Inequalities In Provision Research Articles

A new health technology: where is the consensus on a clinically worthwhile benefit?

New therapies are often introduced into the NHS prior to full evaluation, leading to inequities in provision. Uncertainty exists regarding the value of photodynamic therapy in the treatment of neovascular age-related macular degeneration. We ascertained the availability of this treatment and the information used to inform clinical policy. A postal survey of all clinical directors/lead consultants in the UK sought data on which (if any) patients were referred or treated with PDT by their unit, the sources of evidence informing clinical policy and the threshold of clinical benefit at which respondents would support the use of PDT. 123/152 questionnaires were returned. 42% of units make some provision for PDT on the NHS, including routine provision by 9%. 14.5% of units offer the option of care in the private sector, whilst 26.5% treated or referred no patients. The threshold at which respondents considered introduction of PDT would be justifiable varied widely. Respondents cited local literature review, advice from clinicians, guidance from the Royal College and information from the pharmaceutical industry as most influential in determining current policy. However, the National Institute for Clinical Excellence (NICE) and the Cochrane Library were anticipated as playing a greater role in shaping future practice. Substantial variation exists in the availability of PDT. Advocates of PDT may interpret our data as an indication of the NHS failing to provide an effective therapy equitably, whilst others may deduce that patients are receiving an under-evaluated treatment in routine clinical practice. The differing thresholds at which clinicians believe treatment would be justified may further exacerbate variations and the priority given to PDT.

A Surfeit of Socks? The Impact of the First World War on Women Correspondents to Daily Newspapers

This article is based on such material and shows how the predominant subject matter for ladies’ letters during the war years was that of voluntary fundraising for the many charities and associations connected with the war. Such charities were often suggested to the women through personal or local ties - family members at the front; local regiments or Scottish connections. As we shall see, these women perceived their war work in localised or provincialised terms, and were led by the local elite, in both the city and the surrounding countryside. Whilst this approach did eventually lead to inequalities in provision for the men at the front, the hospitals and the prisoners of war, this voluntary approach was at first the only one which existed - and such an approach was part of the government’s own approach to the war until late 1915. After this time, and with the growing power of Lloyd George, the government and local authorities began to impose a more centralised and less personalised approach to the voluntary organisations. While this approach was at first resented by many of the charitable ladies affected, as can be seen in their letters to the newspapers, it was necessary in order to provide a more uniform approach to the provision of comforts and necessary medical items to the ever-increasing number of men and women in need.

The Limits of External Empowerment: EMU, Technocracy and Reform of the Greek Pension System

This paper seeks to explain an aborted attempt at reform of the Greek pension system, following a series of previous failures. It applies the framework of rational choice institutionalism in order to examine the strategy and setting of the relevant actors. The pension system had become a huge fiscal burden on the state, threatening Greece's position in the European Union. Moreover, its gross inequalities of provision and bureaucratic inefficiency were symptoms of the embedded clientelism and ‘disjointed corporatism’ that stood in the way of the government's self-proclaimed ‘modernization’ programme. In the event, though EMU entry requirements empowered the reform momentum, a combination of the strategic weakness of key actors and the entrenched opposition of sectoral interests dissipated the initiative. The failure suggests the relevance of the wider social setting to reform: in particular, the weakness of the technocratic community and the relative absence of a supportive ‘advocacy coalition’, beyond the dominance of the ‘party state’. Faced with criticism, the political leadership sought to protect their electoral position and postponed pressing decisions. The case study raises important questions about the scope for such reform in Greece and the future stability of the ‘Euro-zone’.

A time for change and a time for equality — Infertility services and the NHS

The provision of infertility services has always provoked controversy. On the one hand, patients' groups and clinicians involved with infertile couples have long campaigned against the ‘postcode lottery’. On the other hand, commissioners have been reluctant to commit resources to what they see as a low priority in health care. The issue has been brought back into the news with the government's decision to ask the National Institute of Clinical Excellence to review the inequalities in provision of fertility services. This article sets out the evidence for viewing infertility as an illness that deserves public funding, and argues that assisted conception should be viewed in the same light as other chronic non-life-threatening conditions that are currently funded by the NHS.

