Author: Andre Coleman

DIABETES

Diabetes Mellitus

The medical name for diabetes mellitus comes from the Greek word that means to siphon and the Latin word that means sweet like honey.

Diabetes mellitus is the name given to a group of conditions where there is too much glucose in the blood. It affects approximately 3% of the population. There are currently 1.4 million people with diabetes mellitus in the UK and it is expected that by 2010 that there will be a further 1 million. It costs the NHS 4.9 billion a year and affects a million people without them even knowing that they have it. (Devendra et al 2004)

RELATED BIOLOGY

Which organ is involved in the regulation of Blood Glucose Levels?

The pancreas.

Where is it located?

Retroperitoneally, within the curve of the duodenum and with the tail extending to the posterior surface of the spleen.

What type of tissue is it made up of?

Primarily glandular tissue that has both endocrine (Insulin) and exocrine (Pancreatic digestive enzymes) functions.

Which area of this organ is responsible for producing the hormones involved in the regulation of blood sugar levels?

The Islets of Langerhans

What are the main functions of insulin?

To reduce the levels of blood sugar by facilitating the uptake of glucose from the bloodstream into the cells.
It increases the rate of glycogen synthesis in the liver
It promotes the synthesis of fatty acids in the liver
It inhibits the breakdown of fatty acids in adipose tissue
It stimulates the uptake of amino acids
It increases cell permeability to potassium

(after Wills C et al 2003),

What type of substance is insulin made of? Circle the correct answer.

Carbohydrate Protein Fats

Name the calls that produce the hormone glucagon.

Alpha cells

What are the main functions of glucagon?

An insulin antagonist, it raises blood glucose levels by increasing hepatic glycogen breakdown.
It activates hepatic glyconeogenesis
It enhances lipolysis of triglycerides

One of these hormones has a Catabolic action and the other an Anabolic action.

State what these terms mean and identify which hormone falls into which category.

CATABOLIC

Catabolism is the breakdown of complex biological molecules into smaller component ones

Glucagon

ANABOLIC

Anabolism is the synthesis of complex biological molecules from simpler components.

Insulin

What are considered normal limits of blood sugar readings?

Fasting blood sugar 3.0 to 6.1 mmol/l (Client note: this is variable – I have quoted WHO figures – check what your tutor recommends and add it here!)
Those with levels of 6.1 to 7.0 mmom/l are said to have impaired glucose tolerance

(WHO 1985)

CLASSIFICATION OF DIABETES MELLITUS

State the 4 main categories.

To the client: this is a loaded question. There are many different classification schemes. I quote the categories as defined in RECD 1997

Type 1 diabetes mellitus

Type 2 diabetes mellitus

Gestational diabetes mellitus

Secondary diabetes mellitus – includes:

Genetic defects of beta-cell function

Genetic defects in insulin action

Diseases of the exocrine pancreas

Pancreatitis

Trauma/pancreatectomy

Neoplasia

Cystic fibrosis

Hemochromatosis

Endocrinopathies

Acromegaly

Cushing’s syndrome

Glucagonoma

Pheochromocytoma

Hyperthyroidism

Somatostatinoma

Aldosteronoma

Drug- or chemical-induced

Vacor†

Pentamidine

Nicotinic acid

Glucocorticoids

Thyroid hormone

Diazoxide

Beta-adrenergic agonists

Thiazides

Phenytoin

Alfa-interferon

Infections

Congenital rubella

Cytomegalovirus

Uncommon forms of immune- mediated diabetes

Other genetic syndromes sometimes associated with diabetes

Down syndrome

Klinefelter’s syndrome

Turner’s syndrome

Wolfram syndrome

Friedreich’s ataxia

Huntington’s chorea

Lawrence-Moon Beidel syndrome

Myotonic dystrophy

Porphyria

Prader-Willi syndrome (RECD 1997)

Diabetes mellitus can be due to a deficiency in insulin synthesis, secretion and also in some cases resistance. It is also thought that some diabetics may have a combination of both.

State 5 causes of Primary Diabetes Mellitus [aetiology].

Primary Diabetes Mellitus is subdivided into Type 1 and Type 2 varieties
Aetiology of Type 1 is multifactorial. It is auto immune and trigger factors can be genetic or environmental
Environmental causes include exposure to Coxsackie B virus, Rubella virus and Cytomegalovirus and exposure to cows milk.
Aetiology of Type 2 is also multifactorial. It includes genetic factors and environmental factors including: western diet, lack of exercise, obesity and hypertension (Todd W et al 2000)

NB Causes are still unknown, the above are thought to be trigger factors.

