New development: Exploring public service markets

The authors explain why public service markets are fundamentally different from regulated utilities markets by looking at the product characteristics, market structure, funding oversight and legal arrangements in such markets. They highlight the issues which will be important as marketized delivery becomes increasingly mainstream in public services provision

Public Service Markets: Their Economics, Oversight and Regulation

This paper has three aims. Firstly, it aims to show that the language of markets can help to frame arguments about how effectively public services are achieving their intended outcomes. Using ‘market’ language and concepts may not always be comfortable for those from a traditional policy-making background. This paper suggests that thinking in these terms can nevertheless be very useful when designing investigations of the effectiveness of public services, whenever those services entail a degree of personalisation or user choice – as is currently the case, for example, in large parts of health, social care and education in England. Secondly, the paper aims to show that public service markets (public services that involve choice on the part of service users) differ quite fundamentally from private markets. Hence the conditions for the success, or failure, of public service markets to achieve public policy intentions may be different from the conditions that are necessary to foster successful (well functioning) markets in the private sector. Although there are analogies between private and public markets, some of which are discussed, the introduction of ‘market mechanisms’ into public service provision does not necessarily mean that the public service markets thus created will behave like private markets, or that policy intentions will be achieved simply by ‘leaving it to the market’. This, of course, has implications for how public service markets are overseen, managed, and regulated. In particular, the nature of the ‘goods’ that are ‘traded’ in public service markets is often very different from those in many private markets. This paper argues that not only are public services typically merit goods (characterised by positive externalities in their consumption), but that there is an important distinction between ‘choice’ merit goods, such as education or social care, and ‘compulsory’ merit goods, such as probation services or welfare-to-work programmes. Choice merit goods could in principle be provided through vouchers or direct payments to users, although doing so would not necessarily achieve other policy objectives such as universality or equity, even if all conditions were in place for the public market to operate efficiently (in practice, this latter requirement is also unlikely to be met). There may also be conflicts between how service users actually make choices, and how the state would ‘like’ them to (for example, hospital patients may value proximity of the hospital to their home more highly than its results on clinical performance measures). The ‘users’ of compulsory merit goods, on the other hand, may not wish to consume them, but it may be welfare-enhancing for society to coerce them to do so. The commissioning or direct provision by the state of such goods may meet public policy objectives more effectively than the market mechanism alone, as users are not able to internalise the full social benefits of their actions. Finally, building on these foundations, the paper discusses when public service markets are likely to be an effective method of achieving public policy objectives, and when they may not be. Issues that arise frequently in public service markets are discussed, such as principal-agent relationships; determining the quality of complex experience goods; the existence of local or regional monopolies of provision, and monopsonies of funding; the operation of competition law in the public sector; and how to deal with provider failure. The paper concludes with some suggestions for what this all means for those charged with overseeing public service markets in practice, based both on the preceding considerations, and on empirical evidence and experience to date

The relationship between staff skill mix, costs and outcomes in intermediate care services

Article: Dixon, S., Kaambwa, B., Nancarrow, S. et al. Reuse Unless indicated otherwise, fulltext items are protected by copyright with all rights reserved. The copyright exception in section 29 of the Copyright, Designs and Patents Act 1988 allows the making of a single copy solely for the purpose of non-commercial research or private study within the limits of fair dealing. The publisher or other rights-holder may allow further reproduction and re-use of this version -refer to the White Rose Research Online record for this item. Where records identify the publisher as the copyright holder, users can verify any specific terms of use on the publisher's website. Takedown If you consider content in White Rose Research Online to be in breach of UK law, please notify us by emailing [email protected] including the URL of the record and the reason for the withdrawal request. R E S E A R C H A R T I C L E Open Access The relationship between staff skill mix, costs and outcomes in intermediate care service

Genomic catastrophes frequently arise in esophageal adenocarcinoma and drive tumorigenesis

Oesophageal adenocarcinoma (EAC) incidence is rapidly increasing in Western countries. A better understanding of EAC underpins efforts to improve early detection and treatment outcomes. While large EAC exome sequencing efforts to date have found recurrent loss-offunction mutations, oncogenic driving events have been underrepresented. Here we use a combination of whole-genome sequencing (WGS) and single-nucleotide polymorphism-array profiling to show that genomic catastrophes are frequent in EAC, with almost a third (32%, n¼40/123) undergoing chromothriptic events. WGS of 22 EAC cases show that catastrophes may lead to oncogene amplification through chromothripsis-derived double-minute chromosome formation (MYC and MDM2) or breakage-fusion-bridge (KRAS, MDM2 and RFC3). Telomere shortening is more prominent in EACs bearing localized complex rearrangements. Mutational signature analysis also confirms that extreme genomic instability in EAC can be driven by somatic BRCA2 mutations. These findings suggest that genomic catastrophes have a significant role in the malignant transformation of EAC

'Choosing shoes': a preliminary study into the challenges facing clinicians in assessing footwear for rheumatoid patients

