Revisiting the 'Missing Middle' in English Sub-National Governance

In the light of the new Coalition Government’s proposed ‘rescaling’ of sub-national governance away from the regional level, it is an opportune time to re-consider the strength and weaknesses of the city or sub-regional approach to economic development and to search, once more, for the ‘missing middle’ in English Governance. In this context, the article initially assesses the case for city or sub regions as tiers of economic governance, before examining the lessons to be learnt from the experiences of the existing city regions in the North East of England. It argues that while contemporary plans to develop Local Enterprise Partnerships (LEPs) can be usefully considered within the context of the emerging city regional developments under the previous Labour Governments, a number of important challenges remain, particularly in relation to ensuring accountable structures of governance, a range of appropriate functions, adequate funding, and comprehensive coverage across a variety of sub-regional contexts. While the proposals of the new Government create the necessary ‘space’ to develop sub-regional bodies and offer genuine opportunities for both city and county LEPs, the scale of the sub-regional challenge should not be underestimated, particularly given the context of economic recession and major reductions in the public sector

Assessing the feasibility, acceptability and potential effectiveness of Dignity Therapy for people with advanced cancer referred to a hospital-based palliative care team: Study protocol

<p>Abstract</p> <p>Background</p> <p>Loss of dignity for people with advanced cancer is associated with high levels of psychological and spiritual distress and the loss of the will to live. Dignity Therapy is a brief psychotherapy, which has been developed to help promote dignity and reduce distress. It comprises a recorded interview, which is transcribed, edited then returned to the patient, who can bequeath it to people of their choosing. Piloting in Canada, Australia and the USA, has suggested that Dignity Therapy is beneficial to people with advanced cancer and their families. The aims of this study are to assess the feasibility, acceptability and potential effectiveness of Dignity Therapy to reduce psychological and spiritual distress in people with advanced cancer who have been referred to hospital-based palliative care teams in the UK, and to pilot the methods for a Phase III RCT.</p> <p>Design</p> <p>A randomised controlled open-label trial. Forty patients with advanced cancer are randomly allocated to one of two groups: (i) Intervention (Dignity Therapy offered in addition to any standard care), and (ii) Control group (standard care). Recipients of the 'generativity' documents are asked their views on taking part in the study and the therapy. Both quantitative and qualitative outcomes are assessed in face-to-face interviews at baseline and at approximately one and four weeks after the intervention (equivalent in the control group). The primary outcome is patients' sense of dignity (potential effectiveness) assessed by the Patient Dignity Inventory. Secondary outcomes for patients include distress, hopefulness and quality of life. In view of the relatively small sample size, quantitative analyses are mainly descriptive. The qualitative analysis uses the Framework method.</p> <p>Discussion</p> <p>Dignity Therapy is brief, can be delivered at the bedside and may help both patients and their families. This detailed exploratory research shows if it is feasible to offer Dignity Therapy to patients with advanced cancer, many of whom are likely to be in the terminal stage of their illness, whether it is acceptable to them and their families, if it is likely to be effective, and determine whether a Phase III RCT is desirable.</p> <p>Trial registration</p> <p>Current Controlled Clinical Trials: ISRCTN29868352</p

Self-neglect and safeguarding adult reviews: towards a model of understanding facilitators and barriers to best practice

