Depoliticisation, Resilience and the Herceptin Post-code Lottery Crisis: Holding Back the Tide

This article: Covers new empirical terrain in the study of depoliticisation, with an in-depth case study of health technology regulation; Analyses depoliticisation from a novel analytical perspective, examining how depoliticised institutions are resilient to external pressure for politicisation; Posits a distinctive framework for analysing resilience, drawing on cognate literatures on policy networks and agencification; Raises interesting and distinctive questions about the nature of depoliticisation in advanced liberal democracies, arguing it is more contested than commonly acknowledged. Depoliticisation as a concept offers distinctive insights into how governments attempt to relieve political pressures in liberal democracies. Analysis has examined the effects of depoliticisation tactics on the public, but not how those tactics are sustained during moments of political tension. Drawing on policy networks and agencification literatures, this article examines how these tactics are resilient against pressure for politicisation. Using an in-depth case study of the controversial appraisal of cancer drug Herceptin in 2005/6 by the National Institute for Health and Clinical Excellence (NICE), the article examines how ‘resilient’ NICE was to external politicisation. It is argued that NICE was resilient because it was effectively ‘insulated’ by formal procedures and informal norms of deference to scientific expertise. This mechanism is termed ‘institutional double glazing’. The conclusion suggests developments to the conceptual and methodological framework of depoliticisation, and highlights theoretical insights into the nature of ‘anti-politics’ in contemporary democracies

Market access agreements for pharmaceuticals in Europe: diversity of approaches and underlying concepts

<p>Abstract</p> <p>Background</p> <p>Market Access Agreements (MAA) between pharmaceutical industry and health care payers have been proliferating in Europe in the last years. MAA can be simple discounts from the list price or very sophisticated schemes with inarguably high administrative burden.</p> <p>Discussion</p> <p>We distinguished and defined from the health care payer perspective three kinds of MAA: Commercial Agreements (CA), Payment for Performance Agreements (P4P) and Coverage with Evidence Development (CED). Apart from CA, the agreements assumed collection and analysis of real-life health outcomes data, either from a cohort of patients (CED) or on per patient basis (P4P). We argue that while P4P aim at reducing drug cost to payers without a systematic approach to addressing uncertainty about drugs' value, CED were implemented provisionally to reduce payer's uncertainty about value of a medicine within a defined time period.</p> <p>Summary</p> <p>We are of opinion that while CA and P4P have a potential to reduce payers' expenditure on costly drugs while maintaining a high list price, CED address initial uncertainty related to assessing the real-life value of new drugs and enable a final HTA recommendation or reimbursement and pricing decisions. Further, we suggest that real cost to health care payers of drugs in CA and P4P should be made publicly available in a systematic manner, to avoid a perverse impact of these MAA types on the international reference pricing system.</p

The four or more medicines (FOMM) support service:results from an evaluation of a new community pharmacy service aimed at over-65s

Background: 57% of all prescriptions dispensed in the UK in 2003 were for people aged ≥60, where ≥20% of them were prescribed ≥ five medicines. Inappropriate prescribing and non-adherence have a significant impact on hospital admissions and patient quality of life. The English government has identified that community pharmacy could make a significant contribution to reducing non-adherence and improving the quality of prescribing, reducing both hospital admissions and medicines wastage. Objective: To evaluate a community pharmacy service aimed at patients over the age of 65 years prescribed four or more medicines. Method: Patients were invited to participate in the service by the community pharmacy team. The pharmacist held regular consultations with the patient and discussed risk of falls, pain management, adherence and general health. They also reviewed the patient’s medication using STOPP/START criteria. Data wereas analysed for the first six months of participation in the service. Key findings: 620 patients were recruited with 441 (71.1%) completing the six month study period. Pharmacists made 142 recommendations to prescribers in 110 patients largely centred on potentially inappropriate prescribing of NSAIDs, PPIs or duplication of therapy. At follow-up there was a significant decrease in the total number of falls (mean -0.116 (-0.217 - -0.014)) experienced and a significant increase in medicines adherence (mean difference in MMAS-8: 0.513 (0.337 – 0.689)) and quality of life. Cost per QALY estimates ranged from £11,885 to £32,466 depending on the assumptions made. Conclusion: By focussing on patients over the age of 65 years with four or more medicines, community pharmacists can improve medicines adherence and patient quality of life

The Probability Distribution of Binary Pulsar Coalescence Rate Estimates. II. Neutron Star-White Dwarf Binaries

We consider the statistics of pulsar binaries with white dwarf companions (NS-WD). Using the statistical analysis method developed by Kim et al. (2003) we calculate the Galactic coalescence rate of NS-WD binaries due to gravitational-wave emission. We find that the most likely values for the total Galactic coalescence rate (R_tot) of NS-WD binaries lie in the range 0.2--10 per Myr depending on different assumed pulsar population models. For our reference model, we obtain R_tot=4.11_(-2.56)^(+5.25) per Myr at a 68% statistical confidence level. These rate estimates are not corrected for pulsar beaming and as such they are found to be about a factor of 20 smaller than the Galactic coalescence rate estimates for double neutron star systems. Based on our rate estimates, we calculate the gravitational-wave background due to coalescing NS-WD binaries out to extragalactic distances within the frequency band of the Laser Interferometer Space Antenna. We find the contribution from NS-WD binaries to the gravitational-wave background to be negligible.Comment: 20 pages, 2 figures, 2 tables, Accepted for publication in Ap

The identification and psychological treatment of panic disorder in adolescents: a survey of CAMHS clinicians

