The unavoidable costs of ethnicity : a review of evidence on health costs

This report was commissioned by the Advisory Committee on Resource Allocation (ACRA), and prepared by the Centre for Health Services Studies (CHESS) and the Centre for Research in Ethnic Relations (CRER) at the University of Warwick. The NHS Executive does not necessarily assent to the factual accuracy of the report, nor necessarily share the opinions and recommendations of the authors. The study reviews the evidence concerning the degree to which the presence of populations of minority ethnic origin was associated with ‘unavoidable additional costs’ in health service delivery. While local health authorities retail full autonomy in their use of funds allocated to them under the Hospital and Community Health Services formula, the size of that budget is governed by a set of weightings applied to their population, to allow for factors known to influence levels of need, and the costs of providing services. The study began by considering the definitions used in describing ‘ethnicity’ and ethnic groups in relevant medical and social policy literature. It is clear that no fixed set of terms can be adopted, and that flexibility is required to respond to social changes. The terms used in the 1991 Census, with additions to allow for local and contemporary developments, provide a suitable baseline but require additional information on religion language and migration history for clinical and health service delivery planning. There have been notable developments in health service strategy to meet the needs of black and minority ethnic groups which have been encouraged by good practice guidelines and local initiatives. Together with research into epidemiology and ethnic monitoring of services, these have enlarged understanding of the impact of diversity. A conceptual model is developed which explores the potential for such diversity to lead to variations in the cost of providing health services to a multi-ethnic population. The research team reviewed the existing published evidence relating to ethnic health and disease treatment in medical, social science, academic and practitioner literature, using conventional techniques. Additional evidence was located through trawls of ‘grey’ literature in specialist collections, and through contacting all English health districts with a request for information. A number of authorities and trusts provided written and oral evidence, and a bibliography of key materials is provided. Key issues considered include the need for and use of, interpreter and translation services, the incidence of ‘ethnically-specific’ disease, and variations in the prevalence and cost of treating ‘common’ conditions in minority ethnic populations. Sources of variation are discussed, and a ‘scoping’ approach adopted to explore the extent to which these variations could be adequately modelled. It is clear that while some additional costs can be identified, and seen to be unavoidable, there are other areas where the presence of minority populations may lead to lessened pressures on budgets, or where provision of ‘ethnic-specific’ facilities may be alternative to existing needs. The literature provides a range of estimates which can be used in a modelling exercise, but is deficient in many respects, particularly in terms of precise costs associated with procedure and conditions, or in associating precise and consistent categories of ethnic group with epidemiological and operational service provision data. Certain other activities require funding to set them up, and may not be directly related to population size. There is considerable variation in the approaches adopted by different health authorities, and many services are provided by agencies not funded by NHS budgets. The study was completed before the announcement of proposed changes in health service commissioning which may have other implications for ethnic diversity. The presence of minorities is associated with the need to provide additional services in respect of interpreting and translation, and the media of communication. In order to achieve clinical effectiveness, a range of advocacy support facilities or alternative models of provision seem to be desirable. Ethnic diversity requires adaptation and additional evidence in order to inform processes of consultation and commissioning. Minority populations do create demands for certain additional specific clinical services not required by the bulk of the majority population: it is not yet clear to what extent the reverse can be stated since research on ‘under-use’ is less well developed. Some variations in levels of need, particularly those relating to established clinical difference in susceptibility or deprivation, are already incorporated in funding formulae although it is not clear how far the indicators adequately reflect these factors. Costs are not necessarily simply related to the size of minority populations. The provision of services to meet minority needs is not always a reflection of their presence, but has frequently depended upon the provision of additional specific funds. There is a consensus that the NHS research and development strategy should accept the need for more work to establish the actual levels of need and usage of service by ethnic minority groups, and that effort should be made to use and improve the growing collection of relevant information through ethnic monitoring activities. A variety of modelling techniques are suggested, and can be shown to have the potential to provide practical guidance to future policy in the field. Current data availability at a national or regional scale is inadequate to provide estimates of the ‘additional costs of ethnicity’ but locally collected data and the existence of relevant policy initiatives suggest that a focused study in selected districts would provide sufficiently robust information to provide reliable estimates. The review has demonstrated that there are costs associated with the presence of minority ethnic groups in the population which can be shown to be unavoidable and additional, but that others are either ‘desirable’ or ‘alternative’. It would be wrong to assume that all cost pressures of this nature are in the same direction. Our study has drawn attention to deficiencies in data collection and budgeting which may hinder investigation of the effectiveness of the service in general. The process of drawing attention to ethnic minority needs itself leads to developments in services which are functional and desirable for the majority population

