Lawfulness of a randomised trial of the new community treatment order regime for England and Wales

This article debates and defends the lawfulness of a randomised controlled trial of compulsory outpatient treatment under the mental health legislation for England and Wales. The trial is designed to compare the outcomes for patients of their treatment under the new Community Treatment Order (CTO) regime with their treatment under the older leave scheme - the two main forms of compulsory care in the community now authorised by the revised Mental Health Act 1983. The methods for the trial involve the random allocation of some patients between the two schemes, when they are considered by their Responsible Clinicians to be eligible for some form of compulsory outpatient care. The main question we consider is the lawfulness of that aspect of the methods. Can a carefully selected group of patients be allocated at random between the two regimes to permit an evaluation to proceed? Or would that involve some departure from the decision-making criteria specified by law? We argue that a group of patients can be identified who meet - simultaneously - the tests for treatment under both the CTO and the leave schemes. Those patients could then be allocated lawfully to treatment under either scheme. This opens the door, we argue, to their random allocation between the two schemes for the purposes of the research. In reaching this conclusion, we explain the methods and aims of the trial and closely compare the respective features of the leave and CTO regimes.     

Administrative reform in china: Issues and prospects

China's experience of organizational reform is representative of the country's attempts to implement more general administrative reform. Forty years of organizational reform have produced only short-term successes. In the 1988 reforms, however, leaders proposed for the first time to re-define the role of the state in society. In general, the reforms have been undermined by political, economic, and institutional problems. These include conflicting elite priorities, cycles of economic centralization and decentralization, the interdependence of government agencies and economic enterprises, and the lack of incentives to economize. Consequently, the organizational reform management institutions are very weak. Successful implementation of organizational reform in the future depends to a large extent on further economic development.     

Inter- and intra-subject variability in ethanol pharmacokinetic parameters: effects of testing interval and dose

Calculation of a blood alcohol concentration (BAC) at the time of an offence by forward or back-extrapolation, using population average values for ethanol pharmacokinetic parameters or a single estimate of individual specific parameters, ignores the possibility of inter- and intra-subject variability. In order to estimate inter- and intra-subject variability in the elimination rate and absorption rate, BAC was measured over time in 12 male volunteers on 4 occasions. Subjects received 0.44 g kg(-1) body weight of ethanol on the first study day, and 0.70 g kg(-1) body weight on subsequent study days 1, 11 and 12 weeks later, to enable comparisons in variability over short and long time periods and when the same or different doses were administered. Evidence of both inter- and intra-subject variability was found, with inter-subject variability substantially smaller than intra-subject variability when the dose varied. Forensically important differences in pharmacokinetic parameters were observed within individuals between occasions. These findings could have an important impact on medico-legal issues related to ethanol pharmacokinetics.     

Medicare coverage, Medicare costs, and medical technology

One possible approach to containing Medicare costs involves explicit changes in Medicare's coverage policy with respect to medical technology. This paper first describes the development and diffusion of medical technology in general and then describes how technologies are identified, assessed, and approved for payment by Medicare. Currently, cost is neither a criterion nor an explicit issue in coverage decisions, although coverage policy is an integral part of payment policy. A combination of policies to reduce the rates of adoption and use of certain technologies is needed--including cost considerations in technology assessments for coverage decisions, limiting diffusion of technology to certain providers and sites, limiting utilization to certain indications, and tightening administrative processes. Finally, the interaction between coverage policy and DRG payment needs to be explored more thoroughly.     

Institutions and social movements: the case of comparable worth

Employing evidence from the history of the comparable worth movement, I argue that (1) the State-citizen shaping process is one in which States shape citizens and movements and citizens and movements shape States; (2) States are not always successful in shaping movements because movemnts require a certain level of both stakes and consciousness on the part of potential members; (3) States are more effective at influencing whether a movement will win than they are at actually producing social movements; and (4) the costs and benefits associated with the various institutional channels impact heavily upon a movement, particularly upon its organization and its alliances. These theoretical propositions provide clues as to why the comparable worth movement has been able to persist at the state and local level despite Federal opposition.