The impact of National Institute for Health and Care Excellence Clinical Guideline 168 on the management of superficial venous disease

INTRODUCTION In 2013, NICE published new guidance (CG168) for the management of lower limb venous disease; these guidelines sought to improve access to secondary care and recognised newer endovenous treatment modalities sufficiently robust to recommend. No formal study had evaluated the effect of the introduction of Guideline CG168 on venous disease management; this prompted the research project embodying this thesis. METHODS The management of venous disease was investigated locally at a secondary care level with primary care management being studied via the Health Improvement Network Database. RESULTS Local secondary care has improved significantly since the introduction of CG168, demonstrating an increased use of endovenous treatments at earlier stage of venous disease. A significantly higher number of patients are being referred for specialist review with leg ulceration. An improvement in referral and management of varicose veins in the community setting was noted, however the increase in referral for leg ulceration was more modest, with patients often not referred at all for secondary care assessment. CONCLUSION Whilst current data presented here suggests enhanced management of superficial venous disease, nationwide primary care improvements have been less marked. Further efforts will be required to continue to publicise the importance of NICE Guideline CG168 in order to extend its beneficial effects on patient care

Financing Long-Term Care for Elderly People

Last year’s report of the Royal Commission on Long Term Care (1) and the expected Government response have prompted fresh interest in the debate on how to fund long-term care. To inform this debate the Personal Social Services Research Unit (PSSRU) has conducted a study, funded by the Department of Health, of long-term care demand and finance. This has involved the construction of a computer model to make projections of likely demand and expenditures to 2031. This article describes the model of long-term care demand and expenditure developed by the PSSRU. It then presents some of the results obtained and sensitivity analysis around them

CO2 sequestration: the risk of leakage

The Utsira Sand is a major North Sea Saline aquifer. It is currently being utilised as a CO2 sequestration reservoir for the Sleipner project, and its large estimated storage capacity and proximity to suitable infrastructure ensures that it is an attractive prospect for further storage projects. As a forerunning CCS project it is the subject for scrutiny from environmental, industrial and governmental regulatory bodies, with the key concern being the confinement of the CO2 within the reservoir. Regulations are in place to ensure that operators monitor closely the migration of the CO2 plume within storage reservoirs and that they can demonstrate that the plume is behaving as modelled. Any unexpected behaviour of the plume requires escalation of the monitoring program and leakage would involve financial penalties in addition to remediation costs. Diligent site selection and a complete and robust understanding of the reservoir, adjacent units, and the overburden is therefore critical pre-injection. Geological features which have become apparent following CO2 injection into the Utsira Sand would suggest that the injection site was not completely understood before injection commenced. This study has contributed to a better understanding of the storage reservoir, specifically in regards to the deformed base of the Utsira Sand, which has been shown to be the result of sand remobilisation from depth in the form of sand intrusions. These intrusions, hosted within low permeability shales, represent permeable migration pathways from the deeper subsurface to the base of the Utsira Sand. Furthermore, their post-emplacement compaction has facilitated subsidence of the overlying strata. This movement, shown to affect strata up to the top of the Utsira Sand, has formed a ring of faults which projects obliquely upwards from the base of the Utsira Sand to the top of the storage reservoir. Amplitude anomalies within the overburden suggest that these zones of increased permeability have been exploited as paleo-gas migration pathways. Other amplitude anomalies within the succession overlying the Utsira Sand are also recognised. These include: high amplitude anomalies interpreted as gas accumulations within the Lower Seal, vertically focused ‘wipe out zones’ and zones of disrupted reflections interpreted as gas chimneys. The gas chimneys in particular, shown to extend to the seafloor, pose a significant leakage risk to sequestered CO2. On the basis of these observations, a plumbing system, from the Mid-Miocene to the seafloor, is presented. Potential CO2 leakage scenarios are proposed and discussed in respect to the storage ‘site’ and storage ‘complex’. It is suggested that potential future operators within this area should be aware of the features observed and appreciate the associated risk to stored CO2. It is also concluded that the viability of carbon sequestration technology as a climate change mitigation option requires that it represents an attractive proposition for those that operate the technology. Therefore it is considered that the regulation of carbon sequestration requires a finely measured balance between careful regulation and appropriate penalties for poor practice and flexibility in the interpretation of a ‘storage complex’ and ‘leakage.

Re-conceptualising Territorial Cohesion Through the Prism of Spatial Justice : Critical Perspectives on Academic and Policy Discourses

Peer reviewe

Securing good care for older people: taking a long-term view

The paper aims to explain and evaluate two key features of Securing Good Care for Older People, the Wanless Report on alternative mechanisms for funding long-term care of older people. One is the new elements of the methodology for evaluating the alternatives (section 1.1). The paper argues that more successfully than previously and analyses in other countries, these elements focus attention on what are really the core issues: the means and ends which are the unique foci of long-term care, and estimates of the consequences of alternatives for them. By doing so, the report faces the politicians and policy analysis and research communities with a formidable challenge, to master and contribute to the development of the new framework and evidence. Failure to meet the challenge will increases the risk that the policy system will reinforce rather than weaken causes of gross inequity and inefficiency caused by the under-funding of long-term care seemingly unanswerably demonstrated by the report. The second key feature is the type of funding model the Report recommends given expected changes in the balance between demands and public expenditure. Section 1.2 argues that the report’s analysis as successfully transforms the state of the argument about this as much as about the framework, methodology and evidence for evaluating alternatives, demonstrating the relative weakness of models widely advocated a decade ago. Part 2 discusses how to build on the Report. Section 2.1 discusses the framing of issues and the analysis of evidence for each of the key foci of the report’s main contribution to evaluation methodology. Section 2.2 discusses whether the recommended model would be the wisest choice given the environment likely during the next few decades

To what degree have the British community care reforms met the pre-reform criticisms of targeting?

It was not until the late 1980s that there was evidence for detailed analysis of the relations between resources, needs, andoutcomes: persons in what need-related circumstances obtained publicly-subsidised and/or brokered access to how much of what kind of service, with what effects on whom, and at what costs to whom. Very soon we shall comparison of resources, needs and outcomes for users recruited in 1984/5 with those recruited in 1995. In what follows, I shall risk some tentative generalisations from the half-analysed results of a before-after evaluation of the community care changes. The study was based on two cohorts of persons assessed and allocated community social services. One cohort was recruited during 1984/5 [hereafter, 1985], and was followed for at least 117 weeks. The second cohort was recruited during 1995, and is still being followed. The evidence is particularly rich about the circumstances and perceptions of field-level triads of users, principal informal caregivers, and their care managers. Data are still being collected and analysed, making some comparisons impossible as yet. The generalisations must be tentative. The analyses for the second cohort are still in progress, and there has not been the analyses for both cohorts simultaneously to get the highest degree of precision achievable with respect to the precise question asked, the definition of variables, and model

Productivities. Efficiency, and Three Policy Propositions

This note applies ECCEP estimates of service productivity curves, service prices, and service utilisation, and the predictions about the consequences of achieving perfect efficiency, in the discussion of three policy propositions. It deals primarily with only two of the seventeen outputs for which productivity curves have been estimated. Section I: defines two dimensions of productive efficiency analysed, explains and justifies in the context of reform argument the choice of three scenarios setting the framework for deducing the implications of productivities, prices and information about utilisation for what would be the best allocation of resources, andrelates the targeting implications of making the best use of resources to targeting strategies for investment in efficiency improvement. Section II suggests what light the results throw on three policy propositions: allocate more to the less on the less dependent, if necessary, releasing resources by allocating less to the more dependentspend less on the older community services, andgive higher priority to caregivers, less to users</li