State 4 causes of Secondary Diabetes Mellitus.

Causes of secondary Diabetes Mellitus. There are several types of secondary Diabetes Mellitus including:

gestational diabetes
malnutrition-related diabetes
pancreatic diseases causing diabetes
endocrine diseases causing diabetes
drugs and chemicals causing diabetes
genetic conditions causing diabetes

Causes depend on the variety but include pregnancy, pancreatitis and various drugs including:

steroids
thiazide diuretics
phenytoin
diazoxide
streptozotocin

Pancreatic diseases can cause Diabetes Mellitus including:

acute and chronic pancreatitis
pancreatic carcinoma
cystic fibrosis
haemochromatosis

Disease processes can also cause secondary Diabetes Mellitus including:

acromegaly
Cushing’s syndrome
glucagonoma
phaeochromocytoma

Complete the following chart by using the recommended textbooks to compare the two main types of Diabetes.

TYPE 1 TYPE 2

Age at onset juvenile (<25) adult (50+)

% of all cases about 10% about 90%

Acute/insidious acute insidious

Body build lean obese

Genetic link high low

Prone to ketoacidosis yes no

Autoimmune Disease yes no

Treatment insulin diet, oral hypog’s

(Harris M 1995).

What age group in the general population has the highest incidence of Type 2?

Typically the 55-75 age range (Harris M 1995).

Certain groups in the general population have an increased risk of developing Type 2 and currently Diabetes UK is promoting a campaign to identify those most at risk earlier, so that they do not develop the major complications associated with this chronic disease. This is called the Missing Million Campaign.

Names these “At Risk” Groups

1. History of Heart Disease

2. History of Stroke

3. Obese (BMI>30)

4. Over 50s

5. Over 40s if from African Caribbean or Asian backgrounds

PATHOPHYSIOLOGY / CLINICAL FEATURES

DEFINITIONS

Define the terms:–

Gluconeogensis

Biosynthesis of glucose from sources other than glycogen

Glycogenolysis

Oxidisation of hepatic glycogen into glucose

Briefly describe how insulin deficiency / absence can cause the above processes to occur.

Insulin deficiency and/or low glucose levels promote the secretion of glycogen

Glucagon promotes the activation of the enzyme adenylate cyclase in the liver which triggers glycogenolysis. This is exactly the opposite process to gluconeogenesis and is mediated by a number of enzymes, the most significant being pyruvate kinease

Clinical Presentation – Complete the following

When blood glucose levels arise above a certain amount the renal threshold in the kidneys is exceeded and glucose spills over in to the urine. This is called glycosuria. This excess glucose sucks up the water so that it can flow from the body; this is called. Large amounts of urine are excreted. This is called polyuria. Excessive thirst is called polydipsia.

Excessive urination can result in lowered blood pressure and shock. Blurred vision can be caused by fluctuations in the amount floaters and water in the lens of the eyes during periods of dehydration. This is called osmotic myopia of the lens. Cells are not able to access glucose so they do not receive any fuel and as a consequence cannot produce energy. This triggers the brain to send a message of hunger. This excessive hunger is called polyphagia. Lack of energy makes the individual feel tired and weak. Other sources of energy are sought. Fat stores are broken down to provide energy. This may result in ketosis. Breakdown of fats results in the production of ketone bodies which are excreted in the urine. These are acidic and alter the blood PH.

There is a sweet smell of ketones on the breath. This is called ketotic respirations. Weight loss also results. Breakdown of protein stores results in muscle wastage. Skin infections are common e.g. Staph boils, erysipelas . Excess glucose suppresses the natural defence mechanisms and the action of the lymphocyte* cells. Electrolyte imbalances occur. The electrolyte potassium affects cardiac muscle causing arrythmias if deficient. Urea and electrolyte imbalances also result in the following symptoms 1. Dry mouth 2. Thirst 3. Muscle weakness 4. Lethargy 5. Cardiac arrythmias.

Numbness and tingling in the feet and cramps may result from peripheral neuropathy.

