The unavoidable costs of ethnicity : a review of evidence on health costs

This report was commissioned by the Advisory Committee on Resource Allocation (ACRA), and prepared by the Centre for Health Services Studies (CHESS) and the Centre for Research in Ethnic Relations (CRER) at the University of Warwick. The NHS Executive does not necessarily assent to the factual accuracy of the report, nor necessarily share the opinions and recommendations of the authors. The study reviews the evidence concerning the degree to which the presence of populations of minority ethnic origin was associated with ‘unavoidable additional costs’ in health service delivery. While local health authorities retail full autonomy in their use of funds allocated to them under the Hospital and Community Health Services formula, the size of that budget is governed by a set of weightings applied to their population, to allow for factors known to influence levels of need, and the costs of providing services. The study began by considering the definitions used in describing ‘ethnicity’ and ethnic groups in relevant medical and social policy literature. It is clear that no fixed set of terms can be adopted, and that flexibility is required to respond to social changes. The terms used in the 1991 Census, with additions to allow for local and contemporary developments, provide a suitable baseline but require additional information on religion language and migration history for clinical and health service delivery planning. There have been notable developments in health service strategy to meet the needs of black and minority ethnic groups which have been encouraged by good practice guidelines and local initiatives. Together with research into epidemiology and ethnic monitoring of services, these have enlarged understanding of the impact of diversity. A conceptual model is developed which explores the potential for such diversity to lead to variations in the cost of providing health services to a multi-ethnic population. The research team reviewed the existing published evidence relating to ethnic health and disease treatment in medical, social science, academic and practitioner literature, using conventional techniques. Additional evidence was located through trawls of ‘grey’ literature in specialist collections, and through contacting all English health districts with a request for information. A number of authorities and trusts provided written and oral evidence, and a bibliography of key materials is provided. Key issues considered include the need for and use of, interpreter and translation services, the incidence of ‘ethnically-specific’ disease, and variations in the prevalence and cost of treating ‘common’ conditions in minority ethnic populations. Sources of variation are discussed, and a ‘scoping’ approach adopted to explore the extent to which these variations could be adequately modelled. It is clear that while some additional costs can be identified, and seen to be unavoidable, there are other areas where the presence of minority populations may lead to lessened pressures on budgets, or where provision of ‘ethnic-specific’ facilities may be alternative to existing needs. The literature provides a range of estimates which can be used in a modelling exercise, but is deficient in many respects, particularly in terms of precise costs associated with procedure and conditions, or in associating precise and consistent categories of ethnic group with epidemiological and operational service provision data. Certain other activities require funding to set them up, and may not be directly related to population size. There is considerable variation in the approaches adopted by different health authorities, and many services are provided by agencies not funded by NHS budgets. The study was completed before the announcement of proposed changes in health service commissioning which may have other implications for ethnic diversity. The presence of minorities is associated with the need to provide additional services in respect of interpreting and translation, and the media of communication. In order to achieve clinical effectiveness, a range of advocacy support facilities or alternative models of provision seem to be desirable. Ethnic diversity requires adaptation and additional evidence in order to inform processes of consultation and commissioning. Minority populations do create demands for certain additional specific clinical services not required by the bulk of the majority population: it is not yet clear to what extent the reverse can be stated since research on ‘under-use’ is less well developed. Some variations in levels of need, particularly those relating to established clinical difference in susceptibility or deprivation, are already incorporated in funding formulae although it is not clear how far the indicators adequately reflect these factors. Costs are not necessarily simply related to the size of minority populations. The provision of services to meet minority needs is not always a reflection of their presence, but has frequently depended upon the provision of additional specific funds. There is a consensus that the NHS research and development strategy should accept the need for more work to establish the actual levels of need and usage of service by ethnic minority groups, and that effort should be made to use and improve the growing collection of relevant information through ethnic monitoring activities. A variety of modelling techniques are suggested, and can be shown to have the potential to provide practical guidance to future policy in the field. Current data availability at a national or regional scale is inadequate to provide estimates of the ‘additional costs of ethnicity’ but locally collected data and the existence of relevant policy initiatives suggest that a focused study in selected districts would provide sufficiently robust information to provide reliable estimates. The review has demonstrated that there are costs associated with the presence of minority ethnic groups in the population which can be shown to be unavoidable and additional, but that others are either ‘desirable’ or ‘alternative’. It would be wrong to assume that all cost pressures of this nature are in the same direction. Our study has drawn attention to deficiencies in data collection and budgeting which may hinder investigation of the effectiveness of the service in general. The process of drawing attention to ethnic minority needs itself leads to developments in services which are functional and desirable for the majority population

Supporting Real-Time Applications in an Integrated Services Packet Network: Architecture and Mechanism

This paper considers the support of real-time applications in an Integrated Services Packet Network (ISPN). We first review the characteristics of real-time applications. We observe that, contrary to the popular view that real-time applications necessarily require a fixed delay bound, some real-time applications are more flexible and can adapt to current network conditions. We then propose an ISPN architecture that supports two distinct kinds of real-time service: guaranteed service, which is the traditional form of real-time service discussed in most of the literature and involves pre-computed worst-case delay bounds, and predicted service, which uses the measured performance of the network in computing delay bounds. We then propose a packet scheduling mechanism that can support both of these real-time services as well as accommodate datagram traffic. We also discuss two other aspects of an overall ISPN architecture: the service interface and the admission control criteria.Research at MIT was supported by DARPA through NASA Grant NAG 2-582, by NSF grant NCR-8814187, and by DARPA and NSF through Cooperative Agreement NCR-8919038 with the Corporation for National Research Initiatives

Inequalities in the dental health needs and access to dental services among looked after children in Scotland: a population data linkage study

