Privity of Contract Reform

“It is important to emphasise that, while our proposed reforms will give some third parties the right to enforce contracts, there will remain many contracts where a third party stands to benefit and yet will not have a right of enforceability”

In 1996, the Law Commission published Privity of Contract: Contract for the Benefit of Third Parties. The proposals set out in this report were later legislated on the basis of, in the Contracts (Rights of Third Parties) Act 1999. The aim of this legislation was fundamentally to alter the law in relation to the concept of privity of contract, in order to grant third parties who were not parties to the original contract certain rights. The doctrine of privity of contract will be considered, and the effect on this of the C(RTP)A will be analysed. Finally, some consideration will be given to the question of whether the legislation has gone far enough in reforming the law of privity.

It has historically been a fundamental and central principle of contract law in England and Wales that only the actual parties to a contract can have either contractual rights or duties conferred upon them. This was established at common law in the case of Tweddle v Atkinson (1861). The doctrine was confirmed in the early twentieth century in the case of Dunlop Pneumatic Tyre Co Ltd v Selfridge and Co Ltd (1915). It is important at the outset to distinguish the doctrine of privity of contract from the possibility of a third party enforcing a collateral contract. These are quite distinct scenarios. Under the first (historically), the third party had no right to claim rights, nor to be held liable for the performance of contractual duties. In the second scenario, as was established at common law in the case of Shanklin Pier v Detel Products Ltd (1951), an actual contract might be found to exist between the third party and one of the parties to the contract. It is the former of the two situations with which the C(RTP)A 1999 is concerned. The two interests (as defined by McKendrick) which a third party can have in a contract to which he is not a party are both whether or not he can acquire rights under that contract, and whether or not the contract in question can impose any liabilities or obligations on him.[1] The most significant impact on this area was that of the C(RTP)A, which Trietel describes as ‘the most significant doctrinal development in English contract law in the twentieth century.’[2]

What, then, is the purpose of privity of contract? It is, rather obviously, to do with the perceived injustice of imposing rights or obligations as between two parties who have had no dealing, at least no contractual dealing. It is clear that if X and Y enter a contractually binding agreement, Y has not made any agreement with Z, and therefore there is no rationale for entitling Z to take enforcement action against Y. The justification for the doctrine flows from the fact that contractual obligations, unlike tortious ones, are voluntary.[3] As Ibbetson states, the ‘rule that a third party could not enforce rights arising under a contract has been a feature of English law since at least the thirteenth century.’[4] The distinction between the acquisition of third party rights and obligations in contracts and other exceptions to privity of contract has already been mentioned. These exceptions can be expanded beyond collateral contracts (as seen in Shanklin Pier v Detel Products Ltd (1951)), to include a trust of a contractual right, whereby a ‘right may be transferred by way of property, as, for example, under a trust’[5]; the assignment of contractual rights to a third party (as in, for example, Linden Gardens Trust Ltd v Lenesta Sludge Disposals Ltd (1994)); in cases of agency, where the agent is acting on his principal’s behalf, with the full authority of that principle, and concludes a contract (following Wakefield v Duckworth (1915), where the agent was operating within his authority, he ‘drops out of the picture and the contract is between the principal and the other contracting party); and cases where a claimant who is a third party suffers loss because of the negligent performance of the contract by a contracting party, as in the classic case Donoghue v Stevenson (1932).

The doctrine of privity, then, was a foundational principle of English contract law until the advent of the Law Commission’s report in 1996. The opening quotation, taken from that report, explicitly seeks to limit the implications of the reforms that would later find their way into the C(RTP)A 1999, and the consideration above of the centrality of the doctrine of privity to contract law generally, shows why these limitations were considered necessary. What is the impact on this doctrine of the C(RTP)A, and does this do enough to reform the law on privity?

The C(RTP)A states that ‘subject to the provisions of this Act, a person who is not a party to a contract may in his own right enforce a term of the contract if the contract expressly provides that he may … or the term purports to confer a benefit on him.’ Furthermore, ‘the third party must be expressly identified in the contract by name, of a member of a class or as answering to a particular description but need not be in existence when the contract is entered into.’[6] There are, then, two separate tests for enforceability. The first test is described by Burrows as the ‘simplest’, and so it is; it is a simple question of fact whether the contract expresses the third party may enforce a term of it.[7] An example of this explicit authorisation of the third party to enforce a term of the contract is where the contract states ‘X [the third party] shall have the right to enforce the following terms of the contract…’ The provision under this section is less restrictive than it might be because of the implications of section 1(3) which complements it, stating that the third party does not need to be named; it is sufficient for the third party to be the member of an identified class.

The second test of enforceability under the Act is, again in the words of Burrows, is concerned with the ‘implied’ conferral of rights on third parties (as opposed to the express conferral discussed above).[8] The reasoning behind including this second test for enforceability can be broken down into 3 key areas. The first concerns the issue of implied rights in contracts, brought into the contract by implied terms. It is considered that to limit third party rights is akin to restricting implied terms. In other words, the parties’ intentions are not always their express intentions. The same can apply to third parties. The second area of justification for implied third party rights revolves around the uselessness of a reform confined to an express conferral of rights, unless the contracting parties included some ‘magic formula’ in the agreement so as to fall within the scope of the first test.[9] Cases where third parties would be unaffected by the C(RTP)A 1999 if the reform was confined to expressly mentioned third parties include Beswick v Beswick (1968), in which A contracted with B to pay money to C; and Trident General Insurance Co Ltd v McNiece Bro (1988), in which liability insurance was taken out to protect third parties to the contract. Finally, the implied conferral of rights on third parties has been justified by the fact that the aforementioned ‘magic formula’ will only be used in informed, well drafted contracts, which many will not be, particularly in the consumer sphere where good legal advice is not affordable.

Do these two tests reflect the spirit of the opening quotation? It can certainly be seen how these two tests of enforceability have altered the doctrine of privity substantially, and in particular the second test of enforceability relating to implied third party rights. The Law Commission’s statement, however, suggests a balance, between maintaining privity for many contracts, and allowing third party rights in others. This balance can be seen to be aimed for by the existence of a rebuttable presumption of intention inherent in the second test of enforceability. This rebuttable presumption attains a further balance, between a sufficient degree of certainty between contracting parties, and sufficient flexibility. This flexibility was required in order for the C(RTP)A 1999 to apply to the potentially huge range of contracts for which it was intended. The presumption is set up by asking the question ‘when are the parties likely to have intended to confer a right on a third party to confer a term?’ If the answer is ‘where the term purports to confer a benefit on the expressly identified third party’, then the presumption is raised.[10] This, of course, can be rebutted by the ordinary contractual interpretation of an indication that the parties did not intend this. The balance can be seen to have been aimed for, at least, in the two tests of enforceability in the C(RTP)A 1999.

An illustration of how the tests would be applied to decided cases is offered by Trietel, who identifies the case of Jackson v Horizon Holidays (1975) as falling within the scope of the second test under section 1(1)(b). He observes that ‘if the person making the booking [for a holiday on behalf of a third party] supplied the names of the other members of the family when the contract was made, those other members would probably acquire rights under subsection 1(1).; but no such rights are likely to be acquired if a person simply rented a holiday cottage without giving any information as to the number or names of the persons with whom he proposed to share the accommodation.’[11] This, then, can be seen to be a limitation to the effect of the reform legislation. It is suggested by McKendrick that section 1 simply gives the contracting parties an incentive to make their intention clear, which, again, returns to the issue mentioned above about the need for well-drafted contracts.[12]

The C(RTP)A 1999 is a highly significant piece of reform legislation, which fundamentally alters a central doctrine of English contract law. It can be seen to represent the superiority of the doctrine of freedom of contract over that of privity of contract. The significance of the Act is that while it maintains the previous exceptions to privity of contract, contracting parties will probably make increasing use of the Act rather than these, as a matter of certainty. The effect of the Act is somewhat limited, however, by the continuing requirement of clarity in the construction of the contract, whereby a presumption of an intention to confer rights on a third party can be rebutted. The effect of this, however, is simply to encourage a clarity of intention on the part of the contracting parties.

BIBLIOGRAPHY

Statutes

Contracts (Rights of Third Parties) Act 1999

Cases

Beswick v Beswick [1968] AC 58

Donoghue v Stevenson [1932] AC 562

Dunlop Pneumatic Tyre Co Ltd v Selfridge and Co Ltd [1915] AC 847

Jackson v Horizon Holidays [1975] 1 WLR 1468

Linden Gardens Trust Ltd v Lenesta Sludge Disposals Ltd [1994] 1 AC 85

Shanklin Pier v Detel Products Ltd [1951] 2 All ER 471

Trident General Insurance Co Ltd v McNiece Bro (1988) 165 CLR 107

Tweddle v Atkinson [1861 – 1873] All ER Rep 369

Wakefield v Duckworth [1915] 1 KB 218

Secondary sources

Burrows, A. (2000) ‘The Contracts (Rights of Third Parties) Act and its Implications for Commercial Contracts (LMCLQ 540)

Ibbetson, D. (1999) A Historical Introduction to the Law of Obligations (Oxford: OUP)

Law Commission (1996) Privity of Contract: Contract for the Benefit of Third Parties (Law Comm 242)

McKendrick, E. (2003) Contract Law: Text, Cases and Materials (Oxford: OUP)

Smith, S.A. (1997) ‘Contracts for the Benefit of Third Parties: In Defence of the Third-Party Rule’, 7 OJLS 643

Trietel, G.H. (1999) The Law of Contract, 10th Edition (London: Sweet & Maxwell)

Trietel, G.H. (2002) Some Landmarks of Twentieth Century Contract Law (Oxford: OUP)

Predicting Individual differences in Mindfulness

Predicting Individual differences in Mindfulness: The role of Trait Anxiety, Openness and Parental Nurturance

­­­­

Abstract

Mindfulness is a way of paying attention, intentionally and without judgement to the present moment. Mindfulness training has shown impressive outcomes in a number of areas such as depression and pain reduction; however, the literature has failed to account for natural, individual differences in levels of mindfulness. This research provides an exploration of the variables: Trait Anxiety, Openness to Experience and Parental Nurturance and their ability to predict individual differences in Mindfulness. 123 participants each completed four questionnaires: The State-Trait Anxiety Inventory (STAI) was used to assess Trait Anxiety, the NEO-FFI was used to measure Openness to Experience, the Parental Nurturance Inventory was used to measure Parental Nurturance, and Mindfulness was assessed using the Freiburg Mindfulness Inventory (FMI). Partially consistent with the predictions, Trait Anxiety was shown to negatively predict Mindfulness, Openness to Experience and Parental Nurturance where not as strong predictors of Mindfulness.

Key Terms: Mindfulness, Trait Anxiety, Openness, Parental Nurturance.

Introduction

Mindfulness is a way of paying attention, intentionally and without judgement to the present moment. The practice of Mindfulness originated in East India and is at the heart of Buddhist meditation. According to Kabat-Zinn (1994, 4) ‘This kind of attention nurtures greater awareness, clarity, and acceptance of present-moment reality’. A lack of or reduced awareness to the present-moment, however, has the opposite affect which results in fear driven ‘unconscious and automatic actions and behaviours’. Continuing in this pattern of diminished awareness results in erosion to ones confidence and hinders the possibility of a life of satisfaction, health and happiness (Kabat-Zinn, 1994). Traditionally, Mindfulness was viewed as a spiritual practice, heavily steeped in Buddhism; however, more recently this practice has been widely encouraged in the western society (Baer, 2003).

According to Baer (2003) there are two main Mindfulness training programmes namely the Mindfulness-Based Stress Reduction Programme and Mindfulness-Based Cognitive Therapy. Other therapies such as Dialectical Behaviour Therapy, Acceptance and Commitment Therapy and Relapse Prevention incorporate principles of Mindfulness into the programme. Most Mindfulness training programmes run for a serious of 8-10 weeks, with a one day a week group meeting which is held for approximately 2 hours. Clients are also required to do homework session including 45 minutes per day, 6 days a week.

Evidence suggests that Mindfulness-based training intervention is effective. Research indicates that Mindfulness-based training is effective in working with borderline personality disorder, mood disorders, pain, generalised anxiety disorder, stress, alcohol and substance abuse, and eating disorders (Baer, 2003; Roemer, 2002; Williams, Teasdale, Segal, & Soulsby, 2000; Witkiewitz, Marlatt, & Walker, 2005; Woodman, Noyes, Black, Schlosser, & Yagia, 1999; Zettle & Rains, 1989).

Without any way of accurately, and objectively measuring levels of Mindfulness, positive findings were attributed to the training alone. Brown and Ryan (2003), however, proposed that individual differences may account for differences in levels of Mindfulness. The introduction of a measure for Mindfulness has made room for researchers to explore this proposal in greater depth. The present study attempts to explore a question: to what extent do individual differences influence levels of Mindfulness. The literature highlights three such individual differences that may be of interest: Trait Anxiety, Openness to Experience and Parental Nurturance.

The experience of anxiety is one that is familiar to most people; and Kaplan and Sadock (1998) describe the related symptoms as including an uneasy feeling followed by automatic responses such as headaches, perspiring and tightness in the chest. Trait anxiety, as apposed to state anxiety, is a persistent and does not wane in less stressful times. These researchers identify anxiety as having two components, namely awareness to the physiological sensations and awareness to being afraid. These experiences often lead to feelings of embarrassment, and in order to feel justified for the anxiety, people tend to focus on certain, conforming aspects of the environment and overlooking others. As a result of this bias to attention, a person is unable to experience the presence as a whole. Trait Anxiety is therefore expected to have an inverse relationship with Mindfulness.

Openness to Experience is one of the five main personality domains and is described by McCrae and John (1992) as encompassing such things as imagination, aesthetic sensitivity, awareness of inner feelings, an inclination towards variety, and intellectual curiosity. Individuals who score high on this scale tend to be motivated to discover their environment, ask questions and have a readiness to question authority. As such, it is hypothesized that a high level of Openness to Experience would be a positive predictor of Mindfulness, since these individuals approach their environment with awareness, which is not clouded by judgment.

The manner in which a parent responds to their child in the first years of his or her life has a far reaching impact on their adult life, affecting their relationships, both intimate, social and professional, how they interpret information given to them from the environment and whether or not they view the world as a safe place, and whether or not people are trust worthy (Fonagy, Gergely, Jurist, & Target, 2005). According to this theory of attachment, Parental Nurturance is also an important factor in determining an individual’s ability to contain his or her own emotions. From this, it is hypothesised that positive Parental Nurturance will be a good predictor of Mindfulness as individuals are able to be present in their environment in a trusting, non-judgmental way.

The present study explores the predictive value of these variables for increased levels of Mindfulness. In light of the literature, it is thought that a low level of Trait Anxiety will have an inverse relationship with Mindfulness, and that Openness to Experience and Parental Nurturance will be positive predictors of Mindfulness.

Method
Design and Measures

For the purpose of the present research study, a cross-sectional, correlational design was adopted. Information was thereby elicited from people in a number of different conditions, namely Trait Anxiety, Openness to Experience and Parental Nurturance (independent variables), and the dependent variable of Mindfulness. The following measures where used:

Spielberger’s (1983) State-Trait Anxiety Inventory (STAI) was used to assess Trait component of Anxiety. The STAI is designed to measure and distinguish between anxiety as a trait or as a state. Trait anxiety is a relatively stable personality trait and is marked by feelings of apprehension and tension, which is heightened in times of perceived threat. State anxiety, however, fluctuates and is heightened at times of stress and low in less stressful periods. This is a self-report, four-point rating scale, including 20 statements that ask people to describe how they feel at a particular moment. A high score is indicative of a high level of Trait Anxiety.

Costa and McCrae’s (1991) NEO-FFI was used to assess Openness to Experience. This is a 60-item version of the NEO PI-R, which measures only the five factors of adult personality, however for the purpose of this study, only the twelve-item scale assessing Openness was employed. This is measure makes use of a five-point rating scale, where participants demonstrated the degree of agreement with given statements. A high score on this scale is indicative of a high level of Openness.

Buri’s (1989) Parental Nurturance scale was used to assess this component of the study. This is a self-report, five-point Likert scale, where participants are required to describe positive and negative aspects of the parental nurturance they received. This is repeated twice, once for information pertaining to the mother and the second time for information relating to the father’s nurturance. An average of these combined scores is used as a final result, with a high score indicative of elevated levels of Parental Nurturance.