Inequalities in provision of systematic care for patients with diabetes.

GPs are now playing a greater role in the care of people with diabetes; however, the level of performance in primary care is variable. Practices with a recall system and diabetes mini-clinic have been shown to achieve better outcome of care of patients with diabetes. Systematic care also requires effective community-based diabetes services and access to primary care diabetes teams including dieticians, chiropodists, and optometrists and ophthalmologists. The aims of this study were to determine how services for people with diabetes are organized in primary care and whether there are inequalities in systematic care of people with diabetes. A piloted postal questionnaire was sent to all 327 general practices in three health authorities in England serving a population of >2 million people. The three health authorities provided practice-based routine data relating to all general practices. A total of 264 (80.7%) practices replied; 236 (89.4%) employed a diabetes recall system and 196 (74.2%) reviewed their patients in a diabetes mini-clinic. Multiple regression showed that having a recall system was associated independently with a GP [odds ratio (OR) 6.2; 95% confidence interval (CI) 2.6-14.9] or a practice nurse (OR 3.5; 1.4-8.7) with an interest in diabetes. Having a diabetes mini-clinic was associated independently with a GP with an interest in diabetes (OR 4.1; 2.1-7.8), a practice nurse having attended a diabetes course (OR 2.8, 1.3-6.2), practices with more partners (OR 1.2 per additional partner; 1.0-1.4) and fundholding practices (OR 2.6; 1.2-5.5). One hundred and sixteen (43.9%) practices had a chiropodist present in the practice, and 90 (34.1%) had a practice-based dietician. A chiropodist and a dietician were significantly more likely to be attached in training practices and in less deprived areas. A practice-based dietician was significantly associated with larger practices. Providing high quality primary care is essential to meeting the government's agenda of reducing inequalities. This study shows high levels of structured diabetes care which are not related to deprivation. However, practices in more deprived areas still lag behind practices in more affluent areas in terms of access to members of the diabetes team. To improve care of people with diabetes in primary care, deficiencies and inequalities highlighted in our survey must be addressed. The results of this survey will be valuable to primary care groups and organizations responsible for commissioning diabetes services.

A survey of social services needs assessments for elderly mentally ill people in England and Wales.

to examine variations in the needs assessment policies and practices of social services departments in England and Wales in dealing with elderly people who have mental illness. postal questionnaire survey. a random sample of 61 of 119 social services departments in England and Wales. 99-item questionnaire. 40 responses were received (66%). There were substantial differences in the way referrals were screened before needs assessment and in the design of needs assessment procedures. Disagreements between health and social services were common and, although mechanisms existed to respond to urgent needs, almost one-third found such responses difficult to make. there are national variations in the way needs assessments are performed by social services, which may lead to inequalities in provision of care to individuals. The lack of a standardized approach impedes comparisons of need between areas which might aid in the distribution of resources at a national level.

Trends in geographical inequalities in provision of general practitioners in England and Wales

The figure plots the trend in the inequality index based on both actual and need-adjusted populations. There was a decline in inequality from 1974 to mid 1980s but inequality then stopped falling and may even have increased. In 1995, 2·9% of GPs would have had to move to achieve an equal provision per head of population. Equal provision per head of need-adjusted population would have required the movement of 5·2%. This would have implied substantial changes in GP/need-adjusted population ratios for some areas: the maximum increase required was 36·7% and the maximum decrease was 26·8%. The finding that there is still substantial inequity is supported by other studies. The distribution of GPs is regulated by the Medical Practices Committee (MPC) which defines two types of under-doctored areas: designated (less than 4 GPs per 10 000 population) or open (between 4 and 4·8 GPs per 10 000). The numbers living in open or designated areas fell from 30·4 million in 1974 to 3·4 million in 1994. The MPC argues that it has been successful in reducing inequality. The MPC uses an absolute inequality concept: provision is compared to some absolute standard. The Robin Hood index reflects relative inequality: provision is compared between areas. A 10% increase in the number of GPs in all areas would reduce absolute inequality but would have no effect on the Robin Hood index. Our finding that there has been no recent reduction in relative inequality suggests that new methods for influencing the location of GPs should be considered.