Background Panic disorder is experienced by around 1% of adolescents, and has a significant impact on social and academic functioning. Preliminary evidence supports the effectiveness of panic disorder specific treatment in adolescents with panic disorder, however panic disorder may be overlooked in adolescents due to overlapping symptoms with other anxiety disorders and other difficulties being more noticeable to others. The aim of this study was to establish what training National Health Service (NHS) Child and Adolescent Mental Health Services (CAMHS) clinicians have received in psychological therapies and panic disorder and how they identify and treat panic disorder in adolescents. Method CAMHS clinicians from a range of professions (n = 427), who were delivering psychological treatments to children and adolescents with anxiety disorders, participated. They completed a cross-sectional, online survey, including a vignette describing an adolescent with panic disorder, and were asked to identify the main diagnosis or presenting problem. Results Less than half the clinicians (48.6%) identified panic disorder or panic symptoms as the main presenting problem from the vignette. The majority of clinicians suggested CBT would be their treatment approach. However, few identified an evidence-based treatment protocol for working with young people with panic disorder. Almost half the sample had received no training in cognitive behaviour therapy (CBT) and around a fifth had received no training in delivering psychological treatments. Conclusions Only half of CAMHS clinicians identified panic disorder from a vignette and although CBT treatments are widely offered, only a minority of adolescents with panic disorder are receiving treatments developed for, and evaluated with young people with panic disorder. There is a vital need for clinician training, the use of tools that aid identification and the implementation of evidence-based treatments within CAMHS

What is the contribution of physician associates in hospital care in England? A mixed methods, multiple case study.

OBJECTIVES: To investigate the deployment of physician associates (PAs); the factors supporting and inhibiting their employment and their contribution and impact on patients' experience and outcomes and the organisation of services. DESIGN: Mixed methods within a case study design, using interviews, observations, work diaries and documentary analysis. SETTING: Six acute care hospitals in three regions of England in 2016-2017. PARTICIPANTS: 43 PAs, 77 other health professionals, 28 managers, 28 patients and relatives. RESULTS: A key influencing factor supporting the employment of PAs in all settings was a shortage of doctors. PAs were found to be acceptable, appropriate and safe members of the medical/surgical teams by the majority of doctors, managers and nurses. They were mainly deployed to undertake inpatient ward work in the medical/surgical team during core weekday hours. They were reported to positively contribute to: continuity within their medical/surgical team, patient experience and flow, inducting new junior doctors, supporting the medical/surgical teams' workload, which released doctors for more complex patients and their training. The lack of regulation and attendant lack of authority to prescribe was seen as a problem in many but not all specialties. The contribution of PAs to productivity and patient outcomes was not quantifiable separately from other members of the team and wider service organisation. Patients and relatives described PAs positively but most did not understand who and what a PA was, often mistaking them for doctors. CONCLUSIONS: This study offers new insights concerning the deployment and contribution of PAs in medical and surgical specialties in English hospitals. PAs provided a flexible addition to the secondary care workforce without drawing from existing professions. Their utility in the hospital setting is unlikely to be completely realised without the appropriate level of regulation and authority to prescribe medicines and order ionising radiation within their scope of practice

Quark Matter in Neutron Stars: An apercu

The existence of deconfined quark matter in the superdense interior of neutron stars is a key question that has drawn considerable attention over the past few decades. Quark matter can comprise an arbitrary fraction of the star, from 0 for a pure neutron star to 1 for a pure quark star, depending on the equation of state of matter at high density. From an astrophysical viewpoint, these two extreme cases are generally expected to manifest different observational signatures. An intermediate fraction implies a hybrid star, where the interior consists of mixed or homogeneous phases of quark and nuclear matter, depending on surface and Coulomb energy costs, as well as other finite size and screening effects. In this brief review article, we discuss what we can deduce about quark matter in neutron stars in light of recent exciting developments in neutron star observations. We state the theoretical ideas underlying the equation of state of dense quark matter, including color superconducting quark matter. We also highlight recent advances stemming from re-examination of an old paradigm for the surface structure of quark stars and discuss possible evolutionary scenarios from neutron stars to quark stars, with emphasis on astrophysical observations.Comment: 15 pages, 1 figure. Invited review for Modern Physics Letters

Arecibo timing and single-pulse observations of 17 pulsars

We report on timing and single-pulse observations of 17 pulsars discovered at the Arecibo observatory. The highlights of our sample are the recycled pulsars J1829+2456, J1944+0907 and the drifting subpulses observed in PSR J0815+0939. For the double neutron star binary J1829+2456, in addition to improving upon our existing measurement of relativistic periastron advance, we have now measured the pulsar's spin period derivative. This new result sets an upper limit on the transverse speed of 120 km/s and a lower limit on the characteristic age of 12.4 Gyr. From our measurement of proper motion of the isolated 5.2-ms pulsar J1944+0907, we infer a transverse speed of 188 +/- 65 km/s. This is higher than that of any other isolated millisecond pulsar. An estimate of the speed, using interstellar scintillation, of 235 +/- 45 km/s indicates that the scattering medium along the line of sight is non-uniform. We discuss the drifting subpulses detected from three pulsars in the sample, in particular the remarkable drifting subpulse properties of the 645-ms pulsar J0815+0939. Drifting is observed in all four components of the pulse profile, with the sense of drift varying among the different components. This unusual `bi-drifting'' behaviour challenges standard explanations of the drifting subpulse phenomenon.Comment: 9 pages, 6 figures. Accepted for publication in MNRA