Mindfulness was measured using the FMI (Walach, Buchheld, Buttenmuller, Kleinknecht, & Schmidt, 2006). This is a short scale, 14-item, self-report measure, requiring participants to indicate their degree of agreement with a given, mindfulness direct statement. A high score on this measure is indicative of elevated levels of Mindfulness.

Procedures, Participants and Ethics

Participants were purposively sampled and personally invited by written invitation to participate in this study. Of the initial 153 participants, 123 were included in the present study. A detailed outline of the nature and details of the study, including a description of what would be required of them was provided in the initial invitation. Participants were assigned to one of three separated testing groups. On receiving consent, participants were handed a package of four questionnaires (STAI, NEO-FFI, Parental-Nurturance Inventory, FMI). Each questionnaire was marked with separate instructions for completion. Each participant completed the pack of questionnaires in the same order.

Results
Reliability of Measures

A reliability analysis of the questionnaires was conducted, yielding satisfactory results indicating that the participants responded in a consistent manner to the questionnaires. The reliability coefficients were as follows: Mindfulness (? = .78); Trait Anxiety (? = .88); Openness (? = .73); Parental Nurturance – mother (? = .96); Parental Nurturance – father (? = .96).

Descriptive Statistics

A descriptive analysis of the data obtained across the variables of Mindfulness, Trait Anxiety, Openness and Parental Nurturance is given in Table 1. As shown, the mean score for openness was 3.62, with a standard deviation (SD) of .55. The total results on the measure of Trait Anxiety yielded a mean score of 2.19, with a SD of .59. The mean score for Parental Nurturance was 3.71, with a SD of .79, and the Mindfulness mean is indicated at 2.69, with a SD of .46.

Table 1: Presentation of Mean Scores and Standard Deviations from the Measures Employed to assess Openness to Experience, Trait Anxiety, Parental Nurturance and Mindfulness.

N

Minimum

Maximum

Mean

Std. Deviation

Openness mean

123

2.25

4.75

3.62

.55

Trait Anxiety mean

123

1.10

3.60

2.19

.59

Parental Nurturance mean

123

1.29

5.00

3.71

.79

Mindfulness mean

123

1.71

3.79

2.69

.46

Valid N (listwise)

123

Inferential Statistics

The correlational analysis undertaken to explore the relationship between the dependent variable, Mindfulness, and the independent variables, Openness, Trait Anxiety and Parental Nurturance. These results are presented in Table 2. A significant, positive correlation was found between Mindfulness and Openness (r = .02, df = 3, p<.05). A negative relationship was found between Trait Anxiety and Mindfulness (r = -.56, df = 3). No significant, positive relationship was found between Parental Nurturance and Mindfulness (r = .14, df = 3, p<.05), however, it may be interesting to note that this correlation borders on significant.

Table 2. Correlational Analysis Presenting the Relationship between Mindfulness and the Variables: Openness, Trait Anxiety and Parental Nurturance.

Mindfulness mean

Openness mean

Trait Anxiety mean

Parental Nurturance mean

Mindfulness mean

Pearson Correlation

1

.19

-.56

.140

Sig. (1-tailed)

.

.02

.00

.06

N

123

123

123

123

Openness mean

Pearson Correlation

.19

1

-.11

-.04

Sig. (1-tailed)

.02*

.

.11

.350

N

123

123

123

123

Trait Anxiety mean

Pearson Correlation

-.56

-.11

1

-.33

Sig. (1-tailed)

.000

.11

.

.000

N

123

123

123

123

Parental Nurturance mean

Pearson Correlation

.14

-.04

-.33

1

Sig. (1-tailed)

.06

.35

.00

.

N

123

123

123

123

* Correlation is significant at the 0.05 level (1-tailed).

** Correlation is significant at the 0.01 level (1-tailed).

An analysis of the degree of variance (ANOVA) yielded F=19.496, which is indicative of a statistically insignificant effect. Therefore, there is no relationship between the constant and the independent variables as a group. With this information in hand, a regression was undertaken to see what differences exist in each group. These results are given in Table 3.

Table 3. Presentation of the Individual Differences between Variables.

Unstandardized Coefficients

Standardized Coefficients

T

Sig.

Model

B

Std. Error

Beta

1

(Constant)

3.4

.37

9.12

.00

Openness mean

.11

.06

.13

1.66

.10

Trait Anxiety mean

-.44

.06

-.56

-6.94

.00

Parental Nurturance mean

-2.274E-02

.05

-.04

-.49

.63

From this it is clear that Trait Anxiety has the strongest, inverse relationship with Mindfulness, which is a negative relationship. Therefore, lower levels of Trait Anxiety are a strong predictor for Mindfulness. Openness is shown to be an insignificant predictor of Mindfulness, and Parental Nurturance is approaching significance.

4. Discussion

The results of this study partially meet the predictions made. Openness to Experience and Parental Nurturance were not demonstrated as positive predictors of Mindfulness, although Parental Nurturance bordered on significance. Trait Anxiety was found to be a negative predictor of Mindfulness, where the lower the level of Trait Anxiety, the higher the level of Mindfulness. These results can be explained in terms of awareness to the environment. Individuals having a high level of Trait Anxiety are unable to be present in the moment since they are subject to cognitive bias, which inhibits the information they are able to process. According to Harvey, Watkins, Mansell and Shafran (2004) individuals with high levels of anxiety have explicit memory bias for concern-relative information. These authors make further reference to the Cognitive Avoidance Theory of Worry, and describe how people who worry excessively have, as a result reduced their awareness of aversive imagery, as well as physiological and emotional responses, which inhibits emotional processes. Since individuals with high levels of Trait Anxiety are working hard at suppressing unpleasant experiences in terms of physiological, emotional and psychological responses, they are reducing their ability to be Mindful. A key component of Mindfulness is the ability to absorb the environment as a whole, without judgement and being completely present in the moment. Individuals with low levels of Trait Anxiety are able to process their environment without bias, they are not fearful and ashamed, and are not required to be vigilant and suspicious of the environment and others. The qualities are similar to those describe in the description of Mindfulness, and should therefore yield similar outcomes of ‘greater awareness, clarity, and acceptance of present-moment reality’ Kabat-Zinn (1994, 4).

From this study, it can be said that the variable of Trait Anxiety is a good predictor of the individual differences in Mindfulness. Further research into the predictive value of other personality variables may aid in the understanding of this phenomenon.

Bibliography

Baer, R.A. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice, 10(2), 125-143.

Brown, K.W. & Ryan, R.M. (2003). The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84(4), 822-848.

Buri, J. R. (1989). Self-esteem and appraisals of parental behavior. Journal of Adolescent Research, 4, 33-49.

** Costa, P. & McCrae, R. (1991). The NEO-Five Factor Inventory – Form S. Odessa, Florida: Psychological Assessment Resources.

Fonagy, P., Gergely, G., Jurist, E.L. & Targer, M. (2005). Affect Regulation, Mentalization, and the Development of the Self. London: Karnac.

Harvey, A., Watkins, E., Mansell, W. & Shafran, R. (2004). Cognitive Behavioural Processes Across Psychological Disorders: A transdiagnostic approach to research and treatment. Oxford University Press.

Kabat-Zinn, J. (1994). Wherever You Go, There You Are: Mindfulness meditation for everyday life. NY: Piatkus.

McCrae, R.R. & John, O.P. (1992). An introduction to the five-factor model and its implications. Journal of Personality, 60, 175-215.

Roemer, L. (2002). Expanding our conceptualization of and treatment for generalized anxiety disorder: Integrating mindfulness/acceptance-based approaches with existing cognitive-behavioral models. Clinical Psychology: Science and Practice, 9(1), 54-68.

** Spielberger, C. (1983). State-Trait Anxiety Inventory for adults. Redwood City, California: Mind Garden

Walach, H., Buchheld, N., Buttenmuller V., Kleinknecht, N. & Schmidt, S. (2006). Measuring mindfulness – the Freiburg Mindfulness Inventory (FMI). Personality and Individual Differences, 40, 1543-1555.

Williams, J.M.G., Teasdale, J.D., Segal, Z.V. & Soulsby, J. (2000). Mindfulness-based cognitive therapy reduces over-general autobiographical memory in formerly depressed patients. Journal of Abnormal Psychology, 109, 150-155.

Witkiewitz, K., Marlatt, G.A. & Walker, D. (2005). Mindfulness-Based relapse prevention for alcohol and substance use disorders. Journal of Cognitive Psychotherapy: An International Quarterly, 19(3), 211-228.

Woodman, C.L., Noyes, R., Black, D.W., Schlosser, S. & Yagia, S.J. (1999). A five year follow-up study of generalized anxiety disorder and panic disorder. Journal of Nervous and Mental Disease, 187, 3-9.

Zeattle, R.D. & Rains, J.C. (1989). Group cognitive and contextual therapies in treatment for depression. Journal of Clinical Psychology, 45, 436-445.

** References borrowed from given notes.

One of the principle aims of the Children Act

One of the principle aims of the Children Act 1989 was to ensure that more attention was paid to the child’s voice.

Critically examine to extent to which this aim has been achieved.

Introduction:

Bridgeman and Monk argue that the development of child law is becoming progressively more distinct from family law. In their view this development can be understood as a reflection of the influence of children’s rights and feminist views of the law that have encouraged a child centred focus where children are not simply seen as family persons but as individuals in their own right (Bridgeman and Monk, 2000, p. 1), a point reiterated by Muncie et al. who point to the recognition of rights of children as now being considered as distinct from the rights of the family as a whole (Muncie at al., 2005).

The Children Act 1989 which came in to force on 14th October 1991 was heralded as the most important legislation pertaining to children in living memory. Lord Mackay called it:

“the most comprehensive and far reaching form of child law which has come before Parliament in living memory.”

Prior to the Act the law relating to children in the UK had been driven by a plethora of different pieces of legislation, leading to considerable complexity and inconsistency. Although European law has come to an increasing level of prominence in domestic law, in practice the Children Act remains the single document most referred to (Prest and Wildblood, 2005, p. 311).

The strength and scope of the Act have been reflected by the considerable body of case law that evolved in a relatively short period of time.

The Act fulfilled two functions as highlighted by Allen:

It brought together all the existing law under the umbrella of one piece of legislation;
The Act acknowledged the limits of the law in family relations. While it was seen as a land mark piece of legislation, it did not contain a magic formula to deal with family problems.

(Allen, 2005, p.1).

The main thrust of the Act was to enable all those involved with the care of children to further their best interests whether living with their families, in local authority care or in respect of protection from abuse.

Private and Public Law:

The private legislation relating to children’s law does not concern public bodies. It refers to issues that are between individuals, usually family members.

The public law relating to children concerns legislation pertaining to intervention by public authorities. This encompasses voluntary agencies as well as social services. The State is typically a party to proceedings.

Purpose of the Act:

It was also hoped that through the Act children would become more central to proceedings concerning their welfare and would be given a considerably stronger voice. Feminist analysts have questioned the effectiveness of this, arguing that the law is often better at protecting the interests of adults than children.

Common Law Before the Act:

Historically, in common law parental rights were traditionally with the father in the case of legitimate children. It was not until 1886 that mothers were given guardianship under the Guardianship of Infants Act and the welfare of the child was to be taken into account when hearing any claim.

Developments in this area of the law saw an increasingly important regard given to the welfare of the child. This evolved into the modern idea of paramnountcy, enshrined in the 1989 Act.

The Law Leading to the Act:

Before the Act there were a number of different aspects of children’s law, described by Allen as chaotic in its nature (Allen, 2005, p.3). The law relating to children had evolved in a somewhat haphazard way, and was becoming increasingly difficult for professionals to interpret. In 1984 a comprehensive review was undertaken in an attempt to integrate the law.

The White Paper published in 1987, The Law on Child care and Family Services, stated that government proposals would involve “ a major overhaul of child care law intended to provide a clearer and fairer framework for the provision of child care services for families and for the protection of children at risk.”[1]

Scope of the Act:

The Act covers many areas including pre-school day care, child protection, local authority provision for children, the care of children in independent schools, children involved in divorce or custody proceedings, children with disabilities, child patients in long stay hospitals and children with learning difficulties (Hendrick, 2003, p.196-107).

Intrinsic to the legislation were four main principles:

(1)The paramountcy principle – this was not really a new idea but added considerable weight to ideas about child welfare, making it clear that this was always to be paramount in any decisions. This guiding principle has, however, been criticised in some quarters because of its vagueness.

The child’s welfare is the paramount consideration in respect of:

(a)the upbringing of the child;

(b) the administration of a child’s property or any income arising from it (s 1 (1)).[2]

(2) A checklist was introduced to assist courts in applying the welfare principle when considering certain categories of order.

(3)The delay principle which states that proceedings should be expedited with minimum delay as any such delay is regarded as being to the child’s disadvantage unless proven otherwise (s 1 (2))[3].

(4) Intervention by the State in the life of the child or the child’s family should only occur when it could be shown that “on balance the bringing of proceedings is likely to be in the best interest of children.” This is the no order principle where no order shall be made unless it is considered to be better for the child than making no order at all.[4]

Some new concepts were introduced. One of the main ones was “parental responsibility”. This emphasised the rights of parents in the context of their parental responsibility. If parents exercise their responsibility with the necessary level of diligence, certain rights in law are afforded, in effect promoting parents as authority figures. The Act also saw something of a swing back in emphasis to parents as opposed to the state being responsible for their children. Parents could only relinquish their responsibility to their children through formal, legal adoption. The term “accommodation” replaced “voluntary care” meaning, in effect that local authorities would care for children on their parents’ behalf only until such times as they could resume their proper role (Eekelaar and Dingwall, 1989, p.26).

Parental Responsibilities:

The Children Act gave courts wide ranging and flexible powers to regulate the exercise of parental responsibility, introducing some sweeping changes in this area.

The Child’s Wishes:

One of the central ideas was that the child’s wishes be taken into consideration, to a degree which was appropriate in any proceedings. The issue has arisen in relation to care proceedings, medical treatment and so on. In the case of local authority accommodation, there is a clear distinction in law between children over and under sixteen years old. The Children Act provides that neither the parental right of objection not the parental right of removal applies where a child of sixteen agrees to being provided with accommodation.[5]

This was tested in Re T (Accomodation by Local Authority)[6]. A seventeen year old girl had been informally accommodated by friends, an arrangement which she sought to formalise so that both parties would be eligible for benefits under section 24 of the Act which would stop when she reached age 18 otherwise. The director of social services refused this request taking the view that her welfare was not likely to be seriously prejudiced if she were not accommodated. This decision was quashed at court, the judge taking the view that social services had no way of ascertaining her future needs and there was no way of establishing whether the local authority would continue to exert the discretionary power it had done up to this point.

The issue of the child’s wishes is a much more contentious area when younger children are involved. Some very emotive case law, particularly in respect of medical arrangements and treatments, has developed in this area.

The child’s age should be taken into consideration when making any decision, but this is dependent on the individual child concerned . It is well recognised that children have the capacity to engage in acts and make decisions which can be dependent on chronological age or the attainment of a level of maturity beyond the chronological age. Precedent concerning a child’s age was first established in the land mark case of Gillick v. West Norfolk and Wisbech Health Authority[7].

The Gillick Case:

In 1980 The Department of Health and Social Security asserted that, while it would be most unusual, it would be lawful in some circumstances for a doctor to give contraceptive advice to a girl under sixteen without prior consultation with her parents. Victoria Gillick, a parent with strongly held religious views, sought assurances that none of her daughters would receive such advice.

Her claim was eventually rejected by the House of Lords, the decision coming to be known as ‘Gillick competence’. Lord Scarman proposed that a high level of understanding would be required, extending beyond the medical issues.

Lord Scarman noted:

“It is not enough that she should understand the nature of the advice which she is being given: she must have sufficient maturity to understand what is involved.”

Critical was the question in respect of whether, once a child has reached a certain level of maturity, whether in chronological or maturational terms, the rights of the patents to be involved, should be terminated or should co-exist with the child’s.

The Gillick decision was contrary to popular opinion and controversial. When faced with the dilemma of Gillick competence again, the courts adopted a somewhat different view. Later case law served to muddy the waters and adolescents were not given clear advice over their right to reach decisions for themselves in the event of family disputes or other issues.

Re R[8] concerned the competence of adolescents to refuse medical treatment.

