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In this paper, we analyze how variations in partisan representation across different levels of government influence Americans’ satisfaction with the democracy in the United States. We conduct two survey experiments and analyze data from the 2016 American National Election Study postelection survey. We find that Americans are the most satisfied with democracy when their most preferred party controls both the federal and their respective state governments. However, we also find that even if an individual’s least preferred party only controls one level of government, they are still more satisfied with democracy than if their most preferred party controls no levels of government. These findings suggest that competition in elections across both the national and state government, where winning and losing alternates between the two parties, may have positive outcomes for attitudes toward democracy.
The considerable normative value of General Assembly resolutions has been recognised in authoritative reports on the formation and identification of customary international law produced by the International Law Association (ILA) and the International Law Commission (ILC) in recent years.1 In his contribution to this volume (Chapter 2), James Summers draws our attention to the various ways in which the International Court of Justice (ICJ) in its Chagos Advisory Opinion sought to harness the growing importance of General Assembly resolutions in relation to the formation of customary international law,2 not least through the ways in which it has enhanced the application of the criteria enumerated in its Nuclear Weapons Advisory Opinion.3 This short chapter offers further reflections on this phenomenon.
Energy deficit is common during prolonged periods of strenuous physical activity and limited sleep, but the extent to which appetite suppression contributes is unclear. The aim of this randomised crossover study was to determine the effects of energy balance on appetite and physiological mediators of appetite during a 72-h period of high physical activity energy expenditure (about 9·6 MJ/d (2300 kcal/d)) and limited sleep designed to simulate military operations (SUSOPS). Ten men consumed an energy-balanced diet while sedentary for 1 d (REST) followed by energy-balanced (BAL) and energy-deficient (DEF) controlled diets during SUSOPS. Appetite ratings, gastric emptying time (GET) and appetite-mediating hormone concentrations were measured. Energy balance was positive during BAL (18 (sd 20) %) and negative during DEF (–43 (sd 9) %). Relative to REST, hunger, desire to eat and prospective consumption ratings were all higher during DEF (26 (sd 40) %, 56 (sd 71) %, 28 (sd 34) %, respectively) and lower during BAL (–55 (sd 25) %, −52 (sd 27) %, −54 (sd 21) %, respectively; Pcondition < 0·05). Fullness ratings did not differ from REST during DEF, but were 65 (sd 61) % higher during BAL (Pcondition < 0·05). Regression analyses predicted hunger and prospective consumption would be reduced and fullness increased if energy balance was maintained during SUSOPS, and energy deficits of ≥25 % would be required to elicit increases in appetite. Between-condition differences in GET and appetite-mediating hormones identified slowed gastric emptying, increased anorexigenic hormone concentrations and decreased fasting acylated ghrelin concentrations as potential mechanisms of appetite suppression. Findings suggest that physiological responses that suppress appetite may deter energy balance from being achieved during prolonged periods of strenuous activity and limited sleep.
This timely book is the most comprehensive account yet of recent commissioning practice in the English NHS and its impact on health services and the healthcare system. Drawing on eight years of research, expert researchers in the field analyse crucial aspects of commissioning, including competition and cooperation, the development of Clinical Commissioning Groups and contractual mechanisms. They also consider the influence of recent commissioning reforms on public health infrastructure. For academics and policy makers in health services research and policy, this is a valuable collection of evidence that deepens understanding of how commissioning works.
This chapter provides a brief contextual summary, setting out the organisation and governance of commissioning in the NHS. It gives an overview of commissioning from the creation of the internal market in the late 1980s to its consolidation pre-and post-HSCA 2012, and highlights the important changes which were brought about by the HSCA 2012. The chapter highlights the programme theories underlying the internal market and the HSCA 2012, in particular the commitment to competition as a means of improving services and the expected benefits of greater clinical involvement in commissioning. The architecture of commissioning following the HSCA 2012 is outlined and an overview of developments since the Act is presented.
