Providing for the Priceless Student: Ideologies of Choice in an Emerging Educational Market

The growing popularity of school choice is typically linked to the spread of neoliberal ideology. Identifying four components of this ideology, we examine the rationales of providers in an emerging private school market. Data come from interviews and site visits at 45 “third-sector” private schools in Toronto, Canada. We find that only one of the four components has a strong resonance among these educators. Few private school operators sharply criticize public schools, compete via quantitative performance indicators, or are strongly business oriented. However, they voice a philosophy of matching their personal talents to the needs of “unique” children. Overall, rather than being influenced by neoliberalism, these providers are more directly driven by personalized rationales that prize tailored education in specialized niches. We draw two conclusions from these findings. First, they demonstrate how ideologies of choice are shaped by their market setting, in this case, small proprietorship, in contrast to a corporate environment. Second, they highlight how providers can be motivated by new cultures of consumerism and intensive child rearing when working in highly uncertain conditions. We recommend that theories of choice recognize the range of educational markets and the specific motives of their providers

Antipsychotic medication for people with first episode schizophrenia: an exploratory economic analysis of alternative treatment algorithms

Available clinical evidence suggests that the newer antipsychotics are similar to conventional antipsychotics for positive symptom control. It has been suggested that they may also be superior for negative symptoms and side effects, but the evidence for this is unclear (Duggan et al, 1999, Kennedy et al, 1999, Srisurapanont et al, 1999, Thornley et al, 1999, Tuunainen and Gilbody, 1999, Wahlbeck et al, 1999). These differences if they exist, may lead to improvements in quality of life and patient satisfaction and subsequent rates of compliance with therapy. If the latter occurs, there may also be improvements in the overall level of symptom control and rate of relapse. Economic evaluations of risperidone suggest that these differences could lead to savings in the use of hospital inpatient care compared to conventional antipsychotics (Guest et al, 1996, Glennie, 1997). The available economic evidence suggests that the use of clozapine has the potential to improve the efficient use of health and social service resources in some patients (Revicki et al, 1990, Davies & Drummond, 1993, Meltzer et al, 1993, Aitchison & Kerwin, 1997, Glennie, 1997, Rosenheck et al, 1997). All of these studies indicate that overall, clozapine is associated with lower rates of hospital inpatient admissions and lower duration of inpatient stay. These are due to earlier discharge from the index inpatient admission and lower rates of relapse. These differences in the use of inpatient care are sufficient to offset the additional costs of purchasing clozapine. However, the designs of all the economic studies raise several issues of concern, such as control for biases, sources of data and methods of data collection, measurement of outcomes, the type and dose regimes of comparator drugs. In addition, the clinical and economic data for these evaluations were collected for a patient population with a long duration of illness and/or who are treatment resistant or intolerant of typical antipsychotic therapy. It is not clear that these are applicable to people with early schizophrenia or those who have not had problems with previous antipsychotics. Patients currently categorised as treatment resistant or treatment intolerant are likely to have a long history of schizophrenia. This is partly due to historical factors, such as the limited number of antipsychotics available, concerns about the safety of clozapine and the restricted use of expensive atypical antipsychotics. These factors may be associated with a relatively poor quality of life and more intensive use of health care services in patients with a longer duration of illness. Any improvements in clinical outcome as a result of a change in antipsychotic may also result in relatively important changes in health status and intensity of ealth service utilisation, compared to those with a recent diagnosis of schizophrenia. In addition, there is some limited evidence that the use of services following entry to a clinical trial is related to the level of resource use prior to entry (Rosenheck et al, 1999). Furthermore, there is a trend to reduce reliance on inpatient or institutional care for people with acute or chronic mental illness. The total number of commissioned hospital bed days for people with mental illness decreased from 14 million to 11.5 million between 1992-3 and 1997-8 and the number of ward attendees fell from 124000 to 93000 (Department of Health, 1998a). Over the same period the number of daily available hospital beds for people with mental illness declined from 47000 to 37000, while the number of outpatient attendances rose from 1.8 million to 2.1 million (HPSS, 1998). Creed et al (1997) suggest that approximately 40% of people with acute episodes of mental illness (including schizophrenia) can be treated by attending psychiatric day hospitals rather then with hospital inpatient admissions. These factors may over estimate the likely value for money of the atypical antipsychotics, in cohorts of people with first episode schizophrenia in the current UK mental health service (Rosenheck et al, 1999). Given the constraints on health and social care budgets, purchasers and providers need to ensure that resources are used efficiently. A variety of guidelines and treatment protocols have been published, or developed for use at a local level to support decisions about the choice of antipsychotic for people with a first episode of schizophrenia. In addition, there are wide variations in the availability and use of the atypical antipsychotics in the UK. Current published literature is not sufficient to address all the economic issues of concern and there is a need for evaluation of the relative efficiency of clozapine and the new antipsychotics. The NHS R&D HTA has funded primary research to assess the relative costs and utility of typical and atypical antipsychotics for people who are resistant to or intolerant of at least two antipsychotics. However, the results of the research will not be available for at least 3 years. In addition, it is also important to assess the value of the new drugs in the context of alternative prescribing guidelines, and for people with a first episode of schizophrenia. This paper presents the results of secondary research to explore the potential economic impact of atypical antipsychotics for people in the context of current clinical guidelines.schizophrenia, QALYs

Prioritising investments in health technology assessment: can we assess the potential value for money?