R was a fifteen year old girl who had been suffering from mental illness which had caused her to be hospitalised under the Mental Health Act. At various times during the course of her treatment she was regarded as being a suicide risk. The unit in which she was hospitalised used sedatives as a last resort as part of the treatment regime. The hospital said that they would not retain R in hospital unless she were prepared to engage in treatment, including taking sedatives.

They put this to the local authority who had parental responsibility for R. The local authority initially agreed to the hospital’s request but, following conversation between R. and a social worker, withdrew its consent. R indicated to the social worker that the hospital were trying to give her drugs which she neither wanted nor needed. The social worker’s opinion was that R. was lucid and rational during the conversation, an assessment subsequently confirmed by psychiatric evaluation. The authority made R. a ward of court to resolve the argument. This is demonstrative of the responsibility to make the child’s voice heard, through the consultation process, a responsibility placed on local authorities by the Act.

The solicitor acting as guardian ad litem argued that, where a child has capacity to withhold consent to treatment based on sufficient understanding, any parental right to give or withdraw consent terminated.

Lord Donaldson reopened the whole discussion in respect of the relationship between a competent minor’s capacity and a parent’s right to consent on a minor’s behalf.

The Court of Appeal upheld the decision of Waite J., that R. failed the test of competence and that, in her best interests, the treatment should be authorised.

The most significant issue was whether the court had the power to over rule the decision of a competent minor. The court held that such an ability existed because the Gillick principles did not have effect in wardship proceedings. It was argued that the court had wider powers than those of normal parents, being derived from the Crown. The court saw no reason not to override the wishes of a competent minor if it believed that to be in the child’s best interests.

The judgement demonstrated that the application of the ‘welfare’ and the ‘Gillick’ tests could lead to different results.

The court’s power to override the decision of a minor were again illustrated in Re M. (Medical Treatment : Consent)[9]. A fifteen year old girl needed a heart transplant to save her life but refused to give her consent. Her reasoning was that she did not want to have some one else’s heart and did not want to have to take medication for the rest of her life.

In the solicitors notes taken at interview, it could be clearly seen that she had considered carefully her decision:

“Death is final – I know I can’t change my mind. I don’t want to die but I would rather die than have the transplant and have someone else’s heart, I would rather die with fifteen years of my own heart.”

While acknowledging the gravity of overriding M.’s decision, and the associated health risks, the operation was authorised.

Children in Court:

English law has not traditionally given minors right of representation in legal proceedings, but this was one of the main issues that the Children Act 1989 sought to address. The usual procedure has been for courts to require welfare reports in respect of children rather than to elicit the views of children themselves or of other interested parties or representatives.

The Children Act considerably changed that nature of representation for children in public proceedings in court. In care proceedings the Act created the presumption of the appointment of a guardian ad litem (Children’s guardian). The child will also automatically be party to the proceedings.

Children’s guardians are individuals who are required to have a thorough knowledge of both social work and child law. Their role is to ensure ‘that the court is fully informed of the relevant facts which relate to the child’s welfare and that the wishes and feelings of the child are clearly established.[10] Their role is to be proactive in its nature and ensure that the wishes of the child are given their due weight in the proceedings.

The issue in respect of private law is markedly different with children rarely being represented in this context. These are generally in relation to divorce and while welfare reports are submitted on occasion, this is not often the case, simply because of the volume of these types of proceedings.

Harm to children:

One of the main purposes of the Children Act was to ensure that children be protected from harm.

Newham London Borough Council v. AG[11]. reflects the difficult choice with which the courts are often faced regarding whether it is better for a child to stay with members of his/ her extended family or other, outside carers. In Newham the Court of Appeal held that placing the child with grandparents would be unsatisfactory as they would be unable to protect the child from the serious risk that was posed by the child’s mother who suffered from severe schizophrenia which manifested itself in her inability to look after the child and to neglect her.

The test case for the risk of significant harm is Re M. (A minor)(Care Order: Threshold Conditions).[12] A father had murdered the children’s mother in front of them, after which they were taken into emergency protection. The father was convicted of the mother’s murder and was sentenced to life imprisonment with a recommendation that he be deported to Nigeria, his home country, on release. Three of the four children were placed with Mrs W., the mother’s cousin, but she felt unable to cope with the youngest child, M. who was placed with a temporary foster mother. Eventually Mrs W. wanted to offer M. a home with his siblings. The father sought to influence the decision from prison, as he was M.’s biological father. The local authority, the guardian ad litem for M., and the father all wanted a care order to be made for M. outside the extended birth family.

Bracewell J. made the care order in the first instance but the Court of Appeal favoured Mrs W., substituting a care order in her favour. The question for the courts was whether, in considering if a child ‘is suffering from significant harm’, is it permissible to consider the situation when protective measures were introduced, or does this test have to be satisfied at the time of the hearing at which the application is being considered. At the time of the hearing M. was no longer suffering, nor was he likely to suffer ‘significant harm because, by this time, he was being properly looked after and the danger had passed.

The House of Lords held that there was jurisdiction to make a care order in these circumstances. Lord Mackay argued that the court was entitled to have regard to the full length from the protection to the disposal of the case. Brackwell had been entitled to, and indeed correct, to look back to the time when the emergency protection was taken. She had been entitled to infer that, at that time, M. had been permanently deprived of the love and care of his mother which constituted significant harm. The care given by the father was not what could reasonably have been expected from a parent, although it could reasonably be argued that the anger and violence was directed to the mother rather than M. The only limitation in the process of looking back was that the initial protective arrangements had remained continuously in place. Lords Templeman and Nolan pointed out that to restrict evidence to that which was available at the hearing could mean that any temporary measures which removed the risk could preclude the court from making a final care order which could not have been Parliament’s intention.

Separated Families:

Contact:

A great deal of case law relates to families where divorce or separation is a factor. Section 8 of the Act deals with the contact order:

“an order requiring the person with whom a child lives, or is to live, to allow the child to visit or stay with the person named in the order, or for that person and the child otherwise to have contact with each other.”[13]

The contact order has become very important in the sphere of children’s law as it is the most common type of order made. Men, who tend not to be the residential parent in cases of divorce, are increasingly applying for contact orders with their children.

Payne v. Payne is one of the leading cases in respect of contact. The mother, originally from New Zealand wanted to return there with the couple’s four year old child following her divorce. Mr Payne argued that, to allow the mother to remove the child from the country, would infringe his right to contact, and that this infringement would be contrary to the principles of the Children Act 1989. The Court of Appeal argued that the child’s happiness was bound up in the happiness of the mother , the primary carer, and any move to separate them might be that her “unhappiness, sense of isolation and depression would be exacerbated to a degree that could well be damaging to the child.”

The judgement in Payne v. Payne was not a denial that the father had a right to contact. It was a demonstration of the application of the welfare principle, protecting the best interests of the child which were, in the courts opinion, inextricably linked to the mother. The decision makes clear that contact is a qualified right which will always be superseded by the welfare of the child.

Paternity:

The paramountcy principle has been criticised as being too limited in its scope. Where the issue of paternity has come before the courts it has been held that this only has an indirect impact upon the child’s upbringing and so falls outside the scope of the test. Freeman has argued that since maternity is rarely in doubt, this stance in respect of paternity allows men to shirk to some degree their paternity in the English Legal system (Freeman, 2000, p.33).

Foster Parents:

While the law relating to children has always had scope in respect of biological families, this is clearly extended to foster parents by the Children Act. The term ‘foster parents’ covers a variety of care arrangements, but is most usually thought of as parents who look after children to whom they are not related. The main distinctions in foster care arrangements are in private or local authority arrangements and short and long term fostering arrangements.

Arrangements and case law have shown that foster carers will not automatically be afforded parental responsibility, legal steps must be taken before this can happen.

In Gloucestershire County Council v. P[14] the child’s guardian ad litem persuaded the court that a residence order in favour of the foster parents, rather than an order freeing the child for adoption or residence order in favour of the extended family, would be appropriate. A majority of the Court of Appeal held that the Court did, in fact, have the power to do this even though the foster parents had cared for the child for less than three years.

More than one child:

Problems with the paramountcy principle have occurred when there is more than one child and their interests appear to be at odds. In Birmingham CC v. H[15] the case concerned a mother, herself a minor, and her child. It was believed to be in the mother’s best interests to maintain some contact with her baby as she may self harm otherwise. It was not held to be in the best interests of her baby. The law said that the interests of both was paramount. The House of Lords held that it was necessary to identify the child who was the subject of the application and make their welfare paramount, in this case the baby. This logic has been applied in subsequent cases on this matter when the interests of siblings have been thought to be in conflict.

Conclusion:

It is generally agreed that the Children Act represents a consensus among interested parties, except of course for children, who were not consulted (Hendrick, 2003, p.198). The concept of welfare or best interests of children reflects a desire to protect children. Some theorists have argued that because the input of children into changes in the law has been neglected, the law may be ineffective in protecting them from harm which may be very different from the harm and pain felt by adults (Bridgeman and Monk, 2000, p.7).

Some aspects of the Act have been problematic. The paramountcy principle has been very difficult in both a practical and an ethical respect. There is considerable tension between a child’s welfare and a child’s voice. The weight of the law is given to the former but many argue that the child’s opinion and wishes should carry more weight than they do at the moment. There are also, as has been seen, questions concerning when the child’s wishes should supersede those of his/ her parents and be respected as valid in their own right.

The law in relation to children has seen more change in recent years but the Children Act still has considerable force in practice. While there has been increasing emphasis placed on children’s individualism, autonomy, capacity and competence (Hallett, 2000, p.389), it has been seen that it is often the case that no matter how lucid or mature a child appears to be, the courts have been reluctant to allow the child to have a full voice in issues of a serious and life changing nature. The complex nature of families and their increasingly diverse nature in society means that these difficult issues will probably become more, rather than less complex in their nature and present themselves with a greater degree of frequency.

References:

Allen, N. (2005) Making Sense of the Children Act 1989. Chichester: John Wiley and Sons.

Bainham, A. (1990) Children : The New Law. Bristol: Jordan Publishing Ltd.

Bainham, A. (2005) Children: The Modern Law. Bristol: Jordan Publishing Ltd.

Bainham, A., Day-Sclater, S. & Richards, M. (Eds)(1999) What is a Parent? A Socio-Legal Analysis. Oxford: Oxford University Press.

Bridgeman, J. & Monk, D. (2000) Reflection on the relationship between feminism and child law in J. Bridgeman & D. Monk (Eds) Feminist Perspective on Child Law. London: Cavendish Publishing.

Corby, B. (2002) Child Abuse and Child Protection in B. Goldson, M. Lavalette and E. McKenchie (Eds) Children, Welfare and the State. London: Sage.

Eekelaar, J. (1991) Parental Responsibility: State of nature or nature of state? Journal of Welfare and Family Law, 1, 37-50.

Eekelaar, J. and Dingwall, R. (1989) The Reform of Child Care Law: A practical Guide to the Children Act. London: Routledge.

Farson, R. (1978) Birthrights. London: Penguin.

Fortin, J. (2003) Children’s Rights and the Developing Law. London: Reed Elsevier.

Freeman, M. (2000) Feminism and Child Law in J. Bridgeman & D. Monk (Eds) Feminist Perspective on Child Law. London: Cavendish Publishing.

Gibson, C., Grice, J., James, R. & Mulholland, S. (2001) The Children Act Explained. London: The Stationery Office.

Hallett, C. (2000) Children’s Rights: Child Abuse Review, 9, 389-393.

Harris, P.M. & Scanlan, D.E. (1991) Children Act 1989: A Procedural Handbook. London: Butterworths.

Hendrick, H. (2003) Child Welfare: Historical Dimensions, Contemporary Debate. Bristol. The Policy Press.

Herring, J. (2004) Family Law. London: Pearson.

Hoggett, B.M. (1987) Parents and Children: The Law of Parental Responsibility. London: Sweet and Maxwell.

Horwarth, J. (Ed)(2001) The Child’s World: Assessing Children in Need. London: Jessica Kingsley Publishers.

Masson, J. (1990) The Children Act 1989: Current Law Statutes Annotated. London: Sweet and Maxwell.

Muncie, J. Wetherall, M., Dallos, R. & Cochrane, A. (Eds)(1995) Understanding the Family. London: Sage.

Prest, C. & Wildblood, S. (2005) Children Law: An Interdisciplinary Approach. Bristol: Jordan Publishing Ltd.

White, R., Carr, P. & Lowe, N. (1995) The Children Act in Practice. London: Butterworths.

Wyld, N. (2000) The Human Rights Act and the Law Relating to Children. Legal Action, September, 17-18.

1

Nurse-led Clinics in Respiratory Care: a Literature Review

INTRODUCTION

1. What is a nurse-led clinic?

As the coined term suggests, a nurse-led clinic is a health care centre in which nurses are involved in high level specialist procedures and assessments. In such centres, nurses are the critical decision makers, being involved in patient care at the micro-, meso-, and macro-levels. While the role of the physician in the provision of health care is undisputable, the deity-like status that medical practitioners typically have in the mind of patients, coupled with the limited time available for individual patient consultations, make it hard for these group of health care professionals to tackle the ‘softer’ side of patient care. Nurses, on the other hand, defined by the Oxford Medical Dictionary as health care professionals that are trained and experienced in nursing matters and entrusted with the care of the sick and the carrying out of medical and surgical routines, are better placed to provide this essential follow-up, especially in the care of patients with chronic diseases.

According to Hatchett (2003), a nurse-led clinic is a clinic in which nurses have their own patient case loads of whom they take complete charge. Hatchett broadly describes the components of such a clinic. There would be an increase in autonomy associated with the nursing role in the nurse-led clinic, with the power to admit, discharge or refer patients, as appropriate. In Hatchett’s own words, the roles which nurses adopt in these revolutionary settings can be broadly classified as follows (Hatchett, 2003):

Education
Psychological support
Patient monitoring

The initiation of nurse-led initiatives probably owes its origins to the rise in nursing specialties in the United Kingdom. Throughout primary and secondary care, nurses are taking senior positions in health care institutions, such as nurse specialists, nurse practitioners, nurse consultants, nurse prescribers, etc, leading to a marked change in service delivery and the profile of the nursing profession. In addition to the usual registered nurse training, nurses working at higher levels of practice receive training to acquire a range of other medical skills such as physical examination and medical history taking in order to recognise abnormal clinical findings.

In a two-phase exploratory study to evaluate the domains of structure, process and outcome of nurse-led clinics in supporting intermediate care after the acute phase of disease, Wong et al (2006) interviewed nurses from 34 clinics and 16 physicians and observed 162 nurse-led clinic sessions. Their findings demonstrated the high level of skill and experience of the nurses who ran the clinics. Their work involved skills such as adjusting medications and initiating therapies, and diagnostic tests according to protocols. Interventions included assessments and evaluations, and health counselling. All patients studied showed improvement after the nurse clinic consultation, with the best rates reported in wound and continence clinics; satisfaction scores for both nurses and clients were high. However, although physicians valued their partnership in care with the nurses, they were concerned about possible legal liability resulting from the advanced roles assumed by these nurses.

Ultimately, nurse-led clinics provide an integral and invaluable patient-centred approach to the management of chronic disease which build upon skills such as counselling, teaching and health promotion which are key to contemporary nursing practice, as well as newly acquired medical skills. The advent if nurse-led clinics provides an opportunity for nurses to develop enhanced roles in which they can achieve more autonomy in their practice. This can be made a reality if adequate training and education, as well as effective leadership are in place (Wiles et al, 2001).