It is perhaps important to note here that clinical involvement in commissioning has been variously referred to as ‘clinically-led’ and ‘GP-led’. In its earliest manifestations (GP fundholding) there was a clear policy commitment to the involvement of local GPs (primary care physicians) in commissioning. As noted in Chapter 1 this policy was driven by a belief in the value of local clinical knowledge, rather than by any evidence of its value. Over time, emphasis in policy has shifted between ‘GP-led commissioning’ (such as fundholding, PBC) and ‘clinically led commissioning’ (such as Primary Care Groups [PCGs]). The use of the wider term ‘clinically led’ has been used by policy makers to signal a commitment to the wider engagement of other clinicians such as nurses and hospital consultants, often in response to representations from other professional groups. Thus, in their first iteration, CCGs were explicitly intended to be GP-focused, but during a consultation period the rules were amended to mandate the involvement of both a nurse and a hospital consultant on CCG governing bodies, and policy documents reflected this by referring to ‘clinically led’ commissioning. However, in practice, clinically led commissioning has generally meant GP-led commissioning, with the involvement of other clinicians tokenistic at best. In this book, for consistency, the term ‘GP-led commissioning’ is used, but acknowledge that policy has, at times, tried to promote a wider clinical engagement beyond local GPs.
Internal market/purchaser– provider split – the origins of ‘commissioning’
The NHS was established initially in 1948 as a hierarchical public Organisation.
The aim of this book is to bring together in one volume the most important research which the Policy Research Unit in Commissioning and the Healthcare System (PRUComm) has undertaken during the period 2011 to 2018. PRUComm is a multicentre research unit based at the London School of Hygiene and Tropical Medicine (LSHTM), the University of Manchester and the University of Kent. It is led by Professors Stephen Peckham (LSHTM and Kent), Kath Checkland (Manchester) and Pauline Allen (LSHTM). PRUComm was funded (following an open competition) by the Policy Research Programme of the English Department of Health and Social Care (DHSC) (that is, the English Ministry of Health) from 2011 onwards to provide evidence to the DHSC to inform the development of policy on commissioning and the healthcare system. The analytical work supports understanding of how commissioning operates and how it can improve services and access, increase effectiveness and respond better to patient and population needs.
The term ‘commissioning’ is used in the context of the quasi-market structures in the English National Health Service (NHS), which will be explained in detail in the following chapter. Briefly, ‘commissioning’ can be understood as ‘the process of assessing needs, planning and prioritising, purchasing and monitoring health services, to get the best health outcomes’ (NHS England, 2018a). In other words, commissioning focuses on the demand side of the NHS quasi-market (where organs of the state make decisions on behalf of patients), as opposed to the providers of care, such as hospitals. The research extends to analysing the structure and operation of the NHS healthcare system as a whole, focusing on how commissioning can be used to influence providers’ behaviour. Clearly, the concept of commissioning is not confined to the English NHS. Quasi (or actual) markets were introduced into many English public services in the 1990s and the necessity for the state to undertake demand-side activities on behalf of (or in conjunction with) citizens became widespread (Le Grand and Bartlett, 1993). For example, social care has also been subject to marketisation (Forder et al, 2004). Although the term commissioning is not always used internationally, many countries have developed institutional structures for their public services in which commissioning functions are undertaken either by the state (for example, in the Italian healthcare system) (France et al, 2005) or social insurance funds (for example, in the Dutch healthcare system) (Rutten, 2004).
The period since the passing of the HSCA 2012 has been one of change and disruption for the NHS and at the time of writing in 2019 it seems unlikely that this turbulence will diminish in the near future. While the LTP (NHS England and NHS Improvement, 2019) published in January 2019 provides some indication of the future direction of commissioning, the lack of specific detail and guidance leaves the Plan open to interpretation. The main thrust of the LTP is to increase the emphasis on collaboration and integration at local level at the expense of competition, but its provisions about commissioning itself are not clear. The structural changes introduced by the HSCA 2012 pursuant to the twin policies of increasing clinical involvement in commissioning and accelerating market forces have had large effects on the practice of commissioning across the NHS. The government also emphasised the need for local freedoms to determine how services should be delivered in relation to the choices and needs of patients and greater public and democratic accountability (Department of Health, 2010a). In addition, while the focus of less attention, the shift of public health from the NHS to LAs discussed in Chapter 8 has also had a profound effect on the commissioning and delivery of services. The broad range of PRUComm's research projects has revealed a series of common themes, which are also found in other research on developments during this period.
As highlighted in previous chapters, since the introduction of changes following the HSCA 2012 there has been a large increase in the complexity of health system governance. The number of bodies undertaking commissioning has increased in two ways: NHSE, PHE and LAs all have a role in commissioning aspects of health care, in addition to CCGs, which were the successor to PCTs; moreover, CCGs are smaller organisations than PCTs so there are many more of them. While the shift to CCGs and LA commissioning appears to fit with the White Paper's language of localism and decentralisation, freeing local commissioners from central control, the reality has been somewhat more mixed.
