Healthcare choice: Discourses, perceptions, experiences and practices

Policy discourse shaped by neoliberal ideology, with its emphasis on marketisation and competition, has highlighted the importance of choice in the context of healthcare and health systems globally. Yet, evidence about how so-called consumers perceive and experience healthcare choice is in short supply and limited to specific healthcare systems, primarily in the Global North. This special issue aims to explore how choice is perceived and utilised in the context of different systems of healthcare throughout the world, where choice, at least in policy and organisational terms, has been embedded for some time. The articles are divided into those emphasising: embodiment and the meaning of choice; social processes associated with choice; the uncertainties, risks and trust involved in making choices; and issues of access and inequality associated with enacting choice. These sociological studies reveal complexities not always captured in policy discourse and suggest that the commodification of healthcare is particularly problematic

Copano Bay, Texas

UT Librarie

Sedimentation in Fluvial Deltaic Wetlands and Estuarine Areas, Texas Gulf Coast -- Literature Synthesis

Deltaic and associated alluvial areas at the mouths of rivers that discharge into the bay-estuary-lagoon system along the Texas coast are the sites of extensive salt-, brackish-, and freshwater marshes that are essential components of these biologically productive estuarine systems. These bayhead depositional systems are constructed primarily by fluvial sediments, sediments transported and deposited by the major rivers that enter estuarine waters. The loss of over 10,000 acres of wetlands in alluvial and deltaic areas of the Neches (White and others, 1987) and San Jacinto Rivers (White and others, 1985) has emphasized the need to examine in more detail the processes that establish and maintain, as well as degrade, these important natural resources along the Texas coast.Bureau of Economic Geolog

Colorado River Diversion Project Reconnaissance Work to Establish Monitoring Stations in Matagorda Bay Near the Mouth of the Colorado River

Fifteen monitoring stations were established in the eastern arm of Matagorda Bay, west of the Colorado River Delta, in the area where the river is to be diverted by the U.S. Army Corps of Engineers (see fig. 1). All stations shown on figure 1 were located by triangulation, and their positions were recorded with respect to features existing on nautical chart 11319 or with respect to features located and plotted on the chart during the field survey. Twenty-foot sections of 2.5-inch PVC pipe were driven into the sediments at eight stations (see table 1) to mark selected deep-water and bay-center sites. The PVC pipes extend about 3 ft above the water. Six cedar posts, 2 inches in diameter by 6 ft long, were placed on land at strategic locations along the bayward side of Matagorda Peninsula. The locations of the posts were confirmed with reference to aerial photographs and were plotted on the nautical chart. The posts were used as reference markers to locate bay-margin sampling sites. The tops of the PVC pipes and fence posts were painted and flagged with orange fluorescent paint and tape. Because the sampling stations were also located by triangulation using more permanent navigation aids such as water tanks, radio antennas, houses, and bay markers, they can be relocated should the PVC pipes or cedar posts be removed.Bureau of Economic Geolog

Sedimentation in Fluvial Deltaic Wetlands and Estuarine Areas, Texas Gulf Coast - Summary

Deltaic and associated riverine deposits near the mouths of rivers that discharge into estuaries along the Texas coast are the sites of extensive salt-, brackish-, and freshwater marshes that are essential components of biologically productive estuarine systems. These bay-head depositional features are constructed primarily by fluvial sediments, sediments transported and deposited by the major rivers that enter estuarine waters. The loss of over 10,000 acres of wetlands in alluvial and deltaic areas of the Neches (White and others, 1987) and San Jacinto Rivers (White and others, 1985) emphasized the need to examine in more detail the processes that establish and maintain, as well as degrade, these important natural resources along the Texas coast.Bureau of Economic Geolog

Sedimentation in Fluvial Deltaic Wetlands and Estuarine Areas, Texas Gulf Coast

Deltaic and associated riverine deposits near the mouths of rivers that discharge into estuaries along the Texas coast are the sites of extensive salt, brackish, and fresh-water marshes that are essential components of biologically productive estuarine systems. These bay-head depositional features are constructed primarily by fluvial sediments, sediments transported and deposited by the major rivers that enter estuarine waters. The loss of over 10,000 acres of wetlands in alluvial and deltaic areas of the Neches (White and others, 1987) and San Jacinto Rivers (White and others, 1985) emphasized the need to examine in more detail the processes that establish and maintain, as well as degrade, these important natural resources along the Texas coast.Bureau of Economic Geolog

Fluvial-Estuarine Sedimentation Texas Gulf Coast

Deltaic and associated alluvial areas located at the mouths of rivers that flow into the bay-estuary-lagoon system along the Texas coast serve as habitats for extensive salt, brackish, and fresh-water marshes, which are crucial components of biologically productive estuarine ecosystems. These bay-head depositional systems are predominantly formed by fluvial sediments transported and deposited by the major rivers that discharge into the estuarine waters. The loss of over 10,000 acres of wetlands in the alluvial and deltaic areas of the Neches and San Jacinto Rivers underscores the necessity to closely examine the processes that establish, sustain, and degrade these vital natural resources along the Texas coast.Bureau of Economic Geolog