2. The general roles of nurses in chronic care management

The chief nursing officer, Sarah Mullally has proposed ten key roles for nurses in autonomous patient care. These are outlined below as cited by Hatchett (2003):

Order diagnostic interventions: just like a medical practitioner would, the present-day nurse is able to ask for laboratory or clinical diagnostic tests to aid the process of diagnosis. Furthermore, a well-trained nurse will also be able to read and interpret laboratory results effectively
Make and receive referrals directly: while the all-important roles of nurses are recognised, the need for a multidisciplinary approach to patient care remains key in order to optimise patient outcomes. Accordingly, nurses should be able to recognise the patients’ needs and refer them to the appropriate health care service as required. Similarly, nurses should be ready to accept referrals from other health care disciplines as necessary.
Admit and discharge patients for specified conditions, within agreed protocols: in order to make the best use of the often limited hospital resources, a nurse should have the power to recommend patients for hospital admission and subsequent discharge
Manage patient case loads: in nurse-led clinics, nurses are also responsible for managing their individual case loads. It is important to delegate patient cases to other members of the team, when necessary to ensure that patients receive the best care possible.
Run clinics: the autonomous role of the nurse in a nurse-led clinic includes all aspects of the management and day-to-day running of the clinic.
Prescribe medications and treatments: nurse prescribers are able to advise patients on appropriate treatment, based on diagnosis of ailment and individual characteristics and laboratory findings.
Carry out a wide range of resuscitation procedures, including defribillation
Perform minor surgery and outpatient procedures: especially in injury clinics. While nurses are probably not equipped to carry out full-fledged surgical operations alone, they are trained to conduct emergency processes as appropriate.
Triage patients, using the latest information technology, to the most appropriate health care professional
Take a lead in the way local health services are organised and in the way they are run

Nurses have always been considered as a supplement to the fundamental care provided by medical doctors. In fact, in some geographical regions, nursing roles are limited to menial tasks such as changing bedpans etc. In the new age, the nursing role as we know it is becoming increasingly important with nurses taking on infinitely more clinical roles. This has led to controversial debates with critics arguing that nurses cannot replace doctors in the provision of health care services. As Richard Hatchett very astutely pointed out (2003), the increased autonomy being acquired by nurses is not a bid to compete with medical doctors. Instead, “it is a case of considering who can provide the most appropriate service to the patient” (Hatchett, 2003).

Thus, it is clear that the roles of nurses in chronic care management is very diverse and can be integrated into any nurse-led clinic intervention to the utmost benefit of the patient and all stakeholders. There have been numerous studies on the role of nurses in the care of patients with chronic diseases. In addition, and more specifically, the feasibility and benefits of implementing nurse-led clinics in practice have also been investigated to some extent. In the subsequent sections, we will review the evidence to support these innovative nursing interventions in an attempt to make the best use of health care resources.

3. Nurse-led clinics in the management of chronic care diseases: the evidence

The World Health Organization (2002) defines chronic diseases as health care problems that require ongoing management over a period of years or decades. The nature of these disease conditions make it necessary to provide long term care and follow-up for the afflicted patients. Nurse-led interventions have been investigated a wide range of chronic diseases. It could be a logical, user-friendly, cost-effective and practical approach to improving long-term patient outcomes and should be explored fully to maximise the contributions of nurses to the chronic care management.

Although this review aims to analyse the effectiveness of nurse-led clinics in the treatment of respiratory diseases, a prior look at the role of these interventions in the management of other chronic care diseases will provide an insight to the general contributory roles of nurses and will serve as a foundation for complete understanding of this state of the art intervention.

3.1 Nurse-led interventions in the management of diabetes

Numerous studies have evaluated the benefits and practicalities of nurse-led clinics in the long-term management of diabetes. The renal diabetic nurse specialist is described as an “essential player” in organising the management of, and to meet, all aspects of need of this group of patients (Marchant, 2002). An unintended benefit of a nurse-led clinic to reduce cardiovascular risk is improved glycaemic control, HbA1c (Woodward et al, 2005). In particular, nurse-led diabetic clinics have been shown to benefit specific ethnic groups. Matthias et al (1998) identified the needs of diabetic patients from minority ethnic groups, such as blacks and Asians and postulated that nurse-led clinics were of particular benefit in this patient group. As epidemiological data show that diabetes is most common in minority ethnic groups (Carter et al, 1996), the importance of these innovative interventions is further emphasised.

3.2 Nurse-led interventions in the management of cardiovascular disease

Care of patients with cardiovascular diseases is broad and involves many aspects, from risk factor management (non pharmacological interventions), primary and secondary prevention of clinical events, pharmacological therapy, surgical procedures, etc. Through a large well-designed randomised controlled trial in Scotland, Campbell et al (1998) showed that nurse-led clinics were practical to implement general practice and led to an significant increase in various aspects of the secondary prevention of coronary heart disease. Significant improvements were noted in aspirin management, blood pressure management, lipid profile management, diet and physical activity, regardless of the individual patient’s baseline cardio performance or status. However, surprisingly, there was no recorded improvement on smoking cessation, which would have been a beneficial intervention in most acute and chronic disease states, including respiratory diseases.

In addition to the apparent effectiveness of the nurse-led clinics in the long-term primary and secondary prevention of coronary heart disease, the optimal use of nurses in the care of these patients has been shown to be cost-effective in terms of quality adjusted life years (QALYs) (Raftery et al, 2005). In this large cost-effectiveness analysis, although the cost of the nurse-led clinic intervention was ?136 higher per patient, the differences in other National Health Service (NHS) costs was not statistically significant. Furthermore, there were 28 more deaths in the non-intervention group leading to a gain, in the intervention group, in mean life-years per patient of 0.110 and of 0.124 QALYs.

3.3 Nurse-led interventions in rheumatology

The role of clinical specialist medical doctors in the care of their patients is unquestionable; however, the role of nurses in the therapy area of rheumatology (i.e. in patients with rheumatoid arthritis) is also well documented. Hill and colleagues (1994) clearly demonstrated the effectiveness, safety and acceptability of a nurse practitioner in a rheumatology outpatient clinic. Although this was a small study with a sample size that only included 70 patients, the statistical significance of the findings of this randomised controlled trial cannot be ignored. In patients managed in the Rheumatology Nurse Practitioner clinic, pain, morning stiffness, psychological status, patient management and satisfaction all improved significantly (p = 0.001; p = 0.028; p = 0.0005; p<0.0001; p<0.0001, respectively). It is worthy of note that these improvements were not mirrored by patients who were managed in the Consultant Rheumatologist clinic.

In addition, patient satisfaction is frequently higher in patients who are allocated to nurse care than those allocated to standard medical care (Hill, 1997). In yet another study by Dr Jackie Hill, a registered nurse at the Academic and Clinical Unit for Musculoskeletal Nursing in the Chapel Allerton Hospital in Leeds, the researchers concluded that a nurse-led clinic is effective and safe and is associated with additional benefits, such as greater symptom control and enhanced patient self-care, compared with standard outpatient care.

3.4 Nurse-led interventions in cancer care

The effectiveness of nurse-led care in different common cancer afflictions has been researched variously. An extensive review article by Loftus and Weston (2001) discussed the patient needs that could be met by nurses working in nurse-led clinics and highlighted the experience and skills of advanced nursing practice that make such innovative care a reality.

The types of nurse-led interventions are as varied as the different types of cancers for which they are used. These range from nurse-led telephone clinics in patients with malignant glioma (Sardell et al, 2001); nurse-led follow up in patients receiving therapy for breast cancer (Koinberg et al, 2004); and nurse-led screening programmes in Hong Kong Chinese women with cervical cancer (Twinn and Cheung, 1999).

In a randomised controlled trial in a specialist cancer hospital and three cancer units in southeastern England, Moore et al (2002) assessed the effectiveness of nurse-led follow-up in the management of patients with lung cancer. The findings of the study showed high levels (75%) of patient acceptability. This negates the possibility of patients’ reduced confidence in nurses’ ability and preference for standard medical doctor care. Clinical outcomes were also greatly improved as shown by less severe dyspnoea at three months (p=0.03), better scores for emotional functioning (p=0.03), and less peripheral neuropathy at 12 months (p=0.05).

3.5 Nurse-led interventions in the management of HIV infection

Using a rigorous model of comprehensive care nurse-led clinic in genitourinary medicine to compare nurse-led and doctor-led clinics at a central London medicine clinic, Miles and colleagues (2003) reported reliable and valid results to support the use of the nurse-led variety as an acceptable alternative to the existing doctor-led clinics. More specifically, the British HIV Association (BHIVA)/British Association for Sexual Health and HIV (BASHH) advocate the benefits that can be accrued from a nurse-led educational intervention in the care of patients with HIV infection (Poppa et al, 2003). A small pilot study that investigated the effects of a 6-month nurse-led educational programme reported that improved virological responses were seen in treatment-experienced patients (Alexander et al, 2001).

While a majority of the studies on nurse-led clinics in other chronic diseases can be broadly applied to nurse-led care in patients with respiratory diseases, differences in the nature of these diseases and the necessary care pathways mean that the extent to which these tested interventions can be applied to other therapy areas is, in actual fact, limited. Government policies that advocate the clinical and economic effectiveness of nurse-led interventions frequently pool together evidence from all therapeutic areas. Indeed, it can be hypothesised that, if nursing interventions are shown be practical alternatives for medical care in complex diseases with poor prognoses, such as cancer, HIV and coronary heart diseases, care of patients with respiratory diseases which generally have better prognoses should be easily, effectively and safely undertaken by qualified and well-trained nurses.

Nevertheless, these findings of the effectiveness of nurse-led interventions in the numerous chronic diseases explored in previous sections, should be applied to the different patient population with respiratory diseases. As much as possible, research findings from similar patient groups should be applied in clinical practice in order to ensure that evidence-based practice in this case is relevant.

4. Government policies influencing the establishment of nurse-led clinics

Government health policies in the United Kingdom actively support the extension of nurses’ skills into areas such as nurse prescribing and the development of nurse practitioner posts (NHS Plan 2000; Department of Health). Government initiatives that that strive to reduce consultation waiting times and optimise the use of medical practitioners indirectly support the establishment of nurse-led clinics. The Government has endorsed the implementation of nurse-led clinics as a means of increasing access to specialist health care and treatment more quickly and also as an effective way to manage chronic conditions (Hatchett, 2003).

In the Department of Health (1999) document, ‘Making a difference’, government plans for strengthening nursing contribution to health care is presented. The Government has launched an ambitious programme of measures to improve the National Health Service and the health of the public, and the role of the nursing profession in this initiative cannot be overemphasised.

The key nurse-related points of the document are outlined below:

To extend the roles of nurses, midwives and health visitors to make better use of their knowledge an skills – including making it easier for them to prescribe
To modernise the roles of school nurses and health visitors in supporting the new health strategy and other policies
To see more nurse-led primary care services to improve accessibility and responsiveness

The document highlights numerous nurse-led initiatives that have been effectively implemented all around the United Kingdom. A nurse-led minor injury service in rural Cornwall has provided patients with a number of benefits: easier accessibility, reduced waiting times, reduced need for on-site medical; attendance, increased patient satisfaction and reduced need for transfers to local Accident and Emergency departments. Similarly, a nurse-led rapid response team in Peterborough responds to acute crisis cases and allows patients to be nursed at home. Evaluation has shown that 71% of patients referred to this ‘hospital at home’ service would have been admitted to hospital if the service did not exist. Other effective live nurse-led services include a nurse-led rheumatology service in Merseyside and a nurse-led intermediate care unit in Liverpool.

Furthermore, several nurse interventions are advocated in the document for contributing to the management of cardiovascular disease. Several of these are also applicable to respiratory diseases; these include:

Smoking cessation clinics using national smoking cessation guidelines
Healthy lifestyle clinics in collaboration with other health professionals to address factors such as diet, nutrition and exercise, thus improving overall health
Care for patients with congestive cardiac failure under ‘home-based’ initiatives
Nurse-led chest pain clinics or risk factor screening and reduction clinics
Nurse-led blood pressure clinics to identify and help manage blood pressure disorders and medication adherence

5. Review objectives

The objectives of this review are:

To briefly summarise various studies on effectiveness and cost-effectiveness of nurse-led interventions in common respiratory diseases
To critically appraise the methods employed by these studies
To evaluate, interpret, and where possible, compare the findings of the various studies
To explore the applicability and generalisability of the results to practice in the appropriate patient population
To make suggestions for future studies in this area.

METHODS

Literature search

A search of two major databases, MEDLINE and EMBASE, was conducted to identify articles published from 1990 through 2008. Search terms that were used include nurse, nurse-led clinic, nurse-led interventions, respiratory diseases, asthma, chronic obstructive pulmonary disease, bronchiectasis, tuberculosis, cystic fibrosis, cost-effectiveness analysis, cost-benefit analysis, and economics. A secondary search of the reference lists was then conducted to identify relevant articles, editorials, and other unoriginal reports that may have been missed in the primary search.

Some studies were excluded based on the following criteria:

They were not conducted in patient populations with respiratory diseases
Independent nurse-led interventions were not investigated
The study populations being investigated were mixed in terms of diagnosis, which would affect the integrity of the study findings for respiratory diseases
The methodology and/ or statistical analysis methods were not clearly elucidated

6. Nurse-led clinics in the management of respiratory diseases: a review of the evidence

The role of the specialist respiratory nurse has evolved since the early 1980’s with the support of the Royal College of Physicians (RCP 1981). The possible complexity of respiratory patients’ regimens necessitates support with various aspects of their care plans, such as:

Supervising nebuliser and inhaler techniques
Monitoring progress, i.e. by periodical assessment of lung function and exercise capacity
Education on the specific disorder, medications, potential adverse events, etc
Counselling and education on positive lifestyle, or non-pharmacological, changes
Adherence support and monitoring

The role has developed further with nurses providing nurse-led clinics in chronic obstructive pulmonary disease (COPD) and asthma along with nurses providing early supportive discharge and ’hospital at home’ for patients with COPD (French et al, 2003). Some schools of thought argue that nurse-led clinics would culminate in the neglect of the more traditional nursing roles, as nurses focus on a more medical-focused aspect of patient care. However, research in other therapy areas, such as rheumatology (Hill et al, 1994) and mental health (Reynolds et al, 2000) shows that nurses can effectively combine the medical role with the traditional nursing approach. Nursing care strives to provide a holistic approach to care through practical management of disability, education and counselling and referral to other health care services as required (Rafferty and Elborn 2002).

6.1 Bronchiectasis

Nurse-led clinics have been evaluated, compared with regular doctor-led clinics, in a single randomised controlled trial in patients with bronchiectasis, a respiratory condition in which there is widening of the bronchi or their branches (Sharples et al, 2002). The study was a randomised controlled crossover trial including 80 patients in a bronchiectasis outpatient clinic. Patients received 1 year of nurse led care and 1 year of doctor led care in random order, and were followed up for 2 years. Various outcome indicators were used in the comparison, including lung function and exercise capacity, infective exacerbations, hospital admissions, quality of life and cost-effectiveness of the intervention. The results of this study are illustrated in Table 1 below.

Table 1: Nurse-led and doctor-led care in care of patients with bronchiectasis (Sharples et al, 2002)

Measurement outcome

Nurse-led

Doctor-led

Mean difference

(95% CI)

p-value

Forced expiratory volume in one second (FEV1) (%)

1.87

1.86

0.01 (-0.04 to 0.06)

Forced expiratory volume in one second (FEV1) (L)

69.7

69.5

0.2 (-1.6 to 2.0)

Forced vital capacity (FVC) (%)

87.6

87.6

-0.02 (-1.5 to 1.4)

12 minute walk distance (m)

765

746

18 (-13 to 48)

Infective exacerbations (patient years of follow up)

262 (79.4)

238 (77.8)

0.34

Hospital admissions attributable to patient’s bronchiectasis

43

23

0.22

As the table above clearly shows, there was no statistical difference in FEV1/FVC percent predicted or distance walked between nurse led and doctor led care in the

two treatment periods. Furthermore, 262 episodes of infective exacerbations were recorded by patients in the nurse practitioner-led care group in 79.4 patient years of follow up, compared with 238 in 77.8 years in the doctor-led care group. Thus, nurse practitioner-led care is associated with a relative rate of exacerbations of 1.09 (95% CI 0.91 to 1.30), p=0.34.

Using the St Georges Respiratory Disease questionnaire to assess differences in health-related quality of life between the two groups, there was no statistically significant differences in each of the scores for Symptoms, Control, Impact or total score. Also, the study showed that nurse-led care resulted in significantly higher costs per patient compared with doctor-led care; this was largely due to the difference in the number of hospital admissions and intravenous and nebulised antibiotic costs. The

authors concluded that nurse practitioner-led care for stable patients within a chronic chest clinic is safe and is as effective as doctor led care, but may use more resources.

This study has several potential limitations which could invalidate the findings. As the study relied on patient report to record the prescriptions issued by general practitioners, these may have been underestimated and could grossly affect the cost analysis. Conversely, the nurse practitioner was required to record prescriptions and tests issued at the clinic, and thus these records are probably more reliable and she would be more likely to have ensured that patients left with supplies of routine treatment. Another possible drawback of this study is the use of a crossover design in the methodology. Unless a wash-out period is incorporated in the study design, there is the possibility of a carryover effect with crossover study designs, with the danger that the effects of the earlier treatment is falsely attributed to the final experimental

treatment. In this study, there was no allowance for a washout period and thus this could affect the reliability and validity of the study results. This order and time effect needs to be checked for within the analyses but it can rarely be excluded as potential biasing factors (Pocock 1983). However, as recruited patients received the interventions in random order, this may negate the carryover effect.