In its Chagos Advisory Opinion, the International Court of Justice (ICJ) ruled that the UK's detachment of the Chagos Archipelago from the colony of Mauritius on the eve of independence constituted a violation of customary international law (CIL). This article analyses the Court's approach to establishing the emergence and content of the right to self-determination in this frustrated case of decolonisation. It goes on to examine the argument that self-determination's peremptory character has decisive consequences in this specific context—a contention which found favour with several judges in their Separate Opinions. The article explores the extent to which the claims and counterclaims, made during the advisory proceedings, turned on countervailing readings of not only the key sources of custom but also of the principle of inter-temporal law. The final sections consider the significance of the Chagos Opinion for the Chagossians, both in relation to the Archipelago's resettlement and for their outstanding appeal in the UK courts (where the European Convention on Human Rights performs a pivotal role).
In its Chagos Advisory Opinion, the International Court of Justice (ICJ) addressed two questions posed in a request from the UN General Assembly. First, had Mauritius's decolonization been completed when it gained independence in 1968, after the excision of the Chagos Archipelago? Second, what were the legal consequences flowing from the United Kingdom's continued administration of the Archipelago? It was thought that the Court might shy away from giving an Opinion in this case as, arguably, it concerned a bilateral sovereignty dispute that the United Kingdom had not agreed to have resolved by judicial decision. However, as it turned out, the Court delivered surprisingly robust responses to the questions posed. The Opinion—and the numerous Separate Opinions that accompanied it—offer a thorough re-evaluation of the customary international law (CIL) concerning the right to self-determination in cases of decolonization.
The associations between growth during early life and subsequent cognitive development and physical outcomes are not widely known in low-resource settings. We examined postnatal weight and height gain through early life and related these measurements to the nutritional status and intellectual development of the same children when they were between 7 and 9 years old. Mothers had enrolled in an randomised controlled trial to evaluate the effect of prenatal micronutrient supplementation on birth weight. Their children were born in 2004, their height and weight were measured at 6, 12, 18 and 24 months of age and were followed up between October 2012 and September 2013 (at ages 7–9 years, n 650). Height-for-age, weight-for-age and BMI-for-age were used to describe the nutritional status, and the Wechsler Intelligence Scale for Children fourth edition was used to measure the intellectual function. Multilevel linear and logistic modelling was used to estimate the association between early growth and subsequent growth and intellectual function. After adjustment, weight gain from 6 to 12 months of age was associated with Full-scale Intelligence Quotient, Verbal Comprehension Index, Working Memory Index and Perceptual Reasoning Index. Weight gain during early life was associated with subsequent nutritional status. For every 1 kg increase in weight during the 0- to 6-month period, the OR for underweight, thinness and stunting at 7–9 years of age were 0·19 (95 % CI 0·09, 0·37), 0·34 (95 % CI 0·19, 0·59) and 0·40 (95 % CI 0·19, 0·83), respectively. Weight gain during the periods of 6–12 months of age and 18–24 months of age was also associated with a lower risk of being underweight. Weight gain during early life was associated with better growth outcomes and improved intellectual development in young school-aged children.
Hospitalized patients placed in isolation due to a carrier state or infection with resistant or highly communicable organisms report higher rates of anxiety and loneliness and have fewer physician encounters, room entries, and vital sign records. We hypothesized that isolation status might adversely impact patient experience as reported through Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys, particularly regarding communication.
Retrospective analysis of HCAHPS survey results over 5 years.
A 1,165-bed, tertiary-care, academic medical center.
Patients on any type of isolation for at least 50% of their stay were the exposure group. Those never in isolation served as controls.
Multivariable logistic regression, adjusting for age, race, gender, payer, severity of illness, length of stay and clinical service were used to examine associations between isolation status and “top-box” experience scores. Dose response to increasing percentage of days in isolation was also analyzed.
Patients in isolation reported worse experience, primarily with staff responsiveness (help toileting 63% vs 51%; adjusted odds ratio [aOR], 0.77; P = .0009) and overall care (rate hospital 80% vs 73%; aOR, 0.78; P < .0001), but they reported similar experience in other domains. No dose-response effect was observed.
Isolated patients do not report adverse experience for most aspects of provider communication regarded to be among the most important elements for safety and quality of care. However, patients in isolation had worse experiences with staff responsiveness for time-sensitive needs. The absence of a dose-response effect suggests that isolation status may be a marker for other factors, such as illness severity. Regardless, hospitals should emphasize timely staff response for this population.