Background: There is limited evidence on the health needs and service access among children and young people who are looked after by the state. The aim of this study was to compare dental treatment needs and access to dental services (as an exemplar of wider health and well-being concerns) among children and young people who are looked after with the general child population. Methods: Population data linkage study utilising national datasets of social work referrals for ‘looked after’ placements, the Scottish census of children in local authority schools, and national health service’s dental health and service datasets. Results: 633 204 children in publicly funded schools in Scotland during the academic year 2011/2012, of whom 10 927 (1.7%) were known to be looked after during that or a previous year (from 2007–2008). The children in the looked after children (LAC) group were more likely to have urgent dental treatment need at 5 years of age: 23%vs10% (n=209/16533), adjusted (for age, sex and area socioeconomic deprivation) OR 2.65 (95% CI 2.30 to 3.05); were less likely to attend a dentist regularly: 51%vs63% (n=5519/388934), 0.55 (0.53 to 0.58) and more likely to have teeth extracted under general anaesthesia: 9%vs5% (n=967/30253), 1.91 (1.78 to 2.04). Conclusions: LAC are more likely to have dental treatment needs and less likely to access dental services even when accounting for sociodemographic factors. Greater efforts are required to integrate child social and healthcare for LAC and to develop preventive care pathways on entering and throughout their time in the care system

Applications of sensitivity analysis for probit stochastic network equilibrium

Network equilibrium models are widely used by traffic practitioners to aid them in making decisions concerning the operation and management of traffic networks. The common practice is to test a prescribed range of hypothetical changes or policy measures through adjustments to the input data, namely the trip demands, the arc performance (travel time) functions, and policy variables such as tolls or signal timings. Relatively little use is, however, made of the full implicit relationship between model inputs and outputs inherent in these models. By exploiting the representation of such models as an equivalent optimisation problem, classical results on the sensitivity analysis of non-linear programs may be applied, to produce linear relationships between input data perturbations and model outputs. We specifically focus on recent results relating to the probit Stochastic User Equilibrium (PSUE) model, which has the advantage of greater behavioural realism and flexibility relative to the conventional Wardrop user equilibrium and logit SUE models. The paper goes on to explore four applications of these sensitivity expressions in gaining insight into the operation of road traffic networks. These applications are namely: identification of sensitive, ‘critical’ parameters; computation of approximate, re-equilibrated solutions following a change (post-optimisation); robustness analysis of model forecasts to input data errors, in the form of confidence interval estimation; and the solution of problems of the bi-level, optimal network design variety. Finally, numerical experiments applying these methods are reported

A Clean-Slate Design for the Next-Generation Secure Internet

This is the report on a workshop held at CMU on July 12-14, 2005. The workshop is part of the planning process initiated by NSF to explore potential architectures for a next generation secure network designed to meet the needs of the 21st century. In considering future architectures, we ignore issues of backward compatibility with the current Internet but seek to benefit from the experience gained by analyzing both the strengths and weaknesses of the current design. Specifically, this workshop looks at the fundamental interplay between security and underlying network architecture and seeks to chart a preliminary course for future work in this crucial research area. This workshop focused on initiating a productive dialog between experts from the network security and network architecture communities. The agenda was arranged to stimulate initial consideration of the security goals for a new Internet, the design space of possible solutions, how research in security and network architecture could be integrated so that security is included as a first-tier objective in future architectures, and to explore methods for identifying and considering the social consequences of these architecture and security design choices

Electron tunnel rates in a donor-silicon single electron transistor hybrid

We investigate a hybrid structure consisting of $20\pm4$ implanted $^{31}$P atoms close to a gate-induced silicon single electron transistor (SiSET). In this configuration, the SiSET is extremely sensitive to the charge state of the nearby centers, turning from the off state to the conducting state when the charge configuration is changed. We present a method to measure fast electron tunnel rates between donors and the SiSET island, using a pulsed voltage scheme and low-bandwidth current detection. The experimental findings are quantitatively discussed using a rate equation model, enabling the extraction of the capture and emission rates.Comment: 10 pages, 3 figure

Factors Influencing Willingness-to-Pay for the Energy Star Label

In the United States, nearly 17 percent of greenhouse gas emissions come from residential energy use. Increases in energy efficiency for the residential sector can generate significant energy savings and emissions reductions. Consumer labels, such as USEPA’s Energy Star, promote conservation by providing consumers with information on energy usage for household appliances. This study examines how the Energy Star label affects consumer preferences for refrigerators. An online survey of a national sample of adults suggest that consumers are, on average, willing to pay an extra $249.82 to$349.30 for a refrigerator that has been awarded the Energy Star label. Furthermore, the results provide evidence that willingness to pay was motivated by both private (energy cost savings) and public (environmental) benefits.Energy Star, willingness-to-pay, eco-label, Consumer/Household Economics, Demand and Price Analysis, Environmental Economics and Policy,

The Myth of Cyberwar: Bringing War in Cyberspace Back Down to Earth

Cyberwar has been described as a revolution in military affairs, a transformation of technology and doctrine capable of overturning the prevailing world order. This characterization of the threat from cyberwar, however, reflects a common tendency to conflate means and ends; studying what could happen in cyberspace (or anywhere else) makes little sense without considering how conflict over the internet is going to realize objectives commonly addressed by terrestrial warfare. To supplant established modes of conflict, cyberwar must be capable of furthering the political ends to which force or threats of force are commonly applied, something that in major respects cyberwar fails to do. As such, conflict over the internet is much more likely to serve as an adjunct to, rather than a substitute for, existing modes of terrestrial force. Indeed, rather than threatening existing political hierarchies, cyberwar is much more likely to simply augment the advantages of status quo powers. </jats:p