Despite the possible limitations of the study that could potentially hinder its applicability in practice, the findings support the implementation of a nurse-led clinic in patients with chronic cases of bronchiectasis as an alternative to the standard rigid medical care.

6.2 Asthma

Similar to the findings in the study by Sharples and colleagues (2002) in patients with bronchiectasis, Nathan et al (2006) more recently compared the effect of follow-up by a nurse specialist with follow-up by a respiratory doctor following an acute asthma admission. In a single centre prospective randomised controlled trial, 154 patients admitted with acute asthma were randomly assigned to receive an initial 30-min follow-up clinic appointment within 2 weeks of hospital discharge with either a specialist nurse or respiratory doctor. The intervention comprised a medical review, patient education, and a self-management asthma plan. Further follow-up was then arranged as was deemed appropriate by the corresponding doctor or nurse, and all patients were asked to attend a 6-month appointment.

Despite hospital outpatient follow-up, there was a significant proportion of patients in both groups who had exacerbations. However, there was no statistically significant difference between the two groups (Table 2). In the same manner, there was no statistically significant difference in quality of life assessed with two different validated questionnaires, the Asthma Questionnaire and the St George Respiratory Questionnaire. Mean change in peak flow at 6 months was similar between the two groups, probably indicating equivalence of the two tested interventions. Nathan et al (2006) concluded that follow-up care by a nurse specialist for patients admitted with acute asthma can be delivered equivocally with comparable safety and effectiveness to that traditionally provided by a doctor practitioner.

Table 2: Nurse-led and doctor-led care in follow-up care of patients admitted with acute asthma (Nathan et al, 2006)

Measurement outcome

Nurse-led

Doctor-led

Odds ratio

(95% CI)

Mean difference

(95% CI)

p-value

Change in peak flow

1.39 (-3.84 to 6.63)

0.122

Infective exacerbations (%)

45.6

49.2

0.86 (0.44 to 1.71)

0.674

Quality of life

87.6

87.6

-0.02 (-1.5 to 1.4)

Asthma Questionnaire

0.78 (-0.64 to 2.19)

0.285

St George Respiratory Questionnaire

1.08 (5.05 to 7.21)

0.891

The possible limitations associated with this study is the large amount of missing data for some outcomes, especially peak flow and quality of life

Financial Reporting Systems of Germany and the Netherlands

Nobes (1998) classifies the German financial reporting system as a ‘Type B (weak equity)’ and The Netherlands as ‘Type A (strong equity)’. Compare the financial reporting systems of Germany and The Netherlands.

National differences have all become stereotypical. Indeed the differences between countries may be vast. Influences such as family origin, or attitudes towards business culture are inherently reflected in the way businesses are run, managed and owned. There are also many reasons as to why there are differences in financial reporting. These depend on the character of the national legal system, the type of industry financing, the interrelationship between tax and finance reporting systems, the extent of accounting theory progression and even language.(Elliott, 2006)[1]

In terms of the legal system between Germany and the Netherlands, it is clear tat they both follow a civil law system which is different to the common la procedure of the United Kingdom contained within the Companies Act 1981.[2] However, for the purposes of this essay, I will focus on the comparisons between the financial supporting systems of German and the Netherlands with regards to the Nobes’ (1998) classification of Germany being a weak equity (Type B) while the Netherlands in a strong Equity (Type A).

I will consider Nobes’ theory by considering equity figures for both Germany and the Netherlands in respect of their types of equity and will briefly compare the financial reporting systems of the two countries.

Although equity is represented in many different forms, it is generally defined as “the value of a company which is the property of its ordinary shareholders (the company’s assets less its liabilities, not including the ordinary share capital)[3]

In terms of financial accounting reporting, considerations of which is the relevant way of financing a business, i.e. the information required by equity investors are different to those of load creditors. Strong equity can be defined as a high ratio between equity market capitalisation and Gross Domestic Product (GDP) whilst weak equity is a low ratio between market capitalisation and Gross Domestic Product (GDP).[4] I, Germany had the lowest equity of 5 countries which were studied. (49%). This shows that unlike America, France or presumably the Netherlands, Germany does not rely heavily on individual investors.

Specifically, Nobes (1998) develops a frameork that seek to explain the differences in international accounting. Nobes catagorises accounting systems into two types: Class A (accounting for outside shareholders) and Class B (accounting for tax and creditors). Two variables determine whether a country will have a Class A or a Class B accounting system: (1) the type of culture and (2) the strength of the equity-outsider financing system. According to the model, countries with Type A cultures have developed strong outsider-equity financing systems that have led to the development of a Class A financial reporting system. Therefore, like America and the UK, the Netherlands has relied on a Type A accounting system that is relaint on a high ratio of equity investment as oposed to loan creditors.

Conversely, countries with Type B cultures have weak outsider-equity financing (i.e. weak equity) systems that have led to the development of a Type B financial reporting system . This model is comonly known to be widespread practice within continenatl Europe including Germany.

Nobes (1998) stsudies the link between the financing system and accounting, but also believes that a Type A system in terms of equity financing is not entirely dependant on Type A accounting, but instead external or outsider equity financing is imperative.

By drawing on examples, Nobes (1998) examines Japan. Japan is a country with many listed companies as well as large equity market, but instead of the market being supported externally, most of the shares are owend by Janpanese banks or other companies, investors etc). According to the model, financial reporting in Japan should exhibit the characteristics of a Type B accounting system. Nonethelss, Nobes (1998) in explaining why Germany is substantialy different to the Netherlands claims that differences in culture, i.e. countries that have altered their culture through war will usually adopt the culture and accounting system imported from the dominating country. This explains, for example, why some post colonial African countries possess a type A system despite having very weak accounting systems.

As noted earlier, Nobes focuses his discussion on the link between financing systems and accounting. He assumes that some cultures lead to strong equity-outsider financing systems and others do not, but he leaves the examination of this assumed relationship for others. Nobes appears to assign a very broad view of culture to this variable in his model. In a simplified model presented earlier in his paper he refers to this variable as “culture, including institutional structures”[5] A brief examination of the differences betweent the culture of institutional structures is examined below.

While a Type A classification separates accounting and tax rules, Type B does not.[6] Type A in comparison to Type B also has an extensive auditing system. This is true for the Netherlands in comparison to Germany. In US, UK and Netherlands, link between taxable income and accounting income is much weaker, with separate tax accounts and financial accounts. The information is prepared with external investor information in mind thereby focusing on a large equity market (Type A). In comparison a Type B taxation system such as that of Germany tax accounts which are published financial accounts are not usually prepared for investors, but instead internal forces such as company investors, shareholders etc.

In sum, the Type A system such as that in practice in the Netherlands and as proposed by Nobes is one of dynamic accounting formulated with the external investor in mind thereby creating increased demand for external investment. On the other hand, Germany experiences the converse of this, with taxation and accounting system which is interlinked and an intention of financial reporting for internal investors rather than external investors in mind.

Bibliography

Classification based on Corporate Finance, http://www.people.ex.ac.uk/wl203/BEAM011/Materials/Lecture 10/IA1 Lecture 10.pdf

Elliott et al, Financial Accounting and Reporting, (2006 10th ed)

Dictionary of Accounting, Collin Publishing (2001)

Nobes (1998)

Nationalism and the French Revolution

The French Revolution is synonymous with nationalism. In fact, there can be little doubt that the concept of a nationalist revolution was born from the discord that built up in and around the periphery of France during the 1780’s. There was, however, little cohesion or malice aforethought with regards to events that took place after the storming of the Bastille in 1789. Rather than being a planned experiment in nationalism, the French Revolution should instead be interpreted as the result of pent up forces and frustrated political ambitions that had been fermenting in France and throughout Europe for the previous one hundred years. The nationalism of the revolution era was thus rare; a total kind of nationalist ideology that in theory was concerned with furthering the ambitions of ‘la patrie’ (the nation) but which in reality was too dynamic for its own good. The various modes of political office that dominated France over the forthcoming decades were wholly unprecedented and unable to be contained within the national borders of France alone. As Bouloiseau declares, “the regime’s intentions were pure, but it lacked the means to put them into practice.”[1]

For the purpose of perspective, the following examination of the role that nationalism played in the French Revolution and Napoleonic Wars must adopt a chronological approach, attempting first to trace the genesis and subsequent evolution of the nationalist uprising before attempting to draw a definitive conclusion as to why the nature of the revolution was far too complex to be explained in simple ideological terms. First, however, a definition of nationalism within the specific historical context in which it was formed must be ascertained in order to establish a conceptual framework for the remainder of the discussion.

Nationalism could not have emerged as a populist form of political ideology without there first having been the introduction of the paradigm of the ‘nation?state’, which was first institutionalised after the Peace of Westphalia in 1648. France, Spain, Prussia, Switzerland, Holland and Sweden all signed treaties during the course of 1648 bringing to an end a variety of international conflicts that had beset the European continent for the previous eighty years. The treaty acknowledged the political legitimacy of states on the European mainland, giving rise in the process to the idea of international relations – the foundation of modern foreign policy. This was an important break with the past where relations between countries had been conducted via the historical continental monarchies and the ‘ancien regime’ that had governed feudal, pre?industrial Europe for centuries. After 1648 the watershed notion had been implanted which suggested that the rule of the old continental monarchies was coming to an end and that it would be the nation?state that would become the determining factor in political affairs in Europe in the future. It is a significant point and one that should be borne in mind throughout the remainder of the discussion: without the Peace of Westphalia there could not have been a nationalist revolution, neither in France or anywhere else. Before it, it is difficult to conceive of nationalism in the modern form that is talked of today.

The revolution itself was the result of a century of frustration that had built up around the inability to turn this new concept of the nation?state into a political reality. For instance, despite the increasing urbanisation and industrialisation of the country the monarchy, nobility, aristocracy and the landowners continued to economically and politically dominate France throughout the opening decades of the eighteenth century. Moreover, as was the case with the last days of the Roman Empire, the behaviour of the traditional elite in France appeared to get more lavish and decadent with each passing year so that, by July 1789, France was absolutely ripe to experience what Marxists would understand as a ‘revolution from below’. The intellectuals and the bourgeoisie were able to use a variety of oratorical and politically inflammatory means of inciting the disaffected French masses into open rebellion at this time. One of these means was nationalism. By constantly claiming that the monarchy and the nobility were destroying the cultural fabric of France, the leaders of the revolution (bourgeois men such as Maximilian Robespierre) were able to quickly turn a large?scale riot into a wholesale nationalist revolution. In this sense, the dictatorship of Robespierre and The Terror that took effect from July 1793 to July 1794 should be seen as marking the birth of political modernity.

“Robespierre is not so much the heir of Enlightenment as the product of the new system called Jacobinism, the beginning of modern politics.”[2]

Modern politics in this instance is a pseudonym for nationalism, which after the French Revolution became the defining concept in European politics until the end of World War Two and the destruction of the Nazi State in 1945. Indeed, the link between the revolution, nationalism and what the twentieth century would come to understand as fascism must at this point be underscored. Fascism, much like the political dictators of the French Revolution, was only able to come to power via a protracted period of liberal decadence having taken place beforehand. Thus – in much the same way as the leaders of the French Revolution – right wing fascist leaders used nationalism as a means of highlighting the need to undergo a revolutionary national re?birth; to attempt to form a phoenix from what they perceived as the ashes of political ineptitude and cultural decadence.

“Fascism is a genus of political ideology whose mythic core in its various permutations is a palingenetic form of populist ultra-nationalism.”[3]

The association with fascism is also useful for the way in which it spreads light on how the revolution was unable to be contained with the sovereign national borders of France alone. Like Nazism, nationalism in the context of the French Revolution was a highly unstable ideological solution to a long-term socio?political problem. The revolution likewise required an external enemy in order to maintain popular support and political legitimacy. Thus, war became the lifeblood of the revolution as, during the course of the 1790’s the leaders of the French Revolution decided that it was no longer enough to have successfully removed from power the former political elite from France; rather, an expansion of the ideology and the means of putting that ideology into practice abroad became the raison d’etre of the regime.

“During the 1790’s the policies pursued by France undoubtedly contributed to mass political mobilisation elsewhere in Europe.”[4]

The Napoleonic Wars which followed should be seen as the wars of nationalism which raged across the European continent over the following two decades. Yet there was a tangible sense of a facade appearing whereby the French claimed to be conquering foreign territory in order to transfer the libertarian, enlightened principles of the revolution to lands that had hitherto not been afforded such a valuable political and social insight when in fact the struggles that Napoleon embarked upon across the continent were simply a means of affirming the French nationalists’ belief that they alone were the superior European race. Nowhere is this better illustrated than in the invasion of Russia – again a move that strikes immediate comparisons with Hitler and Nazi Germany. By crossing the Urals and moving into the realms of Russian authority, Napoleon finally discarded the mask of the revolution that he had so far been sporting. In no way could the take over of Russia be seen as anything other than the expression of nationalism over political theory. Russia at the time was still an almost entirely feudal country with no industrialisation to speak of even in the major towns and cities such as St. Petersburg. In addition, there was no sophisticated social class system to speak of which could have proved to be a launch pad for a nationalist revolution taking place in Russia on anything like the same scale that had happened in France. Therefore, the invasion was, in the final analysis, simply due to the will of Napoleon and the nationalistic French to increase the revolutionary empire by overcoming the historical pariah of European politics. Furthermore, just like all the other nationalist leaders who went before and came after him, Napoleon was ultimately proved to be incorrect: nationalism (as manifested by the Tsar and the Russian civilian population) was a force that was just as capable of defending a sovereign border territory as it was of invading and conquering it.

Nationalism was clearly a double?edged sword so far as France and Napoleon were concerned. Essentially, the more land the French army seized, the more the Prussians and the English revelled in their own forms of nationalism which were ignited in the first place by French aggression and sustained by the military ambitions of its dictatorial leader. It remains within the realms of conjecture as to whether or not the British Empire would have been established as rapidly and successfully as it was without the experience of the Napoleonic Wars to both inspire as well as crystallise it. There can be little doubt that the rivalry of the two (which had been meted out in the colonial wars that took place at the same time in North America and Canada) had been the result of a growing sense of tension due to the nascent nationalism of both countries. The French Revolution proved to be the catalyst behind the ultimate expression of this nationalistic warfare between the United Kingdom and France – a potent political concoction whose reside is still very much in evidence in the modern era.

Mention at this point must be made of the ideological and philosophical impetus behind the French Revolution in order to manufacture an argument against the idea that the uprising was solely the revolt of nationalistic fervour, which it clearly was not. No seizure of power by a people over a ruling government can be anything other than the combination of a number of highly complex social, cultural, economic and political processes.

The build up to the storming of the Bastille has been described as the golden age of Enlightenment – an epoch that oversaw the signing of the Declaration of the Rights of Man in America (July 1776), which signalled the notion of all men being born equal and of human beings having been born with certain rights that must be upheld by national and international law. This vision of liberalism that was sweeping across the early modern western world was not initially a vision that was inspired solely by nationalism. Certainly in the United States it is not possible to speak of a nationalist revolution simply because the thirteen colonies at that time consisted of such a mixture of European immigrants as to make the concept of a nation?state wholly inadequate for the newly conceived ‘Americans.’ The ideal was, rather, a child of ideological and philosophical writings that emanated predominantly from France via contemporary cultural commentators such as Rousseau and Voltaire. Again, these ideals did not accentuate the nationalism inherent within Enlightenment. Instead they promulgated an essentially socialist view of a new European order that was designed upon a kind of meritocracy rather than values pertaining to inheritance; where ability was seen as more important than historical connection.

“Anyone who excels in something is always sure to be sought after, opportunities will present themselves and merit will do the rest.”[5]

This inexorably socialist, libertarian seed that was first planted in what would become the French Revolution is a vital tool for understanding how nationalism alone cannot be seen as responsible for the events of 1789 and the ensuing wars which followed. The ideological impetus behind the revolution was one that genuinely envisaged a utopian new world order that would not be dictated by corrupt and inadequate people the likes of which had conspired to ruin France since the Middle Ages. The reasons as to why this ideal of a revolution from below turned into a large scale international war is entirely due to the make up of mankind, which is especially inclined to be corrupted by power and to look towards routes of making profit out of the conquer and subjugation of alien races. The point has been made before and it must be made again: this kind of overt nationalism that took control of France during the late eighteen and early nineteenth century was the driving force behind all intercontinental relations over the following one hundred and fifty years. The French Revolution thus oversaw the beginnings of the reign of realpolitik when military might became the only means of maintaining dominance in a Europe increasingly influenced by cultural intolerance and overt political nationalism.

