity in England and Wales, c. 1300-1550 ed. by Elisabeth Salter and Helen Wicker Rebecca F. McNamara Salter, Elisabeth and Helen Wicker, eds, Vernacularity in England and Wales, c. 1300-1550 (Utrecht Studies in Medieval Literacy, 17), Turnhout, Brepols, 2011; hardback; pp. vi, 335; 11 b/w illustrations, 1 b/w table; R.R.P. €70.00; ISBN 9782503528830. 'Language' is conspicuously absent from the title of Elisabeth Salter and Helen Wicker's edited collection. One realizes, however, that 'vernacularity' is indicative of the welcome scope of its contents. The vernacular receives due linguistic scrutiny, but it is also treated alongside national origin myths, devotional experience, architectural description and urban identity, and political enfranchisement. Wicker's Introduction elaborates these strands and contextualizes their place within the growing field of 'vernacular studies'. Michael Clanchy opens the volume's first section, 'Reading and Writing', with an analysis of England's ABC primers. He considers their devotional [End Page 336] and cultural functions and their differences from continental counterparts. Amanda Moss's essay explores the combined inflections of orthodox and heterodox thought found in a fifteenth-century devotional anthology. A 'Complaint of Christ' poem across six manuscripts is described by Salter to demonstrate evidence for vernacular practices within contexts of wider devotional reading. Assembled as 'Religious Experiences', contributions from Sarah James, Rob Lutton, and Stewart Mottram engage with vernacular practices of theological writing in England. James highlights 'chronic instability' in Reginald Pecock's idea of the vernacular, and Lutton breaks traditional boundaries of vernacular scholarship by discussing a multi-genre range of media devoted to the Holy Name of Jesus. Mottram contextualizes Wyatt's Penitential Psalms within contemporary prefaces to English Bibles, showing that clarity was neither the goal nor the product in many cases of vernacular translation. 'Political Issues' begins with Wicker's account of treasonable language trials alongside developing political identities and enfranchisement. Helen Fulton gives a masterful survey of medieval Welsh literature, focusing on gentry writer-patron networks and the tensions and integrations of nonnative origin myths into vernacular Welsh traditions. Our perspective of language in central English government is reoriented by Dodd's refreshing assessment of the political and linguistic nature of the records, a review that refutes the theory of a Lancastrian Chancery English standardization policy. In the volume's final section, 'Conceptual Vocabularies', Jayne Rimmer discusses housing in York and Norwich, highlighting differences and similarities in the language of urban dwellings of the wealthy and poor, and across regional areas. Andrew Butcher's analysis of a Canterbury Cathedral administration book includes an index of its English words and posits vernacular behaviour as informing the creation and collection of its documents. Concluding with remarks from Ian Johnson, this collection creatively emphasizes the vernacular aspects and the non-homogeneous nature of late medieval English and Welsh cultures. Its approaches and scope will provide valuable direction for further studies of vernacularity. [End Page 337] Rebecca F. McNamara Medieval and Early Modern Centre The University of Sydney Copyright © 2012 by the Author

Promoting Responsibility, Shaping Behaviour: Housing Management, Mixed Communities and the Construction of Citizenship

This paper examines housing policies aimed at establishing mixed income communities. Based on stakeholder interviews and case study analysis in England and Scotland, the paper pays particular attention to the impact of interventions in housing management. The first part considers the policy context for mixed communities and considers the conceptual basis underlying contemporary housing management through discourses of culture and social control. The second part considers how this agenda has resulted in the adoption of intensive management strategies within mixed communities; illustrated in the development of allocation policies, initiatives designed to tackle anti-social behaviour, and proposals to develop sustainable communities. The main argument is that given that the concept of mixed communities is based on the premise of social housing failure, citizenship has been defined largely in response to private sector interests. This approach to management has been a contributory factor in the construction of social housing as a form of second-class citizenship.