Regional Offices in the New NHS: An Analysis of the Effects and Significance of Recent Changes

This article reports on a two-year, multi-method, qualitative study in two regional offices in the UK National Health Service of the changing role of the regional tier from the autumn of 1994. The nature of the changes from fourteen semiautonomous regional health authorities to eight regional offices of the NHS Executive, whose staff became civil servants, are described together with the way this reorganization changed the role and relationships of NHS Executive HQ, the regional offices and the field. By the end of our research in the autumn of 1996, the change from regional health authority to regional office had gone well in the two regional offices studied; they had become smaller organizations, had established closer working with HQ and believed they had more influence over policy, while retaining good relations with health authorities. Emerging issues from the changes and some of their implications are discussed, particularly the pressures towards greater centralization and the particular forms that these have taken, despite the aim, and in part the achievement, of greater devolution, and the cultural differences between the NHS and the civil service. We conclude by assessing what the future holds for regional offices, in the light of the recent NHS White Paper (Secretary of State for Health 1997)     

Law’s (Masculine) Violence: Reshaping Jurisprudence

This article critiques and expands upon the jurisprudence of law’s violence from feminist and lesbian/gay/queer perspectives. The incorporation of gender and sexuality into the jurisprudence of law’s violence, via the social experiences of women and gay men, highlights the masculine and heteronormative character of law’s violence, while bringing into view particular forms of law’s violence, and forms of extra-legal but thoroughly legitimate heterosexual male violence, that have remained invisible in previous accounts. A feminist analysis of violence also suggests that law’s regime of violence is neither totalising nor inevitable, and that possibilities for resistance, if not avoidance, do exist.     

Flaws in the U.S. Food and Drug Administration's rationale for supporting the development and approval of BiDil as a treatment for heart failure only in black patients

The U.S. Food and Drug Administration's (FDA) rationale for supporting the development and approval of BiDil (a combination of hydralazine hydrochloride and isosorbide dinitrate; H-I) for heart failure specifically in black patients was based on under-powered, post hoc subgroup analyses of two relatively old trials (V-HeFT I and II), which were further complicated by substantial covariate imbalances between racial groups. Indeed, the only statistically significant difference observed between black and white patients was found without any adjustment for potential confounders in samples that were unlikely to have been adequately randomized. Meanwhile, because the accepted baseline therapy for heart failure has substantially improved since these trials took place, their results cannot be combined with data from the more recent trial (A-HeFT) amongst black patients alone. There is therefore little scientific evidence to support the approval of BiDil only for use in black patients, and the FDA's rationale fails to consider the ethical consequences of recognizing racial categories as valid markers of innate biological difference, and permitting the development of group-specific therapies that are subject to commercial incentives rather than scientific evidence or therapeutic imperatives. This paper reviews the limitations in the scientific evidence used to support the approval of BiDil only for use in black patients; calls for further analysis of the V-HeFT I and II data which might clarify whether responses to H-I vary by race; and evaluates the consequences of commercial incentives to develop racialized medicines. We recommend that the FDA revise the procedures they use to examine applications for race-based therapies to ensure that these are based on robust scientific claims and do not undermine the aims of the 1992 Revitalization Act.