Conclusion

“1789 meant a revolution in ideas, in institutions and individual opportunities, which a quarter of a century of upheaval and war made irreversible.”[6]

As the above quotation suggests, the revolution that took France by storm during the final years of the eighteenth century was an extremely potent political process that seemed to gather intensity as the success first of the bourgeois dictatorship of The Terror and second of the military dictatorship of Napoleon cemented the ideals of the Enlightenment upon the European mainland. However, although this process might have began as an expression of egalitarian views pertaining to the freedom of all men, the reality of the revolution was one that spoke volumes about the essentially violent nature of the human condition and the extent of the socio?political frustrations that had been steadily rising since the middle of the previous century. The greatest beneficiary of this volatile mixture was without doubt nationalism – the only ideological force that was able to hold together the disparate aims and ideals that conspired to make up the French Revolution. Nationalism and the defence of la patrie were used as rallying cries by the petty bourgeoisie, the revolutionary instigators of the Terror and the imperial machinations of the Napoleonic war machine.

To what extent these people were successful in their aims of inciting a nationalist revolution remains an issue that still resides predominantly within the realms of conjecture. There certainly appears to be a major schism between the nationalism that gripped the streets of Paris and the other chief urban centres of France and the relative tranquillity of the rural areas of the country that largely retained their bonds both to the nobility and to the ancien regime in the years that immediately followed the revolution[7]. In the final analysis, the concept of la patrie meant very little to the uneducated proletariat working on the rural estates in the agrarian parts of the country where economic necessity took precedence over revolutionary rhetoric and nationalistic uprisings. This then suggests that nationalism is inexorably tied to industrialisation, urbanisation and the ability to wage mobile industrial warfare across a large land mass. This is exactly what happened one hundred and fifty years after the defeat of Napoleon at Waterloo when the distorted vision of nationalism that inspired the French Revolution came back to haunt Europe and the world on an unimaginable scale.

BIBLIOGRAPHY

Andress, D. (2005) The Terror: Civil War in the French Revolution London: Little, Brown & Co.

Bouloiseau, M. (1983) (translated by J. Mandelbaum), The Jacobin Republic, 1792?1794 Cambridge: Cambridge University Press

Dann, O. and Dinwiddy, J.R. (1988) Nationalism in the Age of the French Revolution London: Continuum

Furet, F. (1981) (translated by E. Forster), Interpreting the French Revolution Cambridge: Cambridge University Press

Griffin, R. (1991) The Nature of Fascism London: Pinter

Merriman, J. (2004) A History of Modern Europe Volume 2: From the French Revolution to the Present London: W.W. Norton & Co.

Pilbeam, P.M. (1995) Republicanism in Nineteenth Century France, 1814-1871 Basingstoke: Macmillan

Rousseau, J-J (1971) (introduction and translated by J.M. Cohen) The Confessions London: Penguin

Voltaire (1964) (introduction and translated by J. Butt) Zandig London: Penguin

Zeldin, T. (1980) France 1848-1945: Intellect and Pride Oxford: Oxford University Press

Selected Articles

Biddis, M. (October 1994) Nationalism and the Moulding of Europe, in, Journal of the Historical Association, Volume 79, No. 257 London: Blackwell

Modern Portfolio Theory and Capital Asset Pricing Model

Introduction

The Capital Asset Pricing Model developed by William Sharpe has significant similarities with Harry Markowitz’s Portfolio theory. In fact, the later is rightly considered as the next logical step from the latter, with both based on similar foundations.

There are also differences in how each model/theory is calculated, pertaining to risk considerations.

This paper’s main objective is to identify these differences while highlighting the similarities as well to put things into perspective.

The report will open with an overview of Markowitz’s portfolio theory and explain it further by means of describing the efficient frontier, the Capital Market Line, risk free asset and the Market Portfolio.

The report will then switch its attention to the Capital Asset Pricing Model and explain it further through the Security Market Line.

The report will then close by outlining the differences between the two with a view of answering the main objective.

What will come through in this report is that Markowitz’s portfolio theory uses standard deviation as its risk measure and takes into account all risk in an efficient portfolio, while the Capital Asset Pricing Model uses the beta co-efficient to measure risk and takes into account both efficient and non-efficient portfolios – further more it measures the risks of individual assets within the portfolio.

Modern Portfolio Theory

Modern Portfolio Theory (MPT) was introduced by Harry Markowitz, way back in 1952. At a high level it proposes how rational investors use diversification to optimise their investment portfolios and give guidance on pricing risky assets.

MPT assumes that investors are risk averse, i.e. given two assets A and B offering the same expected return, investors will opt for asset A if it is less risky. In effect, an investor who expects higher returns would need to accept more risk. The expected trade-off between risk and return depends on the individual’s level of risk aversion. The implication of this is a rational investor (a risk averse investor) will not invest in a portfolio if another one exists offering a better risk-return profile (Fabozzi & Markowitz, 2002).

For any given level of risk, investors will opt for portfolios with higher expected returns instead of those with lower returns.

Another assumption under MPT is that investors are only interested in the expected return and the volatility of an investment, as measured by the mean and standard deviation respectively. Investors do not consider any other characteristics, for example, charges.

In effect, based on the assumptions above, investors are concerned about efficient portfolios.

To explain portfolio theory further, let us consider the formula for the expected return and risk of a portfolio under MPT.

Suppose two assets A and B formed a portfolio in proportion (X) each, the expected return for that portfolio would be:

R(p) = X(a)R(a) + X(b)R(b), where:

R(p) = expected returns from portfolio

R(a) = expected returns from asset A

R(b) = expected returns from asset B

The standard deviation or risk of that portfolio would be:

SD(p) = v(X?aSD?a + X?bSD?b + 2XaXbRSDaSDb), where:

SD(p) = standard deviation of expected returns of portfolio

SDa = standard deviation of expected returns of asset A

SDb = standard deviation of expected returns of asset B

R = correlation coefficient between the expected returns of the two assets

The efficient frontier

Under MPT, Markowitz examined the efficient frontier curve. The efficient frontier curve gives a graphic presentation of a set of portfolios that offer the maximum rate of return for any given level of risk (McLaney, 2006). According to Markowitz, an efficient investor will opt for an optimum portfolio along the curve, based on their level of risk aversion and their perception of the risk and return relationship (Fabozzi & Markowitz, 2002).

Figure 1: Efficient Frontier Source: www.riskglossary.com

The curve in the diagram above illustrates the efficient frontier. Portfolios on the curve are efficient – i.e. they offer maximum expected returns for any given level of risk and minimum risk for any given level of expected returns. The shaded region represents the acceptable level of investments when risk is compared against returns. For every point on the shaded region, there will be at least one portfolio that can be constructed and has a risk and return corresponding to that point (www.riskglossary.com)

As aforementioned, each portfolio on the efficient frontier curve will have a higher rate of return for the same or lower level of risk or lower risk for an equal or better rate of return when compared with portfolios not on the frontier.

It is important to note that the efficient frontier is really made up of portfolios rather than individual assets. This is because portfolios could be diversified, i.e. investors can hold assets which are imperfectly correlated (Fabozzi & Markowitz, 2002). This will help to ensure that investors can reduce their risks associated with individual asses by holding other assets – a kind of set-off.

The Capital Market Line

The Capital Market Line (CML) is a set of risk return combinations that are available by combining the market portfolio with risk free borrowing and lending (www.lse.co.uk/financeglossary). The CML defines the relationship between risk and return for efficient portfolios of risky securities. It specifies the efficient set of portfolios can investor can obtain by combining the portfolio (which contains risk) with a risk free asset.

The formula for CML is:

E (r_c) = r(f) + SD(c)*[E(r_m)-r(f)]/SD(m)

Where:

E(r_c) = expected return on portfolio c

R(f) = risk free rate

SD(c ) = standard deviation of portfolio c

E (r_m) = expected return on market portfolio

SD(m) = standard deviation of market return

The CML indicates that the expected return of an efficient portfolio is equal to the risk-free rate plus a risk premium. Both risk and return increase in a linearly along the CML.

Figure 2: Capital Market Line Source: www.riskglossary.com

In Figure 2 above, the CML is the line touching the efficient frontier curve. It passes through the risk free rate (assumed to be 5%). The point where the CML forms a tangent with the efficient frontier curve is the point called the super-efficient portfolio.

The Risk free asset, Sharpe ratio and the Market Portfolio

The risk free asset pays a risk free rate and has a zero variance in returns, e.g. government short-term securities. When combined with a portfolio of assets the change in return and risk is linear.

The Sharpe Ratio is a measure of the additional return to be obtained about a risk free rate for a given portfolio compared with its corresponding risk. On the efficient frontier the portfolio with the highest Sharpe Ratio is known as the market portfolio.

The CML is the result of a comparison between the market portfolio and the risk free asset. The CML surpasses the efficient frontier with the exception of the point of tangency.

The Capital Asset Pricing Model

While the CML focuses on the risk and return relationship for efficient portfolios, it would be useful to consider the relationship between expected return and risk for individual assets or securities. The Capital Asset Pricing Model (CAPM) would be used for this.

CAPM is an extension of Markowitz’s Portfolio Theory or MPT. It introduces the notions of systematic and specific risks. Let us define each:

Systematic risk – this is the risk associated with holding the market portfolio of assets
Individual assets are affected by market movements
Specific risk – this risk is unique to an individual asset and represents that portion of an asset’s return which has no correlation with market movements.

CAPM assumes the following (McLaney, 2006, 199):

Investors are risk averse and maximise expected utility of wealth
The capital market is not dominated by any individual investors
Investors are interested in only two features of a security, its expected returns and its variance or standard deviation
There exists a risk free rate at which all investors may borrow or lend without limit at the same rate
There is an absence of dealing charges, taxes and other imperfections
All investors have identical perceptions of each security

This lends credence to the assertion that CAPM follows a natural progression from MPT. The assumptions are identical with the main difference being how risks are categorised and treated. This will be explored in detail in a later section.

Under CAPM, the market place will compensate an investor for taking a systematic risk but not a specific risk. The rationale for this is that specific risks can be avoided or minimised through diversification.

The formula for CAPM is as follows:

r = Rf + Beta x (RM-RF), where:

r = expected return on an asset

Rf = rate of risk free investment

RM = return rate of the appropriate asset class

Beta is the relative risk contribution of an individual security to the overall market portfolio. It measures the security risk relative to the market portfolio and ignores the specific risk. The beta equation is as follows:

Cov (i,M)/(SDm)?, where:

Cov (i,M) = covariance between market portfolio and security i

(SDm)? = variance of the market’s return

The betas for all assets are measured in relation to the market portfolio beta which is 1. In effect, if individual beta is greater than 1, then individual asset has a higher risk than the market risk. If individual beta equals 1, then individual asset risk and market risk are the same. If individual beta is less than 1, then the risk of that individual asset is less than the market risk.

The value of beta provides an idea of the level or size of the change in an asset’s return when a corresponding change in the returns of an overall portfolio is experienced (McLaney, 2006).

Beta has come under criticism from academics and investors who do not appreciate the value of beta as an appropriate risk measure. However, this is somewhat challenged by actual performance of the betas of portfolios and mutual funds. These are regarded as stable and can be used to predict future betas.

Security Market Line

CAPM can be applied by using the Security Market Line (SML). SML is a graphical representation showing the linear relationship between systematic risk and expected rates of return for individual assets. In the case of the SML, risk is measured by beta. It plots the expected returns on the y axis and the risk as denoted by beta on the x axis.

In other words, the SML expresses the linear relationship between the expected returns on a risky asset and its covariance with market returns. Its formula is:

Figure 3: CAPM and SML

The line in the diagram above is the SML.

Differences relating to MPT (CML) and CAPM (SML)

To explain the differences, it is useful to consider the relationships between risk and return in the perspective of CML and SML. CML compares the relationship from an MPT perspective, while SML does from a CAPM perspective.

The main difference pertaining to MPT’s relationship with CAPM is pertaining to risk.

Under Portfolio theory, CML gives an indication of expected returns in comparison with risk. Here the risk is measured in terms of standard deviation of returns. The rationale for this is CML represents the trade-off for efficient portfolios, i.e. the risk is all systematic risk (McLaney, 2006).

The SML on the other hand, indicates the risk/return trade-off, using beta as the measure of risk. In this case, only the systematic risk element of the individual asset is taken into consideration.

The reason why CML shows no individual security’s risk profile is because all individual securities have an element of specific risk, implying that they are inefficient. CML only looks at efficient portfolios.

The table below summarises the main differences between CML and SML

CML

SML

Scope

Covers efficient portfolios which consist of one risky asset and risk-free assets

Covers all capital assets

Measuring Asset Risks

Standard deviation is used

The beta coefficient or covariance is used

Objectives

CML aims to identify the optimum portfolios for investors

SML seeks to describe how assets are priced by efficient markets in equilibrium

Table 1: Tabular difference between CML and SML

Summary

As has been shown above, CAPM has been developed along the lines of Markowitz’s Portfolio theory. They both use expected returns and risk as the investor’s main determinant of their investment decisions. They both assume that investors are risk averse and do not consider anything else other than risk and returns.

However, there are some subtle differences which will now be summarised below:

Under Portfolio theory, the CML measures risk by standard deviation or total risk. The SML measures risk by beta or systematic risk under CAPM – it ignores specific risks
The CML graph is interested in providing information on efficient portfolios only. The SML graph on the other hand provides insight into both efficient and non-efficient portfolio and securities

REFERENCES AND BIBLIOGRAPHY

Books

Bodie, et al (2006) ‘Investments’ (7th edition), McGraw-Hill/Irwin, London
Elton, E et al (2003) ‘Modern Portfolio Theory and Investment Analysis’, Wiley, London
Fabozzi, F. & Markowitz, H. (2002) ‘Theory and Practice of Investment Management’, Wiley, London
McLaney, E. (2006) ‘Business Finance – Theory and Practice’ (7th edition), Prentice Hall, London
O’neill, W.J. (2002) ‘How to Make Money in Stocks’, (3rd edition), McGraw-Hill, London

Internet Sources

www.lse.co.uk

www.riskglossary.com

www.wikipedia.com

“Ministerial responsibility is the cornerstone

In medieval times, the royal will was signified in documents bearing royal seal and was applied by one of the King’s ministers. Maitland has described this practice as being “the foundation for our modern doctrine of ministerial responsibility – that for every exercise of the royal power some minister is answerable”[1]. This essay will consider the modern doctrine of ministerial responsibility and examine the extent to which it forms, in modern political times, the cornerstone of accountability in the UK constitution.

The convention of ministerial responsibility has been described by Loveland as “perhaps the most important non-legal rule within our constitution”[2]. The convention may be said to be concerned with regulating the conduct of government activities, both in respect of Ministers’ relations with each other, and with the two Houses of Parliament[3]. Ministerial responsibility comprises of two branches: collective responsibility and individual responsibility[4].

Collective ministerial responsibility may be further reduced into three main rules: the confidence rule; the unanimity rule, and; the confidentiality rule[5]. Through the operation of these rules, Ministers of the Government all appear to others to share the same policy opinions, whatever their own personal views. They are therefore collectively responsible for any decisions made by the Government and the Government as a whole should resign if it loses confidence. The doctrine of collective responsibility was stated in 2005 in the following form:

“Collective responsibility requires that Ministers should be able to express their views frankly in the expectation that they can argue freely in private while maintaining a united front when decisions have been reached. This in turn requires that the privacy of opinions expressed in Cabinet and Ministerial Committees should be maintained.”[6]

It therefore follows that where a Minister does not wish to be publicly accountable to Parliament and the electorate for a Governmental decision, he should resign from the Government. This occurred, for example, when Robin Cooke resigned over the Labour Government’s decision to invade Iraq in 2003[7].

Collective ministerial responsibility allows all members of Government to be accountable as a whole, thus avoiding arguments and blame-shifting between different Ministers and Departments. In this way, collective responsibility enhances the accountability of Government.