Interface Equations for Capillary Rise in Random Environment

We consider the influence of quenched noise upon interface dynamics in 2D and 3D capillary rise with rough walls by using phase-field approach, where the local conservation of mass in the bulk is explicitly included. In the 2D case the disorder is assumed to be in the effective mobility coefficient, while in the 3D case we explicitly consider the influence of locally fluctuating geometry along a solid wall using a generalized curvilinear coordinate transformation. To obtain the equations of motion for meniscus and contact lines, we develop a systematic projection formalism which allows inclusion of disorder. Using this formalism, we derive linearized equations of motion for the meniscus and contact line variables, which become local in the Fourier space representation. These dispersion relations contain effective noise that is linearly proportional to the velocity. The deterministic parts of our dispersion relations agree with results obtained from other similar studies in the proper limits. However, the forms of the noise terms derived here are quantitatively different from the other studies

Influence of Disorder Strength on Phase Field Models of Interfacial Growth

We study the influence of disorder strength on the interface roughening process in a phase-field model with locally conserved dynamics. We consider two cases where the mobility coefficient multiplying the locally conserved current is either constant throughout the system (the two-sided model) or becomes zero in the phase into which the interface advances (one-sided model). In the limit of weak disorder, both models are completely equivalent and can reproduce the physical process of a fluid diffusively invading a porous media, where super-rough scaling of the interface fluctuations occurs. On the other hand, increasing disorder causes the scaling properties to change to intrinsic anomalous scaling. In the limit of strong disorder this behavior prevails for the one-sided model, whereas for the two-sided case, nucleation of domains in front of the invading front are observed.Comment: Accepted for publication in PR

An integrated care pathway for menorrhagia across the primary–secondary interface : patients' experience, clinical outcomes, and service utilisation

Background: ‘‘Referral’’ characterises a significant area of interaction between primary and secondary care. Despite advantages, it can be inflexible, and may lead to duplication. Objective: To examine the outcomes of an integrated model that lends weight to general practitioner (GP)-led evidence based care. Design: A prospective, non-random comparison of two services: women attending the new (Bridges) pathway compared with those attending a consultant-led one-stop menstrual clinic (OSMC). Patients’ views were examined using patient career diaries, health and clinical outcomes, and resource utilisation. Follow-up was for 8 months. Setting: A large teaching hospital and general practices within one primary care trust (PCT). Results: Between March 2002 and June 2004, 99 women in the Bridges pathway were compared with 94 women referred to the OSMC by GPs from non-participating PCTs. The patient career diary demonstrated a significant improvement in the Bridges group for patient information, fitting in at the point of arrangements made for the patient to attend hospital (ease of access) (p,0.001), choice of doctor (p = 0.020), waiting time for an appointment (p,0.001), and less ‘‘limbo’’ (patient experience of non-coordination between primary and secondary care) (p,0.001). At 8 months there were no significant differences between the two groups in surgical and medical treatment rates or in the use of GP clinic appointments. Significantly fewer (traditional) hospital outpatient appointments were made in the Bridges group than in the OSMC group (p,0.001). Conclusion: A general practice-led model of integrated care can significantly reduce outpatient attendance while improving patient experience, and maintaining the quality of care

Influence of polymer-pore interactions on translocation

We investigate the influence of polymer-pore interactions on the translocation dynamics using Langevin dynamics simulations. An attractive interaction can greatly improve translocation probability. At the same time, it also increases translocation time slowly for weak attraction while exponential dependence is observed for strong attraction. For fixed driving force and chain length the histogram of translocation time has a transition from Gaussian distribution to long-tailed distribution with increasing attraction. Under a weak driving force and a strong attractive force, both the translocation time and the residence time in the pore show a non-monotonic behavior as a function of the chain length. Our simulations results are in good agreement with recent experimental data.Comment: 4 pages, 5 figures, Submitted to Phys. Rev. Let