Client Note (*)– this is debatable – your tutor may have a specific answer in mid for this one

The recommendations of the W.H.O “Definition, Diagnosis and Classification of Diabetes Mellitus and its Complications” were formally adopted in the UK on the 1^st June “2000. The key recommendation, with regard to diagnosis is that fasting plasma glucose should be lowered from 7.8mmol/L to 7mmol/L.

What is an OGTT?

The Oral Glucose Tolerance Test

In the oral glucose tolerance test the patient, after fasting for 15 hours, drinks 75 g of glucose in 300 ml of water, over 5 minutes. Blood glucose is measured before the drink and after 30, 60, 90 and 120 minutes. Urine is collected before the drink, and after 60 and 120 minutes. Before the test, for a period of 6 hours, the patient should avoid smoking and drinking coffee.

There is a normal glucose tolerance if the venous plasma value is less than 7 mmol/l after the 2 hour period,

If after 2 hours after the glucose load the value is between 7 and 11 mmol/l, then there is impaired glucose tolerance.

If glucose is greater than or equal to 11.1 mmol/l this is diagnostic of Diabetes Mellitus

OTHER TESTS / SCREENING PROCEDURES

What is an HbA1c Test and why is it carried out?

This is a measure of glycosylated haemoglobin in the blood. It is a longer term measure of the degree of blood glucose control. (DCCRG 1993)

NICE target is 6.5 – 7.5 HbA1c

When would Urea and Electrolyte levels and Blood Gases be tested?

Normally only if metabolic imbalance is suspected, dehydration, renal involvement or occasionally as a screen for end-organ pathology (kidneys). U’s + E’s may be requested as part of a monitoring procedure. Blood gases may be useful if severe ketoacidosis is present.

When would a Full blood count, specimen check and chest X-rays be carried out?

This is more likely to be done as a screening or monitoring procedure (FBC or Urinalysis) unless there was an obvious clinical reason for doing them such as suspected anaemia etc. A CXR would be less likely to be carried out unless pulmonary or cardiac pathology was suspected (Client: this is contentious – as different clinicians have different rationales for these investigations.)

When would and ECG and Lipid levels be checked?

ECGs are likely to be checked on diagnosis, as a monitoring procedure or if arrythmias have been detected. They may also be done as a baseline investigation, with hypertension or if cardiac involvement is suspected.

Lipids are very likely to be abnormal in Diabetes Mellitus. They would be checked as a monitoring investigation at most visits. (DCCRG 1993)

When would a neurological assessment and inspection of the lower limbs be carried out?

Peripheral neuropathy and vascular impairment are common sequelae to Diabetes Mellitus and this would be actively considered and evaluated at each monitoring visit. Probably at least twice a year or more frequently if indicated. (DCCRG 1993)

Why are protein levels checked?

Proteinuria is a good indicator of diabetic nephropathy. Urine protein should be checked at every monitoring appointment. Serum proteins are less sensitive but if renal pathology is established then it may be a useful investigation. (DCCRG 1993)

When is urine checked for ketones?

In the presence of dehydration, clinical suspicion of ketonuria, pregnancy and as a monitoring procedure. (DCCRG 1993)

When would an eye inspection / photography be carried out and why is this done?

Retinopathy is a potent cause of visual impairment and commonly found in the diabetic state. It is commoner with poorly controlled Diabetes Mellitus and Type I diabetes mellitus. It is one of a number of ophthalmic complications seen with diabetes and should be actively screened for at every routine visit. (DCCRG 1993)

Why would a diabetic require having their blood pressure regularly recorded and what value is recommended?

Hypertension is a common cardiovascular complication of Diabetes Mellitus and is an independent risk factor in Type II diabetes mellitus. The presence of hypertension and Diabetes Mellitus coexisting in the same patient will increase the overall morbidity risk of both cardiovascular disease and cerebro-vascular accident.

A blood pressure reading below 130/85 mmHg is an ideal goal for most people with diabetes who don’t have kidney complications, but some authorities may recommend an even lower blood pressure goal (below 120/75 mmHg) for people with diabetes who have kidney complications. (DCCRG 1995)

State the main complications

Short-Term

Hypoglycaemia, dizziness, lethargy, impaired conscious level – drowsiness.

Hyperglycaemia, nausea, headache, malaise, ketosis.