School Choice and the Common Good: a reply to Brighouse

In my previous article and rejoinder (Walford, 1996a & b) I argued against the view put forward by David Hargreaves (1996) for increased choice and diversity in secondary schooling. First, I argued that his application of a 'cost-benefit' approach to discussions about the desirability of greater choice and diversity is itself highly problematic and ideological. Second, I examined documents on which he based his argument and showed them to be only partially relevant. Third, I traced elements of the social and political context that generated the current interest in increased choice of school and argued that, within this context, his proposals were highly likely to lead to greater inequity between the experiences of children. Finally, I outlined and defended my own proposals for reform that David Hargreaves had attacked in his paper. My discussion of the various government policies that have attempted to increase choice and diversity was designed to provide a context in which the likely practical consequences of David Hargreaves's proposals could be understood. I sought to show that, the 'now widespread (i.e. common-sensical) view that choice is desirable' did not simply appear from nowhere, but had to be generated by government and that, in practice, various policies that invoked 'choice and diversity' have led to increased selection and inequality of provision. I argued that there is actually very little demand for true diversity. Choice is not 'naturally' paired with diversity, but with selection and inequity of provision. While there are some parents who desire schools that serve their own particular religious beliefs, in general there is little demand for curriculum specialisms or schools supporting particular religious or moral philosophies. There is growing research evidence that, where such curriculum specialisms are being introduced by schools, they are acting as selection mechanisms for high academic ability and middle-class children. In particular, the development of specialisms such as dance or music indirectly discriminates against working-class children, and allows schools a greater chance to select 'appropriate' children.

A Rejoinder to Hargreaves

(1996). A Rejoinder to Hargreaves. Oxford Review of Education: Vol. 22, No. 2, pp. 159-160.

Gender differences in child care and work: An interdisciplinary perspective

During the past several decades, women have increased their labor-force participation while remaining primarily responsible for the care of children. Men have not correspondingly increased their home activity, and women's earnings have not reached parity with men's. A primary reason that women have failed to gain equality in the labor market may be the remaining inequalities in provision of child rearing. We consider the constraints on child rearing faced by men and review literature on animal behavior to elucidate the conditions that facilitate parental investment by males. Some factors appear to have congruent effects, in general, on paternal behavior in many species: the benefit to young of male help, the male capacity for providing help, and paternity certainty. We discuss the role of these factors in slowing the achievement of gender equality and the potential efficacy of social policy in changing existing behavior patterns.

The Economics of Bureaucracy and the British National Health Service

mists have analyzed the British National Health Service (NHS). Common to most of these studies are the findings that the NHS has failed to achieve efficiency in the use of resources and equality in access to health care. However, the studies differ with respect to what is the basic cause of these problems. Cooper (1975) and Culyer (1976) seem to argue that the problem is essentially one of poor information and excessive discretion on the part of physicians. According to Cooper (1975:107), "the clinical freedom to differ widely as to their [physicians'] conception of need has led to inconsistencies of treatment between patients and to the allocation, without challenge, of scarce resources to medical practices of no proven value." He also notes that "lack of research into indicators of need has enabled gross inequalities of provision to persist on the grounds that, in the absence of any evidence to the contrary, they might in fact, however accidentally, reflect needs" (Cooper, 1975:109). In a similar vein, Culyer (1976:110) claims that "the efficient and fair operation of the health service requires the establishment of national norms and a substantial reduction in the discretion of individual hospital doctors." The latter would be accomplished by requiring