Purpose – One purpose is to update the core dataset of self-neglect safeguarding adult reviews and accompanying thematic analysis. A second purpose is to draw together the learning available from this dataset of reviews to propose a model of good practice that can be used as the basis for subsequent safeguarding adult reviews. Design/methodology/approach – Further published reviews are added to the core dataset from the web sites of Safeguarding Adults Boards. Thematic analysis is updated using the four domains employed previously. A sufficient number of reviews have been done from which to construct an evidence-based model of good practice. A framework is presented with the proposition that this can be used as a proportional methodology for further safeguarding adult reviews where self-neglect is in focus. Findings – Familiar findings emerge from the thematic analysis. This level of analysis, constructed over time and across reviews, enables a framework to be developed that pulls together the findings into a model of good practice with individuals who self-neglect and for policies and procedures with which to support those practitioners involved in such cases. This framework can then be used as an evidence-based model with which to review new cases where safeguarding adult reviews are commissioned.   Research limitations/implications – The national database of reviews commissioned by SABs is incomplete and does not contain many of the safeguarding adult reviews reported in this evolving dataset. The Care Act 2014 does not require publication of reports but only a summary of findings and recommendations in SAB annual reports. It is possible, therefore, that this dataset is also incomplete. Drawing together the findings from the reviews nonetheless enables conclusions to be proposed about the components of effective practice, and effective policy and organisational arrangements for practice. Future reviews can then explore what enables such effective to be achieved and what barriers obstruct the realisation of effective practice. Practical implications – Answering the question “why” is a significant challenge for safeguarding adult reviews. A framework is presented here, drawn from research on safeguarding adult reviews featuring self-neglect, that enables those involved in reviews to explore the enablers and barriers with respect to an evidence-based model of effective practice. The framework introduces explicitly research and review evidence into the review process. Originality/value – The paper extends the thematic analysis of available reviews that focus on work with adults who self-neglect, further building on the evidence base for practice. The paper also proposes a new approach to safeguarding adult reviews by using the findings and recommendations systematically within a framework designed to answer “why” questions – what promotes and what obstructs effective practice.   Keywords: Safeguarding adult reviews, evidence, self-neglect, proportionality Paper type: Research pape

Sea-level rise impacts on transport infrastructure: the notorious case of the coastal railway line at Dawlish, England

Future climate change is likely to increase the frequency of coastal storms and floods, with major consequences for coastal transport infrastructure. This paper assesses the extent to which projected sea-level rise is likely to impact upon the functioning of the Dawlish to Teignmouth stretch of the London to Penzance railway line, in England. Using a semi-empirical modelling approach, we identify a relationship between sea-level change and rail incidents over the last 150 years and then use model-based sea-level predictions to extrapolate this relationship into the future. We find that days with line restrictions (DLRs) look set to increase by up to 1170%, to as many as 84–120 per year, by 2100 in a high sea-level rise scenario (0.55–0.81 m). Increased costs to the railway industry deriving from maintenance and line restrictions will be small (£ millions) in comparison with damage caused by individual extreme events (£10s of millions), while the costs of diversion of the railway are higher still (£100s of millions to billions). Socio-economic costs to the region are likely to be significant although they are more difficult to estimate accurately. Finally, we explain how our methodology is applicable to vulnerable coastal transport infrastructure worldwide

Identification and validation of oncologic miRNA biomarkers for Luminal A-like breast cancer

Introduction: Breast cancer is a common disease with distinct tumor subtypes phenotypically characterized by ER and HER2/neu receptor status. MiRNAs play regulatory roles in tumor initiation and progression, and altered miRNA expression has been demonstrated in a variety of cancer states presenting the potential for exploitation as cancer biomarkers. Blood provides an excellent medium for biomarker discovery. This study investigated systemic miRNAs differentially expressed in Luminal A-like (ER+PR+HER2/neu-) breast cancer and their effectiveness as oncologic biomarkers in the clinical setting. Methods: Blood samples were prospectively collected from patients with Luminal A-like breast cancer (n=54) and controls (n=56). RNA was extracted, reverse transcribed and subjected to microarray analysis (n=10 Luminal A-like; n=10 Control). Differentially expressed miRNAs were identified by artificial neural network (ANN) data-mining algorithms. Expression of specific miRNAs was validated by RQ-PCR (n=44 Luminal A; n=46 Control) and potential relationships between circulating miRNA levels and clinicopathological features of breast cancer were investigated. Results: Microarray analysis identified 76 differentially expressed miRNAs. ANN revealed 10 miRNAs for further analysis ( miR-19b, miR-29a, miR-93, miR-181a, miR-182, miR-223, miR-301a, miR-423-5p, miR-486-5 and miR-652 ). The biomarker potential of 4 miRNAs ( miR-29a, miR-181a , miR-223 and miR-652 ) was confirmed by RQ-PCR, with significantly reduced expression in blood of women with Luminal A-like breast tumors compared to healthy controls (p=0.001, 0.004, 0.009 and 0.004 respectively). Binary logistic regression confirmed that combination of 3 of these miRNAs ( miR-29a, miR-181a and miR-652 ) could reliably differentiate between cancers and controls with an AUC of 0.80. Conclusion: This study provides insight into the underlying molecular portrait of Luminal A-like breast cancer subtype. From an initial 76 miRNAs, 4 were validated with altered expression in the blood of women with Luminal A-like breast cancer. The expression profiles of these 3 miRNAs, in combination with mammography, has potential to facilitate accurate subtype- specific breast tumor detection