Coronary heart disease,

Cardiovascular disease (macro- & microvascular disease)

Retinopathy which can lead to blindness

Nephropathy, which can lead to kidney failure and the need for dialysis

Neuropathy which can lead to, among other things, ulceration of the foot requiring amputation

Microvascular

Retinopathy,

Nephropathy

Neuropathy

These are generally related to HbA1c levels with the highest incidence of complication occurring when HbA1c levels are above 12%

Atherosclerosis

Arteriosclerosis

Both processes can lead to :

heart disease
stroke
peripheral vascular disease

(Stratton I et al 2000)

What are the SIGN Guidelines and name those that relate to Diabetes.

A set of guidelines originally drawn up by Scottish Intercollegiate Guidelines Network. They include:

visual impairment (SIGN 4)

pregnancy (SIGN 9)

children and young people (SIGN 10)

renal disease (SIGN 11)

foot disease (SIGN 12)

cardiovascular disease (SIGN 19).

Treatment- Give Principles

Type 1

Always insulin dependent.

Active treatment involves titrating insulin dose against glucose levels and then maintaining levels by manipulation of the insulin regime

Constant monitoring by either patient or physician

Constant vigilance for complications

Type 2

Depends on cause, but in most cases treatment involves lifestyle modification, weight loss, dietary carbohydrate restriction.

If not successful then progression to oral hypoglycaemics and occasionally to insulin.

Constant monitoring for the presence of complications

Reduction of secondary causes of complication i.e. cessation of smoking.

INSULIN

Insulin was identified as a substance that prevented diabetes in the early 1890’s. Banting and Best extracted insulin from the pancreas of a dog in 1921 and the first human received a crude extract of insulin from the pancreatic glands of cattle in 1922. Over the years there have been many advances in the synthesis of insulin. Insulin is a protein. Insulin injections are vital for people with Type 1 diabetes as they are unable to produce insulin them selves and also for many with Type 2 diabetes whose condition has progressed to a point where tablets and diet cannot control it adequately. The aim of this treatment is to ensure that blood glucose levels are maintained at less that 6.5 mmol/l. (Client: see previous comments)

Name 4 factors which influence control

1. Weight

2. Severity of disease process

3. Diet

4. Level of exercise

(Wing RR, et al 2001)

There are a variety of insulins available on the market.

The two main sources are animal and human.

How is human insulin produced?

By recombinant DNA technology inserting human genes into bacteria such as E.coli which then produces insulin in commercial quantities.

The majority of diabetics are now on Human insulin but unfortunately some people are still required to take animal insulin. Many drug companies are wishing to phase out animal insulin and at present Diabetes UK is campaigning to maintain these.

Why does insulin have to be given by injection?

Being a protein it cannot be given by mouth as it would be denatured in the gastro-intestinal tract.

What other route is being researched as an alternative?

A great deal of research has been lavished on alternative modes of drug delivery.

Transdermal routes do not give reproducible and consistent blood levels.

Oral insulin has not been a possibility in the absence of a specific peptide carrier system that would work in the gut.

Nasal administration has been tried, but there was low bioavailability and absorption enhancers were needed, in addition the clinical effect was only over a very short period.

Pulmonary routes appear to be promising but we already know that the pulmonary route is comparatively inefficient and requires ten times the amount of insulin to achieve the same clinical effect.

Initial clinical trials show no side effects and research is currently continuing. (Heinemann L 2001)

SIDE EFFECTS

Initially on the commencement of insulin people may experience sensitivity around the injection site.

How would you recognise this?

This is a form of allergy.

It can be local, in which case the local skin becomes red and itchy at the injection site.

It may (rarely) be systemic giving rise to a uticarial reaction, tachycardia and tachypnoea. Very rarely a patient may experience anaphylaxis.

Symptoms of hypoglycaemia may occur if too much insulin is injected or if not enough carbohydrate is consumed or if there is increased exercise without taking extra food.

Hard lumps under the skin may occur at injection sites if they are not rotated.

What is the correct medical term for these?

Lipodystrophy

The number of units prescribed is calculated depending on time of day, age, weight and lifestyle.

Typical dose is 0.7-1.0 units per Kg of body weight.

WARNINGS

Insulin should never be administered in cases of HYPO.

The body may get used to low levels of blood glucose and therefore the warning signs for HYPOs are reduced. Individuals who have lost these may be advised to raise their blood glucose levels slightly for up to 3 months to resensitise themselves to symptoms. Some people have also found that they have lost some or all of their symptoms of HYPO when transferring from animal to human insulin.