Individual ministerial responsibility is the convention that a Minister answers to Parliament for his department, with praise and blame being addressed to the minister and not civil servants[8]. It has been said that “the fundamental purpose of the convention of individual ministerial responsibility is that it provides an important means of drawing information into the public domain”[9] The principle has often been associated with the idea that ministers must resign in cases of official wrongdoing[10] but it also encompasses Ministers’ on-going obligations to account to Parliament for their departments’ work[11].

However, in 2000, Jowell and Oliver suggested that ministerial responsibility to Parliament had been “significantly weakened over the last ten years or so… so that it can no longer be said, in our view, that it is a fundamental doctrine of the constitution”[12]. Their opinion may have been influenced by the structural changes in government. During the 20th century tasks of the state expanded and vast Whitehall departments were created, with the effect that ministers could not oversee all aspects of the departments’ work[13]. Executive ‘Next Steps’ agencies created since 1988 had the specific purpose of delegating managerial power. Indeed, as Turner states: “Ministerial responsibility, however, is a different matter in the modern era. It has shrunk, it seems, almost to nothing, thanks, in no small part, to the creation of “independent” agencies to undertake the work of government.”[14]

Where civil servants have great authority, the question arises as to what extent a Minister is responsible for any acts of maladministration, and whether maladministration results in a duty to resign. Is it fair to hold the Minister responsible? If not, who should be and how does this affect accountability?

As Tomkins notes, during the Major Government’s office from 1990 to 1997 “Ministers and senior civil servants… proposed a number of initiatives that sought significantly to undermine the tenets of individual responsibility”[15]. It was claimed that Ministers were responsible only for those decisions in which they were directly and personally involved. Michael Howard claimed, after serious failings leading to Prison escapes, that Ministers were responsible to Parliament only for policy matters, with “operational” failings falling outside the scope of individual responsibility[16]. Furthermore, it was argued that where Ministers had misled Parliament, they should resign only if they had done so knowingly rather than inadvertently[17].

In this way Ministerial responsibility was weakened, with accountability becoming more prominent. A minister may be said to be accountable to Parliament for everything which occurs in a department, having a duty to inform Parliament about the policies and decision of the department and to announce when something has gone wrong. However, this does not bring with it responsibility in the sense that the Minister takes the blame.

In 1997 the Ministerial Code reformulated ministerial responsibility to the effect that:

Ministers must uphold the principle of collective responsibility; (b) Ministers have a duty to Parliament to account, and be held to account, for the policies, decisions and actions of their departments and agencies; (c) it is of paramount importance that Ministers give accurate and truthful information to Parliament, correcting any inadvertent error at the earliest opportunity. Ministers who knowingly mislead Parliament will be expected to offer their resignation to the Prime Minister; (d) Ministers should be as open as possible with Parliament, refusing to provide information only when disclosure would not be in the public interest…; (e) Ministers should similarly require civil servants who give evidence before Parliamentary Committees on their behalf and under their direction to be as helpful as possible in providing accurate, truthful and full information…[18]

This new formulation would suggest that it is now ministerial accountability rather than responsibility which forms the cornerstone of accountability in the UK constitution. Unless there is fully open Government, there may be situations which arise where no person will take responsibility for actions and Ministers’ relationship with the Civil Service will be fundamentally changed. As Hennessy points out: “For the Civil Service the buck-stopping question is of crucial importance. Under the doctrine of ministerial responsibility, ministers are the ultimate can-carriers for everything done by the civil service in their name”[19]. This will no longer be the case where a Minister’s responsibility ends with alerting Parliament to a problem.

Bibliography

Allen, M. & Thompson, B., Cases and Materials on Constitutional and Administrative Law, 9th Edition, (2008), OUP

Bamforth, N., “Political accountability in play: the Budd Inquiry and David Blunkett’s resignation”, (2005), Public Law, 229

Bradley, A.W. & Ewing, K.D., Constitutional and Administrative Law, 14th Edition (2007), Pearson Longman

Brazier, R., “It is a Constitutional Issue: Fitness for Ministerial Office in the 1990s”, (1994), Public Law, 431

Cooke, R., The Point of Departure (2003), Simon and Schuster

Hansard, HC cols 31-46 (January 10, 1995)

Hennessy, P., Whitehall, (1989), Secker & Warburg

Hough, B., “Ministerial responses to parliamentary questions: some recent concerns”, (2003), Public Law, 211

Jowell, J. & Oliver, D., The Changing Constitution, 4th Edition, (2000), OUP

Lewis, N. & Longley, D., “Ministerial Responsibility: The Next Steps”, (1996), Public Law, 490

Loveland, I., Constitutional Law, Administrative Law, and Human Rights: A Critical Introduction, 4th Edition, (2006), OUP,

Maitland, Constitutional History,

Marshall, G., Constitutional Conventions, (1984)

Ministerial Code: a Code of Ethics and Procedural Guidance for Ministers (reissued, July 2005)

Tomkins, A., The Constitution after Scott: Government Unwrapped, (1998), Clarendon

Tomkins, A., Public Law, (2003), OUP

Turner, A., “Losing heads over the lost data”, (2007), 171, Justice of the Peace, 841

1

Marketing Communications: Promotion Strategy for Wimbledon

BACKGROUND AND INTRODUCTION

The All England Lawn Tennis and Croquet Club (“Club”) located at Wimbledon, is a private club founded in 1868. Its first ground was situated off Worple Road, Wimbledon, and the first Wimbledon Lawn Tennis Championship was instituted in 1877. By the turn of the century, Wimbledon, as the event had become known had grown in popularity and reputation, acquiring international status as the premier tennis event. By 1920, a company was formed to acquire and equip the present site at Church Road. A complex agreement governs and defines the relationship between the Club, the Lawn Tennis Association (LTA), the company, and Wimbledon as a self financing event. Profits from Wimbledon, held during June and July of each year, accrue to the LTA after meeting expenses of the Wimbledon tournament. LTA in turn utilises the surplus funds to develop tennis as a sport in Great Britain. A second company to exploit trademarks and brand opportunities was established in 1993, whereby any profits would accrue for the benefit of Wimbledon to improve the quality of the event for spectators, players, officials, and stakeholders. Surplus funds from Wimbledon that have been made available to LTA were 25.8 million in 2003. Wimbledon does not disclose revenue or sponsorship figures but it is estimated that it had a net income of ? 34 million during 2004. (Wimbledon 2005 and Schwartz, 2004)

Wimbledon, as an event does not appear to have a vision statement defined by Johnson and Scholes (2005) p13 as a “desired future state” or “aspirational statement.” Wimbledon has equally not published a mission statement, or “overriding purpose in line with the values or expectations of stakeholders.” (Johnson and Scholes, 2005, p13) However, given the close association with the LTA described above, it can be argued that the event’s underlying vision and mission are aligned and it is appropriate to quote the LTA’s vision, “to make Britain a great tennis nation,” and the mission statement, “more players, better players,” to give context to Wimbledon. (LTA, 2005) Wimbledon is marketed as an international event rather than a British event although British tennis derives the economic benefit. (Cambridge Econometrics, 2003)

Essentially a small business employing less than 100 full time staff, the club is a local tennis facility in South West London, with a web site, clubhouse, museum, and a shop for 50 weeks of the year. Its distinguishing feature is a seating capacity of 35,500 spectators to accommodate Wimbledon. The total area of the club including courts, premises, and car parks is 42 acres. There are 375 full members plus a number of honorary members (including past singles champions) and approximately 100 temporary members elected annually. The workforce increases to 6000 during the period of the tournament. (Wimbledon, 2005)

This report focuses on Wimbledon as a discrete, ring fenced event. It proposes an marketing communications strategy to the Club and the LTA committee, after due consideration of the macro, micro and market influences.

MACRO-ENVIRONMENT ANALYSIS

The environmental context of Wimbledon encompasses a number of driving or restraining forces that have the capacity to influence the effectiveness of the communication strategy.

PESTEL

A common framework is that of PESTEL comprising political, economic, socio-cultural, technological, environmental, and legal influences. (Johnson and Scholes, 2005.) Fill (2002) suggests that seasonality is an additional factor in an event environment. The framework provides broad data from which the key drivers of change can be identified.

Mega events on the scale of Wimbledon, which target an international market, and the success of which influences urban logistics such as transport and security, requires significant political support. (Bull, 2004) The United Kingdom government has established a set process for government involvement and investment that requires a clear assessment of benefits. This should also be seen in the context of post September 11th security concerns that may affect Wimbledon. (Strategy Unit, 2002) The positive economic benefits in terms of tourism expenditure and promotion of London as a destination highlight the interdependence of the PESTEL influences and the host city. Socio-cultural influences such as changing population demographics in Wimbledon’s target audience needs to be considered in terms of media access and viewing patterns. (Fill, 2002) Emerging technologies were used during 2004 as innovative mediums for the first time to expand the audience reach. These included a combination of online media, video on demand, interactive television, and live coverage to Personal Digital Assistants (PDA) and mobile phones.

The impact on promotion strategy in the lead up to and during the championship requires careful analysis to maximise audience reach. (Schwartz, 2004) The environmental impact of Wimbledon is substantial, albeit over a short period, in terms of noise, traffic, waste management and other influences. The Merton borough in which the event is located is revenue dependant on Wimbledon’s success as part of its urban regeneration programme and hence supports the event upon which it in turn derives a benefit. An emerging influence is that of corporate social responsibility and re-investment back into the community. This has a positive impact on legal influences such as council regulations and bylaws. (Gratton et al, 1999) Seasonality affects Wimbledon in terms of weather and the time of year in which the event is held. (Fill, 2002 and Wimbledon, 2005)

Porter’s Five Forces

Inherent to the theory of marketing communication strategy is the notion of competitiveness and gaining advantage over competitors. Porter’s development of generic strategies and a five forces model of analysis of competition within an industry are useful in understanding Wimbledon as a unique event. (Johnson and Scholes, 2005) Wimbledon’s prestige and history allows it to follow a differentiated premium pricing strategy in which the objective is to “maintain the quality and character of the tournament and not to maximise income.” (Wimbledon, 2005) Although Wimbledon is a profitable venture in the event industry, the barrier to entry to a rival wishing to compete is high and the prestige of Wimbledon not substitutable in terms of world attention and focus. Buyer power is limited by the spectator facilities and hence access in high demand, whilst are suppliers fragmented without a single dominant player. Competitive rivalry between Wimbledon and other events is not material and hence unlikely to threaten Wimbledon. Arguably Wimbledon’s position may be threatened in the future if the dynamics of the macro environment change. However a marketing communication strategy that builds on the successes of the past that continues to capitalise on innovative, leading edge communication strategies will ensure an image re-invention for future audiences.

Product Life Cycle

Wimbledon has changed its strategy from the garden party approach of the early 20th century through the skilful use of technology for its target audience in the 21st century, demonstrating that whilst in a mature phase of the life cycle model as a brand, it can maintain market share through re-invention of its product delivery. (Czinkota, Ronkainen, and Tarrant, 1995)

MICRO-ENVIRONMENT ANALYSIS

Strategic Resources

The analysis of the macro-environment has indicated Wimbledon’s positive base for competitive advantages. The sustainability of competitive advantage in terms of capability is based on strategic resourcing that reflects the distinctive resources which allow the Club and its partners to generate a superior product at a premium price. This is based on Wimbledon’s tangible resources such as facilities and grounds as well as intangible resources such as information, reputation, and knowledge. Wimbledon’s competencies are represented by the activities and processes whereby it deploys its resources year on year, building, and learning from successes of the past and ensuring that they cannot be imitated, thus sustaining its competitive advantage. The path dependency of Wimbledon’s resources has evolved through its culture and history that is influenced by causal ambiguity implying that worldwide perception of Wimbledon would be difficult to replicate. (Johnson and Scholes, 2005)

Marketing Mix

The marketing mix is a key element of an integrated marketing communications plan. The concept has evolved from McCarthy’s 4P’s (product, price, place, and promotion) into different models that depend on their context. Recent developments have been the addition of personnel, physical assets, and procedures to the marketing mix forming the 7P’s in Booms and Bitner’s extended marketing mix model. This has especially reached acceptance in the discipline of services marketing and arguably Wimbledon’s combination of tangible and intangible resources, falls within that category. (Goldsmith, R. E. 1999) Goldsmith, 1999, p178 proposes an eighth P, “personalisation” in terms of individual needs and wants of the consumer. Wimbledon’s product offering is based on a combination of tangible cues represented by its physical offering, and intangible attributes such as prestige and status of the event.

Premium brands such as Rolex have for example endorsed Wimbledon in their capacity as the “official timekeeper of the tournament” for over 25 years at a cost of approximately ?7 million. (Schwartz, 2004) Direct pricing is represented by the gate price for access, and indirect pricing through the sale of television rights to channels such as the BBC and NBC TV, to attract worldwide viewer audiences. The personnel or people component is represented by pride with which employees and volunteers provide quality services to the public and players. (Schwartz, 2004) The top players themselves compete for the privilege of playing and hence are frontline line actors both directly and indirectly in the service space. Personalisation can be demonstrated by the clever use of technology. For example the BBC has provided interactive television coverage allowing five simultaneous live matches on one screen that allowed viewers to personalise their choice of matches thus capturing 4 million viewers in 2004. (Schwartz, 2004)

Competitors

The Davis Cup is an international team competition introduced in 1900 by American player Dwight Davis. Originally called the International Lawn Tennis Challenge Trophy, while initially only two teams participated (the USA and Great Britain), the competition has grown into an event in which over 100 nations now participate. It is a roving event and has been hosted at the Wimbledon grounds from time to time. The event itself has the same target market as Wimbledon but complements rather than competes with the championship event. Wimbledon therefore arguably has no competitors in terms of its positioning. (Wimbledon, 2005)

SWOT Analysis

A SWOT analysis (Strengths, Weaknesses, Opportunities, Threats) illustrated below in Table 1, is often used as a convenient summary of key issues from the business environment that may potentially impact on an organisation’s marketing communication strategy. (Johnson and Scholes, 2005.) The purpose is to identify the strategic options available to Wimbledon. A detailed analysis is beyond the scope of this report but Table 1 below illustrates focal elements that will be discussed in the creative proposal.

Table 1: SWOT Matrix

STRENGTHS

WEAKNESSES

Prestige brand-considered heritage and cultural symbol

Limited spectator space

Extremely popular

Small retail space

Loyal following internationally

Limited space for expansion

Well organised

Increasing visitor numbers

Attended by top ranked players

Spectator demographics

OPPORTUNITIES

THREATS

Joint promotion and marketing with London as a destination.

Weather: visitor number dependant on good weather.

Increased retail opportunities via the Internet

Security

Commercial use of brand

MARKET ANALYSIS

This section of the report considers key figures and statistics relevant to Wimbledon as a basis for a creative proposal.

Attendance

Figures from the early 20th century are not available but in 1932 219,000 spectators attended the event. The 400,000 barrier was broken in 1986 and a record attendance of 490,081 in 2001 when play was extended into a fourteenth day. (Wimbledon, 2005)

Table 2: Daily Attendance 2000-2004

2000

2001

2002

2003

2004

Monday

39,330

38,561

38,561

38,500

35,335*

Tuesday

41,320

40,995

40,995

41,929

34,312*

Wednesday

41,146

42,457

42,457

40,787

29,156**

Thursday

41,440

41,410

41,410

41,976

36,130

Friday

40,834

41,440

41,440

39,833

39,659

Saturday

40,043

41,595

41,595

38,913

32,746**

Sunday

22,155*

First Week

244,113

244,740

244,740

241,938

229,493

Monday

38,247

41,236

38,764

39,389

39,229

Tuesday

34,083

38,375

34,448*

34,696

34,041

Wednesday

31,789

36,969

32,367*

35,911

33,703*

Thursday

29,718

30,120

33,560

30,237*

29,404*

Friday

28,303

28,813

28,016*

29,872

28,254*

Saturday

27,542

27,770*

27,857

28,216

27,956

Sunday

29,806*

29,315

29,762

30,543

29,128

Monday

9159

13,370

TOTAL

455,752

490,081

469,514

470,802

451,208

* Bad Weather (more than 2 hours lost) ** Entire Day Rained Off

(Source: Wimbledon, 2005)

The table above clearly illustrates the effect of bad weather with significant decreases in spectator numbers due to cancelled matches. The wet weather refund policy to spectators attempt to compensate spectators who are an important element of Wimbledon theatre. Weather negatively influences viewers when coverage is not available which in turn may affect sponsors through loss of on-sold advertising revenues. However, plans for the remodelling of Centre Court at Wimbledon were unveiled in January 2004 and included a transparent, retractable roof over the centre court as well as an increase in spectator capacity.