Delivering NEET policy packages? A decade of NEET policy in England

This article explores the way in which government policy shapes the lives of young people who are not in education, employment or training (NEET). In particular it examines how the concept of NEETs is set within a specific infrastructure and discourse for managing and supporting young people. The article provides a brief history of the NEET concept and NEET initiatives, before moving on to scrutinise the policies of the Coalition Government. A key distinction is made between those policies and practices that seek to prevent young people becoming NEET from those that seek to re-engage those who are NEET. It is argued that the Coalition has drawn on a similar active labour market toolkit to the previous Labour administration, but that this has been implemented with fewer resources and less co-ordination. It concludes that there is little reason to believe that Coalition policy will be any more successful than that of the previous government, and some reason to be concerned that it will lead to young people becoming more entrenched within NEET

The ‘appropriate adult’: what they do and what they should do in police interviews with mentally disordered suspects

Background: In almost all countries worldwide, the first point of contact with the criminal justice system is with the police. A large proportion of these individuals may have vulnerabilities, such as mental health difficulties. Given the complexities associated with vulnerable suspects, such interviews may be compromised, which could lead to a miscarriage of justice. In England and Wales, the Police and Criminal Evidence Act (PACE) 1984 and its accompanying Codes of Practice lay down requirements for interviewing vulnerable suspects and provide for attendance of ‘appropriate adults’ to support communication between police and the vulnerable suspect. To date, however, their role has been under-researched. Aims/Hypotheses: To explore the role of appropriate adults in police interviews and test the hypotheses first that appropriate adults more commonly remain passive during interview than expected from guidance and, secondly, that any interventions are more likely than not to follow examples in current guidance. Methods: Transcripts of police interviews conducted with suspects with possible mental disorder and an appropriate adult present (N = 27) were analysed using a specially developed coding framework. Results: Appropriate adults were significantly more likely to remain passive than to intervene, even when current guidance would suggest intervention. When they did intervene, however, such interventions were significantly more likely than not to follow from guidance and the vulnerable suspect’s needs. Conclusions/Implications for practice: In our sample, appropriate adults were not fulfilling their role as outlined in the Police and Criminal Evidence Act (PACE) 1984 and accompanying Codes of Practice, specifically, they appeared to know what to do but not when to do it. There is a heightened risk of a miscarriage of justice in such circumstances without improvements

Amount and timing of group-based childcare from birth and cognitive development at 51 months: a UK study

This study investigated whether the amount and timing of group-based childcare between birth and 51 months were predictive of cognitive development at 51 months, taking into account: other non-parental childcare; demographic characteristics; cognitive development at 18 months, sensitive parenting and a stimulating home environment. Children’s (N=978) cognitive development was assessed at 51 months with four subscales of the British Ability Scales, two verbal and two non-verbal. Mothers were interviewed and observed at 3, 10, 18, and 36 months and the quality of group care was assessed at 10, 18 and 36 months (N=239) if it was used for ≥12 hours per week. Age of starting in group care and amount were highly associated (r=-.75). Multiple regressions indicated that, controlling for other factors, higher cognitive development and particularly non-verbal ability was associated with more hours per week in group care from 0 to 51 months, or an earlier start, or group care before age 2. Nevertheless, the majority of variance was explained by other predictors: sex (girl), higher cognitive development at 18 months, older mother, first language English, mother of white ethnic background, with more qualifications, higher family social class, more maternal responsivity at 10 months and a more stimulating home learning environment (HLE) at 36 months. Hours per week in relative care or home-based care were not significant predictors of cognitive scores. For the smaller relatively advantaged sample who had group care quality information (N=239), quality was a marginal predictor of better cognitive development but age of starting group care was not. Most variance was explained by 18 month cognitive development, maternal education and family social class