Sedimentation and Historical Changes in Fluvial Deltaic Wetlands Along the Texas Gulf Coast with Emphasis on the Colorado and Trinity River Deltas

The most extensive losses in coastal wetlands in the United States over the last two decades have occurred along the Gulf Coast. Wetlands are disappearing at an alarming rate on the Mississippi River Deltaic Plain, indicating a reversal in the trend of net progradation of the delta that characterized much of the past 5,000 years (Gagliano and others, 1981). The land-loss rates have accelerated geometrically during the 20th century, apparently as a result of natural and artificial processes, the latter including artificial levees and control structures that have harnessed the Mississippi River and virtually eliminated the deltaic sedimentation processes of overbank flooding, crevassing, and upstream diversion; extensive canalization and accelerated subsidence related to mineral extraction compound the problem (Gagliano and others, 1981). Investigations of marsh losses in Louisiana indicate that marsh aggradation (vertical accretion) rates are not keeping pace with relative (apparent) sea-level rise (Delaune and others, 1983; Hatton and others, 1983; Baumann and others, 1984; Boesch and others, 1984). Although less extensive than in Louisiana, losses in wetlands along the Texas coast have also been documented (McGowen and Brewton, 1975; Gosselink and others, 1979; Johnston and Ader, 1983; White and others, 1984; 1985; 1987). Some of the most dramatic changes have occurred in fluvial-deltaic areas such as near the mouths of the San Jacinto and Neches Rivers where wetland losses totaled more than 4,000 hectares (10,000 acres) between the mid-1950s and the late 1970s (White and others, 1985; 1987). The losses are characterized by submergence and displacement of marshes, swamps, and fluvial woodlands by shallow subaqueous flats and open water, indicating, as in Louisiana, that marsh aggradation rates are not keeping pace with relative sea-level rise.Bureau of Economic Geolog

Decision making in NICE single technological appraisals (STAs): How does NICE incorporate patient perspectives?

The National Institute for Health and Care Excellence (NICE) provides guidance and recommendations on the use of new and existing medicines and treatments within the NHS, basing its decisions on a review of clinical and economic evidence principally, at least for STAs, provided by the drug manufacturer. The advice provided by NICE is aimed at overcoming the previously ad hoc, discretionary decisions in order to standardise access to healthcare technologies across England based on evidence. A Single Technological Appraisal (STA) is one element of NICE’s decision-making processes in which evidence about a selected technology (often medicines) is evaluated in 3 distinct phases (scoping, assessment and appraisal). In the last phase of this process an independent Appraisal Committee evaluates evidence in a meeting, partly held in public with the latter half taking place in a ‘closed’ session. During the meeting, the Appraisal Committee considers evidence based on clinical and cost-effectiveness, as well as from statements expressed by patients, commissioning experts and clinical specialists. The Institute encourages experts attending the meeting to provide both written and oral commentary about their personal view in the current management of the condition and the expected role and use of the technology – in particular how it might provide benefit to patients. Yet, NICE and its committees find themselves in a potentially incongruous position: how to take on board the experiential evidence from individual experts along with the evidence on cost-effectiveness when reaching a decision, about whether or not to recommend a treatment on cost-effectiveness grounds. This paper considers how NICE committees incorporate the views of patient perspectives in making rationing decisions about STAs. The findings from the study will discuss where points of tension / conflict arise during meetings and how Committee members navigate experiential accounts with scientific data, which types of patient perspectives are regarded favourably and which perspectives are treated with greater caution (tension between representing patients views vs tokenism), and will highlight how Committee members in fact reflect upon their own personal experience and background in the appraisal process, and thereby are at odds with retaining an element of neutrality in decision-making, as they contend with combining their own subjective views alongside considerations of rationing in the STA process. The analysis is drawn from an ESRC funded study which used an ethnographic approach to understand the decision making process within STAs involving three contrasting pharmaceutical products. Data collection methods included analysis of documentary evidence released by NICE, non-participant unstructured observations of nine STA meetings, and qualitative interviews with key informants (n=41) involved in each of the three case studies

The Health and Social Care Act for England 2012: The extension of ‘new professionalism’

The 2012 Health and Social Care Act, introduced by the coalition government, has been seen as fundamentally changing the form and content of publicly funded health care provision in England. The legislation was hugely controversial and widely criticized. Much of this criticism pointed to the ways in which the reforms undermined the funding of the National Health Service, and challenged the founding principle of free universal provision. In this commentary we take issue with the argument that the Act represented a radical break with the past and instead suggest that it was an extension of the previous Labour government’s neo-liberal reforms of the public sector. In particular, the Act invoked the principles of ‘new professionalism’ to undermine professional dominance, and attract private providers into statutory health care at the expense of public providers. In turn, this extension of new professionalism may encourage public distrust in the medical profession and absolve the state of much of its statutory health care obligation. </jats:p