Revenue

Wimbledon derives revenue from entrance tickets, “official suppliers,” or sponsors, media distribution and broadcasting rights. Ticket sales are not the primary source of revenue with a maximum income estimated at ?20 million using average ticket prices. The 15 official suppliers contribute an estimated gross income of ?120 million. Wimbledon does not publish revenue or sponsorship figures and the aforementioned figures are estimates. NBC TV for example pays an estimated ?7 million for broadcasting rights. (Schwartz, 2004 and Wimbledon, 2005)

Official Suppliers provide goods and services, which are both essential for the staging of Wimbledon, and which meet the Club’s objective of improving the quality of the service provided to the players, spectators and the media. For example, Rolex appears on court scoreboards as the official timekeeper and Hertz provides transport for the players. (Schwartz, 2004 and Wimbledon, 2005)

Demand for Wimbledon tickets has for decades exceeded supply. Tickets are also sold through the LTA and to their affiliated tennis clubs, schools, membership scheme and to foreign tennis associations. Wimbledon remains one of the very few major UK sporting events for which one can still buy premium tickets on the day. Each day (excluding the last four days, approximately 500 are specifically reserved for sale at the turnstiles. Ground tickets may also be purchased on the day of play on every day. Costs of pre-booked tickets range from ?24 to ?59 or ?4 or ?16 sold on the day. Every five years centre court Wimbledon debentures are sold. The issue of 2,300 debentures for the 2006-2010 Championships inclusive has already been oversubscribed. Each debenture, priced at ?23,150 (nominal value ?2,000, a premium of ?18,000 and VAT of ?3,150), entitles the holder to a reserved seat in Centre Court on each day of the tournament during the five year period. (Schwartz, 2004, and Wimbledon, 2005)

The lack of detailed financial information does not allow a realistic or accurate comparison with Wimbledon’s competitors in the international arena.

Target Market

Wimbledon has an 82.4% adult television reach in Britain during the tournament. UK Sport suggests that tennis tournaments and Wimbledon in particular to the younger ABC1 income group with a gender bias towards a women audience for British success in sport. Accurate figures for the world audience are not readily available. (Taylor Nelson and Sofres, 2002)

Hassan, Kraft, and Kortam, (2003) suggest that the scale and reach of an event such as Wimbledon requires rethinking in terms of a converging commonality of a global consumer’s interest in the event. They recommend an avoidance of over complex marketing plans that rise above domestic or micro buyer attitudes, motivation, and behavioural demographics commonly used for segmentation in local markets.

CREATIVE PROPOSAL

The proposal to Wimbledon’s committee is to leverage the existing brand equity associated with the tournament in order to improve perceptions of tennis in the broader international environment as basis for entrenching Wimbledon’s position as the premier international tennis event. The concept is a natural extension of the LTA’s British vision to that of the international arena and represents an affirmation of Wimbledon’s commitment to the principles of corporate social responsibility. It is suggested that the current “tennis ace” campaign of identifying talented, but economically disadvantaged players be extended to the third world whereby winners would be invited to celebrity matches during the tournament hence leveraging off the existing promotional mix of the event. (LTA, 2005, and Wimbledon, 2005)

Brand equity is a measure of a number of differing components including beliefs, images, and core associations that consumers have about a particular brand such as Wimbledon. A brand with strong equity has the capacity to strengthen barriers to entry and ensure sustainable competitive advantage, and in so doing, maintain premium pricing. (Johnson and Scholes, 2005) An integrated marketing communication strategy has an important role to play to ensure consistency of message across domestic and international marketing initiatives. (Fill, 2002)

The marketing communication objectives will be to raise levels of awareness amongst stakeholders with respect to Wimbledon’s commitment to developing tennis as a sport internationally and more particularly in potential future markets in the developing world. In order to achieve this objective, Wimbledon will have to maintain its position as an important contributor to the LTA and hence it’s commitment to Britain, but at the same time extend the awareness of its developmental commitment to tennis globally. Suitably credible spokespersons representing tournament winners will be important balance the possible conflicting interests of LTA domestically and Wimbledon internationally.

CAMPAIGN

A campaign is a unique combination of advertising, promotional events, public relations and other marketing communication activities that all express the same consistent message. When implemented effectively, they present a cumulative strategic message to the target markets under a collective symbolic umbrella whilst enhancing the emotional connection to a brand. (Robinson and Hauri, 1991) The proposed campaign methodology for Wimbledon is a gentile form of ambush marketing in that the official suppliers and television broadcasters will provide the communication channel for the initiative. A programme definition, scope, and schedule of activity will be constructed for the “tennis ace” project to coincide with the promotional strategies that lead up to the tournament. (Arens, 1999)

The indirect endorsement by mega brands such as American Express, Hertz, and Rolex will add to the strength of the message. It is Wimbledon’s stated objective that free-to-air television, and radio access across the world should be made available for all or part of the tournament and by default, to the developing world and emerging markets. (Wimbledon, 2005) This will ensure accessibility to talented players participating in the scheme and arouse local country interest in the programme.

Campaign scheduling would automatically align with the promotional activities of official suppliers and broadcasters. The profile and push strategy defining the campaign is estimated at ?1.2 million, including concept, creative and limited internal marketing with a ?500,000 budget for control and evaluation. Important to note is that an estimated 1.8 billion people in 164 countries watched 5,700 hours of Wimbledon coverage in 2004 through existing channel arrangements. (Schwartz, 2004)

Control and evaluation would be affected partly through external agencies such as the sponsors and broadcasters, but Wimbledon would be responsible for overall message delivery and control. Focus groups, tracking studies of awareness and perception and recall tests will be used to monitor the impact of the campaign. In particular the marketing communication objectives will be assessed regularly as the main form of evaluation. (Fill, 2002)

CONCLUSION

This reported has reviewed the external and internal environments of a highly successful event with the objective of leveraging off existing competitive advantages to entrench an already strong position as a means of expansion into potential new markets. It takes cognisance of the emerging importance of corporate social responsibility in terms of itself and its official suppliers and establishes a cost efficient programme to meet international requirements whilst contributing to its own future success.

REFERENCES

Aarens, W. F. (1999) Contemporary Advertising, International Edition. Irwin, McGraw Hill.

Bull, A. O. (2004) “Mega Or Multi-Mini? Comparing The Value To A Destination Of Different Policies Towards Events.” Unpublished paper presented at Third DeHaan Tourist Management Conference, 14 December 2004.

Cambridge Econometrics. (2003) “The Value of the Sports Economy in the Regions: the Case of London.” Sports England.

Czinkota, M. , Ronkainen, I. A. and Tarrant, J. J. (1995) The Global Marketing Imperative. Lincolnwood, Illinois, NTC Business Books.

Fill, C. (2002) Marketing Communications: Contexts, Strategies and Applications. London, Financial Times, Prentice Hall.

Getz, D. (1997) Event Management and Event Tourism. New York, Cognizant Communications.

Goldsmith, R. E. (1999) “The Personalised Marketplace: Beyond the 4P’s.” Marketing Intelligence and Planning. Volume 17, 4.

Gratton, C., Shibli, S. and Coleman, R. (1999) The Economic Benefits of Hosting Major Sporting Events. Insights.

Hassan, S. S., Craft, S. and Kortam, W. (2003) “Understanding the New Bases for Global Market Segmentation.” Journal of Consumer Marketing. Volume 20, 5.

Johnson, G., and Scholes, K. (2005) Exploring Corporate Strategy Seventh Edition. Harlow, Pearson Education Ltd.

LTA. (2005) Lawn Tennis Association. www.lta.org.uk Accessed 21 April 2005.

Robinson, W. A. and Hauri, C. (1991) Promotional Marketing. Lincolnwood, Illinois, NTC Business Books.

Strategy Unit. (2002) “Game Plan: A Game Plan for Delivering Government’s Sport and Physical Activity Objectives.” www.number-10.gov.uk. Accessed 19 April 2005.

Schwartz, J. A. (2004) Wimbledon’s Marketing Grand Slam. www.imediaconnection.com. Accessed: 21 April 2005.

Taylor, Nelson and Sofres (2002) UK Sporting Preferences. UK Sport.

UK Sport

Wimbledon. (2005) “All England Lawn Tennis and Croquet Club: the Official Web Site.” www.wimbledon.org. Accessed: 20 April 2005.

Life expectancy, the number of years that a

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A discussion of the factors that contribute to lower life expectancy in

the west of Scotland as compared to other parts of the U.K

Life expectancy, the number of years that a person can expect to live on average, is a single measure of population health which is used to monitor public health, health inequalities, and the outcome of health service interventions and to allocate resources.

Life expectancy in Scotland

The relationship between health and wealth is complex. One as yet unexplained paradox in Scotland is that, even when matched with their English counterparts of comparable socio-economic status, Scots are relatively less healthy over a range of indicators from age standardised mortality to specific disease outcomes (Figure 1).

Figure 1: Directly standardised mortality rates per 1,000 populations, 1990/92, by country and deprivation quintile.

These findings suggest that there are factors at work, other than simply wealth, which are making Scots unhealthier than people in other parts of the UK (Scottish executives 2007).

West of Scotland: A Description

West of Scotland is one of the eight electoral regions of the Scottish Parliament which were created in 1999. In terms of local government areas the region covers:

West Dunbartonshire

East Renfrewshire

Inverclyde

Most of Renfrewshire (otherwise within the Glasgow region)

Most of East Dunbartonshire (otherwise within the Central Scotland region)

Part of Argyll and Bute (otherwise within the Highlands and Islands region)

Part of North Ayrshire (otherwise within the South of Scotland region)

Within Scotland, life expectancy is lowest for people living in the west of Scotland. According to the Scottish household survey, healthy life expectancy at birth is 63.3years and 60.3years in females and males, respectively of greater Glasgow for example. These figures are the lowest in the UK (Scottish Public Health Observatory 2007).

Life in the West of Scotland

While parts of west Scotland have prospered with greater employment and better paid middle-class jobs, in other parts ‘worklessness’ and low income are commonplace. The issue for west Scotland is that greater reductions in disease have been achieved elsewhere and so west Scotland’s health has become worse relatively in comparison to other UK cities. Estimates of life expectancy suggest that people living in west Scotland not only live shorter lives, but succumb to disease and illness earlier in life. An explanation to this is that the health of an individual is largely determined by the circumstances in which he or she lives. Poor health is associated with poverty, poor housing, low educational status, unemployment and a variety of other life circumstances (Tackling Health Inequalities 2007). Health inequalities within Scotland and between the west of Scotland and the rest of the UK appear to be widening. In the 10 years to 2001, average male life expectancy in Scotland increased by 3% but the rate of increase was more rapid in the most affluent parts of the country, with the least affluent west areas falling behind (Whyte and Walsh 2004). The recent decline in death rates from common conditions such as cardiovascular disease has also been more rapid among the more affluent (Krawczyk 2004). Thus, despite the overall improvements, the west of Scotland still lags behind.

Economic factors

A number of trends related to the economy are also notable in West Scotland. There are now more women than men in employment in Glasgow and part-time work has grown to represent more than a quarter of all jobs. The service sector has grown to become the most important sector of the heart of West Scotland’s economy, while manufacturing employment has shrunk (Scottish Public Health Observatory 2007).

Social factors

It is common knowledge that those who smoke, become obese through eating a poor diet or through lack of exercise, and those who drink alcohol in excessive quantities or abuse drugs have poor health. Smoking levels in west Scotland have remained higher than those observed in other parts of the UK. Hanlon and his colleagues (2001) have shown that, by 1991, deprivation appears to explain only 40% of the excess deaths in Scotland (2001). Gillis and his colleagues (1988) have found that, at comparable daily smoking rates and levels of affluence, men in the West of Scotland are more likely to die from lung cancer than other populations in the UK or the US (Gillis 1988) (Figure 2).

Figure 2: Comparison of lung cancer mortality in Renfrew and Paisley with three major cohorts in US and UK.

The increasing impact of alcohol is undeniable: There are estimated to be more than 13,500 ‘problem alcohol users’ resident within Glasgow City, and since the beginning of the 1990s, there has been a striking increase in numbers of alcohol related deaths and hospitalisations especially in west Scotland. Simple projections of alcohol related deaths based on recent trends suggest that the number of alcohol related deaths in Greater Glasgow could double in the next twenty years (Figure 3) (Scottish executives 2007).

Figure 3: Alcohol related mortality in West Scotland: Greater Glasgow

The impact of the use of illicit drugs also serves to further decrease life expectancy in west Scotland in comparison with other parts of the UK. Between 1996 and 2004, drug related deaths in Greater Glasgow for example, rose by a third. There are estimated to be around 25,000 problem drug users in the West of Scotland, of whom more than 11,000 live in Glasgow (Scottish executives 2007). Life expectancy for drug addicts is expectedly very low and these figures will impact negatively on the overall life expectancy for the region.

In Glasgow and other parts of west Scotland, it is predicted that single adults will account for 49% of all households in the next ten years, while lone parent households may rise to make up almost one in two of households with children (Scottish Public Health Observatory 2007).

Obesity levels have risen exceedingly in west Scotland to the extent that in Greater Glasgow, for example, a fifth of males and almost a quarter of females are now estimated to be obese, with well over half classified as overweight. Trends in hospitalisation for diabetes, much of which is associated with obesity, have also risen dramatically in recent years (Scottish executives 2007).

A cultural issue

The ethnic minority population of west Scotland has risen in recent years and looks set to increase further, particularly taking into account the recent rise in the asylum seeker and refugee population. The influence of this trend on life expectancy within the region remains to be determined (Scottish Public Health Observatory 2007).

Provision of services

Despite improvements in overall house conditions and dramatic decreases in levels of overcrowding, housing-related problems persist for considerable numbers of residents of Greater Glasgow and the West of Scotland (Scottish Public Health Observatory 2007).

Recent research suggests other important ways in which the environment and life circumstances can affect biological processes which in turn can make individuals more susceptible to ill health. By following the progress of male civil servants over a 10 year period, Marmot and his colleagues found that mortality was approximately three times greater among the lowest grades than the highest (Marmot et al 1978). When deaths from heart disease were considered, the recognised risk factors of smoking, high blood pressure and elevated cholesterol levels could account for part of the differences between the groups. Other studies have confirmed that higher levels of risk of death in a working population are explained by health-related behaviours (Marmot 2000). There is mounting evidence that at least part of the unexplained increase in risk across the social classes is related to how the body responds to social stress. Available data shows that people are perhaps exposed to a high level of stress factors in west Scotland (Scottish Public Health Observatory 2007). Whether these stress types and levels are more or comparable to what is obtainable in other parts of the UK remains an unanswered question.

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References

Gillis CR, Hole DJ, Hawthorne VM, 1988.Cigarette smoking and male lung cancer in an area of very high incidence-II Report of a general population cohort study in the West of Scotland. J Epidemiology and Community Health 42: 44-48.

Hanlon P, Walsh D, Buchanan D, Redpath A (2001). Chasing the Scottish Effect. Public Health Institute of Scotland (now NHS Health Scotland) Glasgow 2001.

Marmot MG, Rose G, Shipley M, Hamilton PJ. (1978) Employment grade and Coronary Heart Disease in British civil servants. J Epidemiol Community Health. 1978 Dec; 32(4): 244-9.

Marmot MG (2000) Multi-level approaches to understanding social determinants in Berkman and Kawachi (eds) Social Epidemiology New York. Oxford University Press pp 349-367.

Scottish executives (2007) [Internet] Available at http://www.scotland.gov.uk/Topics/Statistics/Browse/Health/TrendLifeExpectancy

Scottish Public Health Observatory (2007): Healthy life expectancy in Scotland (Internet) (Accessed 15/04/07) http://www.scotpho.org.uk/web/site/home/Populationdynamics/Healthylifeexpectancy/hle_intro.asp

Tackling Health Inequalities – An NHS Response (2007) [Internet] (Accessed 15/04/07) www.sehd.scot.nhs.uk/nationalframework/Documents/TACKLING%20HEALTHINEQUALITIES240505

Whyte B and Walsh D. (2004) Scottish Constituency Profiles 2004.www.phis.org.uk/info/sub.asp?p=bbb

Krawczyk A. (2004) Monitoring Health Inequalities. Scottish Executive Health Department Analytical Services Division 2004.