Toward health technology assessment of whole-genome sequencing diagnostic tests: challenges and solutions

Whole-genome sequencing (WGS) is being applied within research settings across Europe to develop genomic WGS-based diagnostic tests. The focus of this perspective paper is to describe if, and how, current approaches of health technology assessment could be applied to WGS-based diagnostic tests. This perspective draws on the collective view from a trans-European multidisciplinary consortium of methodologists, clinicians and scientists. Specific challenges can be described by using the PICO (population, intervention, comparator, outcome) framework to inform health technology assessment. Practical solutions are suggested which require joined-up, multidisciplinary working across healthcare systems using existing expert networks so that emergent issues for the health technology assessment of WGS can be met in a timely fashion

Employment promotion in a minerals economy

There is a sense of mystery and frustration that the SA economy has not grown as much as expected nor generated employment in the 1990s. GEAR incorrectly assumed that growth would be premised on foreign direct investment, which was meant to spur new value-adding industries and related clusters. It is not surprising that this did not occur. The SA economy can be characterized as a minerals economy, with a small market and low skill levels. Hence, most foreign investment is attracted to resource extraction, basic beneficiation or government-generated opportunities. There are many indications that SA suffers from the 'resource curse'. The dominance of basic minerals and metals in SA's export profile contributes to business cycle volatility, making it difficult for more employment-generating domestic market-oriented firms to expand. How can a resource-based economy shift its competitive advantage so that the composition of its domestic production and export profile reflect a higher value added? Why and how is this relevant to employment generation? Some authors argue that the promotion of higher value-added, higher productivity tradeables is inappropriate in a labour surplus economy. This paper argues that a sustainable industrial strategy in SA must rely on the development of a core of higher productivity or higher value industries: these industries are reflective of SA's cost structure and would support a dynamic or virtuous development cycle. It is the incomes and demand from these industries that support employment multipliers in the low productivity, job-creating industries. In a context of extremely high household dependency ratios and low wage elasticities, it is argued that the incomes from the high productivity core would have a more important impact on household welfare, and direct and indirect employment generation, than would a strategy that relies on a core of low wage, low productivity industries. Job creation is more likely to be found in the promotion of low productivity non-tradeables and non-traded goods and services, but the expansion of these activities will rely on the stable generation of incomes and foreign exchange from higher value tradeables. Domestically, this (or any) strategy relies on improved coordination of 'markets'. It is argued that the main supply constraints in South Africa lie in under-developed and poorly coordinated contingent markets, namely for labour and finance: this is not simply a problem related to price flexibility, but rather to the orientation of embedded institutions. In this context, an 'equilibrium' could be achieved at relatively low levels of employment. To unblock these supply constraints, and promote an integrated industry strategy, a number of policy levers are identified. In addition to improving the general investment environment, the movement from the minerals base will require a targeted technology policy and the use of 'second-best' policy tools where government leverages-in new forms of investment and behaviour. Low-productivity mass employment is supported by these incomes through indirect demand and intra-household and fiscal transfers. A social contract is formed, where it is implicitly or explicitly agreed that fiscal transfers will be made to protect or generate large numbers of low-productivity jobs in non-tradable goods and services. Copyright © 2001 John Wiley & Sons, Ltd.

Improving skills and care standards in the support workforce for older people: a realist synthesis of workforce development interventions

Background Support workers make up the majority of the workforce in health and social care services for older people. There is evidence to suggest that support workers are not deployed as effectively as possible, are often undervalued, and that there are gaps in understanding support worker roles across different care settings. In the context of a population that is growing older, having a skilled and knowledgeable workforce is an imperative. Workforce development includes the support required to equip those providing care to older people with the right skills, knowledge and behaviours to deliver safe and high-quality services. Objective The review answered the question ‘how can workforce development interventions improve the skills and the care standards of support workers within older people’s health and social care services?’. Design A realist synthesis was conducted. In realist synthesis, contingent relationships are expressed as context–mechanism–outcomes (CMOs), to show how particular contexts or conditions trigger mechanisms to generate outcomes. The review was conducted in four iterative stages over 18 months: (1) development of a theoretical framework and initial programme theory; (2) retrieval, review and synthesis of evidence relating to interventions designed to develop the support workforce, guided by the programme theories; (3) ‘testing out’ the synthesis findings to refine the programme theories and establish their practical relevance/potential for implementation; and (4) forming recommendations about how to improve current workforce development interventions to ensure high standards in the care of older people. Participants Twelve stakeholders were involved in workshops to inform programme theory development, and 10 managers, directors for training/development and experienced support workers were interviewed in phase 4 of the study to evaluate the findings and inform knowledge mobilisation. Results Eight CMO configurations emerged from the review process, which provide a programme theory about ‘what works’ in developing the older person’s support workforce. The findings indicate that the design and delivery of workforce development should consider and include a number of starting points. These include personal factors about the support worker, the specific requirements of workforce development and the fit with broader organisational strategy and goals. Conclusions and recommendations The review has resulted in an explanatory account of how the design and delivery of workforce development interventions work to improve the skills and care standards of support workers in older people’s health and social care services. Implications for the practice of designing and delivering older person’s support workforce development interventions are directly related to the eight CMO configuration of the programme theory. Our recommendations for future research relate both to aspects of research methods and to a number of research questions to further evaluate and explicate our programme theory. Limitations We found that reports of studies evaluating workforce development interventions tended to lack detail about the interventions that were being evaluated. We found a lack of specificity in reports about what were the perceived and actual intended impacts from the workforce development initiatives being implemented and/or evaluated. Study registration This study is registered as PROSPRERO CRD42013006283. Funding The National Institute for Health Research Health Services and Delivery Research programme