The objective was to develop an economic prioritisation model to assist those involved in (i) the selection and prioritisation of health technology assessment topics and (ii) commissioning of HTA projects. The model used decision analytic techniques to estimate the expected costs and benefits of the health care interventions which were the focus of the HTA question(s) considered by the NHS Health Technology Assessment Programme in England. Initial estimation of the value for money of HTA was conducted for a number of topics considered in 1997 and 1998. The main conclusion was that it is feasible to conduct ex ante assessments of the value for money of HTA for specific topics. However, a considerable amount of work is required to ensure that the methods used are valid, reliable, consistent and an efficient use of valuable research time.INAHTA, NCCHTA

La crise en travail social : un exemple de la pratique auprès des cas d’abus d’enfants

Même encadrée par une politique qui en détermine règles et procédures, la pratique sociale en protection de l'enfance, en Angleterre, laisse aux praticiens une certaine autonomie et un pouvoir discrétionnaire. Dans un tel contexte, cependant, les intervenants ont besoin de protection et de support. L'auteure propose d'élargir la perspective de l'enfance maltraitée aux aspects structurels de la violence. Elle invoque de plus la nécessité de démocratiser la pratique et de mobiliser d'autres travailleurs de l'État pour provoquer des changements significatifs

The conquest of infant mortality: the case of Hemsworth, 1871-1911

This thesis began as part of wider project undertaken by postgraduate students of the Open University looking at the decline of infant mortality during the period 1871-1911. The main primary source for this has been the Vaccination Registers which were produced to record vaccination of infants under the Vaccination Act of 1871. Under this Act vaccination against smallpox became compulsory for all infants. The registers therefore give us a unique opportunity to examine the data on all infants born during this period in the areas where the registers survive. The district selected for this thesis is the Hemsworth district in the West Riding of Yorkshire. In 1871 the economy of the district was purely based on agriculture, but by 1911 several deep coal mines had been sunk in the area which had led to a rapid and steep rise in the population. This rise in the population was accompanied by an increase in infant mortality which grew from below the mean for England and Wales in 1871, to above the mean by the late 1890s. Unlike most of the rest of the country the IMR in Hemsworth did not actually begin to decline until 1905. This thesis examines the causes of the high IMR through a comparison between a large village which grew to be a colliery township. South Kirkby, and those townships in the district which remained purely agricultural even after the sinking of the deep mines. A micro-study of one street in South Kirkby with a particularly high IMR facilitates a detailed examination of the households and the infant deaths which occurred there

Financing Long-Term Care for Elderly People

Last year’s report of the Royal Commission on Long Term Care (1) and the expected Government response have prompted fresh interest in the debate on how to fund long-term care. To inform this debate the Personal Social Services Research Unit (PSSRU) has conducted a study, funded by the Department of Health, of long-term care demand and finance. This has involved the construction of a computer model to make projections of likely demand and expenditures to 2031. This article describes the model of long-term care demand and expenditure developed by the PSSRU. It then presents some of the results obtained and sensitivity analysis around them

The New Entrepreneurship in Higher Education: The Impact of Tuition Increases at an Ontario University

Recent increases in university tuition fees are part of a new entrepre- neurial trend in higher education in which institutions are expected to generate more of their own revenue. We examine the effects of this trend on access to universities for students of lower socioeconomic origins, and identify a series of cross cutting pressures. On the one hand, tuition fees pose an obvious financial barrier for these students, whom researchers have shown to be relatively cost-sensitive and debt-averse. On the other hand, the demand for university education among youth from all backgrounds remains buoyant, and student cultures may be increasingly resigned to accepting large debts to finance their schooling. We then examine empirical evidence from two surveys from the University of Guelph, along with some supplementary sources. We find that the representation of students from low socioeconomic backgrounds fell substantially during a decade of rising tuition costs. In discussing this finding, we link the phenomena of higher and de-regulated tuition to the new entrepreneurship, and argue that it has the potential to increasingly stratify Canadian higher education.Les augmentations récentes des frais de scolarité à l'université font partie d'une tendance à un «nouvel entrepreneurship» dans l'enseignement supérieur, tendance à l'intérieur de laquelle on s'attend à ce que les institutions génèrent leurs propres revenus. Dans cet article, nous nous intéressons aux effets de cette orientation sur l'accès aux universités des étudiants d'origine socioéconomique modeste et constatons une série de tendances opposées aux coupures. D'une part, les frais de scolarité créent une barrière financière évidente pour ces étudiants qui, selon les démonstrations des chercheurs, sont relativement sensibles à l'évolution des coûts et opposés à l'endettement. D'autre part, la demande d'un niveau universitaire d'éducation demeure soutenue chez les jeunes de toutes les provenances, et les cultures étudiantes peuvent se résigner de plus en plus à accepter de grosses dettes pour financer leurs études. Nous examinons ensuite les preuves empiriques provenant de deux enquêtes de l'Université de Guelph qui confirment nos prétentions, de même que quelques autres sources. Nous constatons que la représentation des étudiants venant des milieux socioéconomiques modestes a considérablement diminué durant cette décennie des coûts croissants des frais de scolarité. Dans la discussion de ces résultats, nous associons ce phénomène de frais de scolarité plus élevés et déréglés au nouvel entrepreneurship académique, et soutenons qu'il possède un potentiel de clivage de plus en plus grand en enseignement supérieur canadien