Ecosystems with mutually exclusive interactions self-organize to a state of high diversity

Ecological systems comprise an astonishing diversity of species that cooperate or compete with each other forming complex mutual dependencies. The minimum requirements to maintain a large species diversity on long time scales are in general unknown. Using lichen communities as an example, we propose a model for the evolution of mutually excluding organisms that compete for space. We suggest that chain-like or cyclic invasions involving three or more species open for creation of spatially separated sub-populations that subsequently can lead to increased diversity. In contrast to its non-spatial counterpart, our model predicts robust co-existence of a large number of species, in accordance with observations on lichen growth. It is demonstrated that large species diversity can be obtained on evolutionary timescales, provided that interactions between species have spatial constraints. In particular, a phase transition to a sustainable state of high diversity is identified.Comment: 4 pages, 4 figure

Polymer translocation through a nanopore under an applied external field

We investigate the dynamics of polymer translocation through a nanopore under an externally applied field using the 2D fluctuating bond model with single-segment Monte Carlo moves. We concentrate on the influence of the field strength $E$, length of the chain $N$, and length of the pore $L$ on forced translocation. As our main result, we find a crossover scaling for the translocation time $\tau$ with the chain length from $\tau \sim N^{2\nu}$ for relatively short polymers to $\tau \sim N^{1 + \nu}$ for longer chains, where $\nu$ is the Flory exponent. We demonstrate that this crossover is due to the change in the dependence of the translocation velocity v on the chain length. For relatively short chains $v \sim N^{- \nu}$, which crosses over to $v \sim N^{- 1}$ for long polymers. The reason for this is that with increasing $N$ there is a high density of segments near the exit of the pore, which slows down the translocation process due to slow relaxation of the chain. For the case of a long nanopore for which $R_\parallel$, the radius of gyration $R_{g}$ along the pore, is smaller than the pore length, we find no clear scaling of the translocation time with the chain length. For large $N$, however, the asymptotic scaling $\tau \sim N^{1 + \nu}$ is recovered. In this regime, $\tau$ is almost independent of $L$. We have previously found that for a polymer, which is initially placed in the middle of the pore, there is a minimum in the escape time for $R_\parallel \approx L$. We show here that this minimum persists for a weak fields $E$ such that $EL$ is less than some critical value, but vanishes for large values of $EL$.Comment: 25 Pages, 10 figures. Submitted to J. Chem. Phys. J. Chem. Phys. 124, in press (2006

Glassy Solutions of the Kardar-Pasrisi-Zhang Equation

It is shown that the mode-coupling equations for the strong-coupling limit of the KPZ equation have a solution for d>4 such that the dynamic exponent z is 2 (with possible logarithmic corrections) and that there is a delta function term in the height correlation function = (A/k^{d+4-z}) \delta(w/k^z) where the amplitude A vanishes as d -> 4. The delta function term implies that some features of the growing surface h(x,t) will persist to all times, as in a glassy state.Comment: 11 pages, Revtex, 1 figure available upon request (same as figure 1 in ref [10]) Important corrections have been made which yield a much simpler picture of what is happening. We still find "glassy" solutions for d>4 where z is 2 (with possible logarithmic corrections). However, we now find no glassy solutions below d=4. A (linear) stability analysis (for d>4) has been included. Also one Author has been adde

Anomalous Sliding Friction and Peak Effect near the Flux Lattice Melting Transition

Recent experiments have revealed a giant "peak effect" in ultrapure high $T_c$ superconductors. Moreover, the new data show that the peak effect coincides exactly with the melting transition of the underlying flux lattice. In this work, we show using dynamical scaling arguments that the friction due to the pinning centers acting on the flux lattice develops a singularity near a continuous phase transition and can diverge for many systems. The magnitude of the nonlinear sliding friction of the flux lattice scales with this atomistic friction. Thus, the nonlinear conductance should diverge for a true continuous transition in the flux lattice or peak at a weakly first order transition or for systems of finite size.Comment: 4 pages, to appear in Phys. Rev.