Background: Footwear has been accepted as a therapeutic intervention for the foot affected by rheumatoid arthritis (RA). Evidence relating to the objective assessment of footwear in patients with RA is limited. The aims of this study were to identify current footwear styles, footwear characteristics, and factors that influence footwear choice experienced by patients with RA. Methods: Eighty patients with RA were recruited from rheumatology clinics during the summer months. Clinical characteristics, global function, and foot impairment and disability measures were recorded. Current footwear, footwear characteristics and the factors associated with choice of footwear were identified. Suitability of footwear was recorded using pre-determined criteria for assessing footwear type, based on a previous study of foot pain. Results: The patients had longstanding RA with moderate-to severe disability and impairment. The foot and ankle assessment demonstrated a low-arch profile with both forefoot and rearfoot structural deformities. Over 50% of shoes worn by patients were opentype footwear. More than 70% of patients’ footwear was defined as being poor. Poor footwear characteristics such as heel rigidity and sole hardness were observed. Patients reported comfort (17%) and fit (14%) as important factors in choosing their own footwear. Only five percent (5%) of patients wore therapeutic footwear. Conclusions: The majority of patients with RA wear footwear that has been previously described as poor. Future work needs to aim to define and justify the specific features of footwear that may be of benefit to foot health for people with RA

Whole genome expression array profiling highlights differences in mucosal defense genes in Barrett's esophagus and esophageal adenocarcinoma

Extent: 15p.Esophageal adenocarcinoma (EAC) has become a major concern in Western countries due to rapid rises in incidence coupled with very poor survival rates. One of the key risk factors for the development of this cancer is the presence of Barrett's esophagus (BE), which is believed to form in response to repeated gastro-esophageal reflux. In this study we performed comparative, genome-wide expression profiling (using Illumina whole-genome Beadarrays) on total RNA extracted from esophageal biopsy tissues from individuals with EAC, BE (in the absence of EAC) and those with normal squamous epithelium. We combined these data with publically accessible raw data from three similar studies to investigate key gene and ontology differences between these three tissue states. The results support the deduction that BE is a tissue with enhanced glycoprotein synthesis machinery (DPP4, ATP2A3, AGR2) designed to provide strong mucosal defenses aimed at resisting gastro-esophageal reflux. EAC exhibits the enhanced extracellular matrix remodeling (collagens, IGFBP7, PLAU) effects expected in an aggressive form of cancer, as well as evidence of reduced expression of genes associated with mucosal (MUC6, CA2, TFF1) and xenobiotic (AKR1C2, AKR1B10) defenses. When our results are compared to previous whole-genome expression profiling studies keratin, mucin, annexin and trefoil factor gene groups are the most frequently represented differentially expressed gene families. Eleven genes identified here are also represented in at least 3 other profiling studies. We used these genes to discriminate between squamous epithelium, BE and EAC within the two largest cohorts using a support vector machine leave one out cross validation (LOOCV) analysis. While this method was satisfactory for discriminating squamous epithelium and BE, it demonstrates the need for more detailed investigations into profiling changes between BE and EAC.Derek J. Nancarrow, Andrew D. Clouston, B. Mark Smithers, David C. Gotley, Paul A. Drew, David I. Watson, Sonika Tyagi, Nicholas K. Hayward, David C. Whiteman, for the Australian Cancer Study and the Study of Digestive Healt

“Come and live with my feet and you’ll understand”–a qualitative study exploring the experiences of retail footwear in women with rheumatoid arthritis

Background: Foot pain and deformity are common in people with rheumatoid arthritis (RA). Previous research has identified that women with RA seek retail footwear to alleviate their foot problems. The specific footwear features that women with RA require, and what would help them to find shoes that meet these requirements, are unknown. This study aimed to determine the factors that influence the choice of appropriate retail footwear by women with RA. Method: An overarching qualitative approach was taken, using reflexive thematic analysis of conversational style interviews. The interviews explored experiences and use of retail footwear in 20 women with RA. The interviews were digitally recorded transcribed verbatim and analysed using a reflexive thematic framework. Results: Women with RA sought retail footwear which had adequate cushioning, width, a flexible sole, lightweight, were made from breathable materials and were easy to put on and take off. However, this choice was driven by the need for comfort, cost and usability, with aesthetics being less of a priority. Despite having opinions on what criteria they felt that they needed, these women did not feel empowered to make good choices about purchasing retail footwear for symptomatic relief. Furthermore, they did not receive the necessary support from podiatrists and shoe shop staff. Conclusion: Women with RA have clear ideas about what features a retail shoe should have to achieve comfort. There is a constant compromise between achieving comfort and their feelings about their appearance and how they feel others perceive them. Women with RA describe negative experiences with shoe shop assistants and podiatrists leading to poor footwear choices. Both retail staff and podiatrists need increased understanding about the particular problems that women with RA experience. Keywords: Footwear, Rheumatoid arthritis, Thematic analysi