Dermatofibrosarcoma presenting as a nodule in the breast of a 75-year-old woman: a case report

ABSTRACT: INTRODUCTION: Dermatofibrosarcoma protuberans is a rare neoplasm of soft tissues and its location in the breast is extremely uncommon. Confusion is possible with other primary breast lesions. CASE PRESENTATION: A 75-year-old Caucasian woman presented with a mass in her left breast 21 years after being diagnosed with invasive ductal carcinoma of the right breast, treated by a right mastectomy and axillary dissection followed by radiotherapy and breast reconstruction. Mammography revealed a dish-shaped skin nodule formation in the upper outer quadrant of her left breast. Echography confirmed the presence of a lesion measuring 1.4 x 0.8 cm. Based on imaging, the diagnosis was a probable angiosarcoma. Due to the presence of a pacemaker for cardiac arrhythmia and full anticoagulation therapy for a pulmonary embolism, magnetic resonance imaging and a biopsy were not done. We proceeded directly to a quadrantectomy and the final diagnosis revealed a dermatofibrosarcoma protuberans, 1. 8 cm in its greatest microscopic dimension, located 0.1 cm from the upper surgical margin. To ensure the wide resection margins required for this type of neoplasm, a re-excision was performed. CONCLUSION: A dermatofibrosarcoma protuberans of the breast is an uncommon discovery. The aim of this case report is to highlight the importance of the surgical procedure in cases of the discovery of dermatofibrosarcoma protuberans. Re-excision may be necessary to ensure adequate resection margins

Incidence and survival of oesophageal and gastric cancer in England between 1998 and 2007, a population-based study

BACKGROUND: Major changes in the incidence of oesophageal and gastric cancers have been reported internationally. This study describes recent trends in incidence and survival of subgroups of oesophageal and gastric cancer in England between 1998 and 2007 and considers the implications for cancer services and policy. METHODS: Data on 133,804 English patients diagnosed with oesophageal and gastric cancer between 1998 and 2007 were extracted from the National Cancer Data Repository. Using information on anatomical site and tumour morphology, data were divided into six groups; upper and middle oesophagus, lower oesophagus, oesophagus with an unspecified anatomical site, cardia, non-cardia stomach, and stomach with an unspecified anatomical site. Age-standardised incidence rates (per 100,000 European standard population) were calculated for each group by year of diagnosis and by socioeconomic deprivation. Survival was estimated using the Kaplan-Meier method. RESULTS: The majority of oesophageal cancers were in the lower third of the oesophagus (58%). Stomach with an unspecified anatomical site was the largest gastric cancer group (53%). The incidence of lower oesophageal cancer increased between 1998 and 2002 and remained stable thereafter. The incidence of cancer of the cardia, non-cardia stomach, and stomach with an unspecified anatomical site declined over the 10 year period. Both lower oesophageal and cardia cancers had a much higher incidence in males compared with females (M:F 4:1). The incidence was also higher in the most deprived quintiles for all six cancer groups. Survival was poor in all sub-groups with 1 year survival ranging from 14.8-40.8% and 5 year survival ranging from 3.7-15.6%. CONCLUSIONS: An increased focus on prevention and early diagnosis, especially in deprived areas and in males, is required to improve outcomes for these cancers. Improved recording of tumour site, stage and morphology and the evaluation of focused early diagnosis programmes are also needed. The poor long-term survival reinforces the need for early detection and multidisciplinary care