The funding and organization of infection control in NHS hospital trusts: a study of infection control professionals' views.

The problems associated with hospital-acquired infection have been causing increasing concern in England in recent years. This paper reports the results of a nationwide survey of hospital infection control professionals' views concerning the organizational structures used to manage and obtain funding for control of infection. A complex picture with significant variation between hospitals emerges. Although government policy dictates that specific funding for hospital infection control is formally made available, it is not always the case that infection control professionals have adequate resources to undertake their roles. In some cases this reflects the failure of hospitals' infection control budgetary mechanisms; in others it reflects the effects of decentralizing budgets to directorate or ward level. Some use was made of informal mechanisms either to supplement or to substitute for the formal ones. But almost all infection control professionals still believed they were constrained in their ability to protect the hospital population from the risk of infectious disease. It is clear that recent government announcements that increased effort will be made to support local structures and thereby improve the control of hospital acquired infection are to be welcomed.

Routine monitoring of performance: what makes health research and development different?

Increasing attention is being directed to measuring and monitoring the use of health-related R&D funding, partly to justify this expenditure and partly to ensure that R&D effort is directed to achieving the paybacks desired by funders. These paybacks include contributing to knowledge, contributing to R&D capacity, political benefits, benefits to the health service and to patients, and more general economic benefits. This paper addresses the issues that must be considered when designing a routine performance management system for health R&D. Conventional methods of routine performance management are often rendered inappropriate in this context by the intangible and unpredictable outcomes of research, which are heterogeneous across projects and programmes and which can be hard to attribute to particular R&D support. Instead, to be effective in this context, a routine system must combine quantitative and qualitative indicators, utilising information from a number of different sources. The system must achieve acceptable levels (defined by the funder) on each of the following criteria: it must measure those dimensions of payback that are valued by the funder; it must be decision-relevant; it must be consistent with truthful compliance; it must minimise perverse incentives; and it must have acceptable net costs. It is vitally important that the system itself generates a positive payback. We illustrate these issues by outlining a system that might be used to monitor the payback from government-funded R&D.

The foundation and evolution of the Middlesex Hospital's lying-in service, 1745-86.

The Middlesex Hospital was founded in 1745, and opened the first British in-patient lying-in service in 1747. Men-Midwives were instrumental in founding and supporting the service. The hospital's lying-in service featured prominently in its fundraising literature, and the level of demand from benefactors suggests it was popular. From 1764 the hospital also provided domiciliary services, initially to cope with excess demand and later to compete with domiciliary charities. In 1786 it closed the in-patient services, and from this date provided only domiciliary lying-in services. From 1757, in common with the London lying-in hospitals, the Middlesex Hospital faced competition from a domiciliary charity: The Lying-In Charity for Delivering Poor Married Women in Their Own Homes. Later in the century it also faced competition from dispensaries. This paper describes the foundation and evolution of the Middlesex Hospital's lying-in service, including quantitative information about admissions and about the hospitals income and expenditure during the eighteenth century. It compares the characteristics of domiciliary and in-patient services, to analyse why in-patient services were supported by men-midwives and by benefactors.

Community care. Home service.

A nurse-led scheme to prevent hospital admissions by providing emergency services in the community for up to 72 hours cared for 155 people in its first six months. The scheme operated well below full capacity partly because of initial opposition from GPs. The mean age of service users was 79 and the main reasons for referral were chest infections, pneumonia and the need for support following an injury. More than three quarters of those cared for were fit to be discharged from the scheme within 72 hours.

From private club to professional network: an economic history of the Health Economists' Study Group, 1972-1997.

HESG was founded in 1972 as part of a conscious effort to establish health economics as an identifiable sub-discipline. It is debatable whether the growth of health economics was demand-led or supplier-driven, but in either case the existence of a HESG played a vital role. HESG was founded as a private club, in the tradition of English gentlemen's clubs, designed to provide a forum for debate and an invisible, supportive faculty for health economists dispersed between different organisations throughout the UK. It was given impetus by public economists at the University of York, who were effectively academic entrepreneurs, motivated in part by private gain, but by their actions overcoming the free-rider problem that might otherwise have retarded the development of health economics. Over the course of its first 25 years, HESG has changed and its membership has grown and altered in composition - over this period, HESG has evolved from a private club to a professional network. It has made a vital contribution to the existence and form of health economics as a subdiscipline in the United Kingdom, and has in turn itself been influenced by the subdiscipline. As a subdiscipline, UK health economics in the 1990s generally draws on a small body of economic theory and is practised by a distinct, identifiable group of economists. This paper was commissioned by HESG, as a history of the organisation. It also analyses the foundation and evolution of HESG as an institutional arrangement designed to overcome a collective action problem.

A cost effectiveness analysis of the treatment of end stage renal failure.

An economic evaluation of continuous ambulatory peritoneal dialysis (CAPD), home haemodialysis, incentre haemodialysis and transplantation was carried out using cost effectiveness analysis to evaluate the cost per life year saved. The probability that a person with end stage renal failure would change treatment modalities was used to calculate an average five year treatment profile. The present value of the cost per life year saved (expressed in 1988 $NZ) was $35,270 for incentre dialysis, $28,175 for home haemodialysis, $26,390 for CAPD at Middlemore Hospital, $25,395 for CAPD at Auckland Hospital and $18.463 for transplantation. This ranking was unchanged after various sensitivity analyses. This apparent ranking of the cost effectiveness of the different modalities cannot, however, be used to support a decrease in haemodialysis in favour of an increase in transplants and CAPD until marginal cost factors have been studied. It must also be recognised that social and medical characteristics define which treatments are appropriate for any patient so that the different modalities are not perfect substitutes for each other.