Insulin dosages may have to change if there is disease of the adrenal pituitary and thyroid glands and also in the presence of liver and kidney disease. Taking of steroids will increase the insulin requirement.

During illness, puberty or emotional trauma glucose levels can become elevated and therefore insulin doses require to be adjusted and more regular blood sugar monitoring is essential.

During pregnancy insulin requirements may decrease in the first trimester and increase in the second and third trimester.

The following drugs may increase blood glucose levels and therefore lead to a need for more insulin –

Steroids
Contraceptives
Asthma Inhalers

Some drugs lower blood glucose levels and therefore result in a reduction in insulin. These are:-

Aspirin
Beta blockers
Mono-amine oxidase inhibitors.

There are four categories of insulin. Give an example of each.

Very short acting [ANALOGUE] – e.g. Humalog.
Short acting [SOLUBLE, NEUTRAL] – e.g. Actrapid, Human Velosulin.
Medium and long acting [ISOHANE, PROTAMINE ZINC] e.g. Human Insulotard.
Combination of short and medium acting [MIXED, BIPHASIC] e.g. Human Mixtard.

Who would most likely be prescribed very short acting insulins?

The very unstable or out of control diabetic. Children more likely than adults.

How long before a meal does short acting insulin require to be injected?

Depends on type. Sol. Insulin starts working within 30-60 mins and lasts about 6-8 hrs. Other types such as Insulin aspart and insulin lispro both start working within 15 minutes and last for up to five hours.

The glucose rise after a meal typically begins within about 15 mins so the insulin should ideally be in the system to counteract it.

How often daily would you require to take the following insulins:-

Short acting – about 2-4 times a day( when stable)

Medium acting – about twice a day

Long acting – Once (or perhaps twice) a day

These answers depend on the age and size of the patient, as well as the severity of the disease process.

Why is short acting insulin sometimes given with medium acting insulin?

To give a smoother blood glucose profile and also to “fill in the gap” before the medium acting insulin becomes biologically active.

Where should insulin be stored?

In the fridge, but not frozen.

Briefly discuss the types of equipment that are used to administer insulin?

Commonest is still the disposable insulin syringe. Syringe should always be calibrated to match the insulin type. Most are U-100 now.

Other options include the pen devices (expensive but convenient and largely “fool proof”).

Jet injectors are occasionally seen, but not very common.

In hospital surroundings insulin pumps (drivers or infusers) can be used.

Ambulatory subcutaneous pumps are increasingly used to deliver continuous infusion. Very expensive but arguably capable of producing the best control.

(HSG 1997)

What advice would you give to a diabetic who is planning to go abroad on holiday with regard to their insulin?

Take plenty with you as your brand may not be available abroad.

Make sure you can keep it refrigerated.

Run your blood glucose levels slightly higher than you are used to a) because of probable increased exercise and b) to reduce the risk of Hypo whilst away from home.

Be extra vigilant with the blood sugar monitoring. Strange diet may have unexpected consequences.

ORAL HYPOGYCAEMICS

Below are the main categories of drugs. Give an example of each, including daily dosage and side effects?

Sulphonylureas

Chlorpropamide

250 mg (100 mg in the elderly)

This is a very long acting drug, usually taken once daily with breakfast. Alcohol may cause flushing to the face.

Biguanides

Metformin

Start at 500 mg twice a day or 850 mg once daily. The maximum daily dose is 2550 mg given in three divided doses

Gastrointestinal side effects are a common occurrence in people taking metformin. Problems often include bloating, flatulence, nausea, stomach cramps and diarrhoea

Occasionally a metallic taste in the mouth. Rare complication lactic acidosis

(Knowler WC et al 2002)

Prandial glucose regulator

Repaglinide

0.5 to 4 mg with each meal

Occasional gastro intestinal side effects

(Bokvist K et al 1999)

Alpha glucosidase inhibitor

Acarbose

50 mg then titrated against clinical effect.

Flatulence soft stools or diarrhoea.

Glitazones [new drug]

Rosiglitazone

4mg as starting dose increasing to 8mg if required

Possible toxic effects on the liver (theoretical rather than practical)

(Park JY et al 2004)

ACUTE COMPLICATIONS

The most common is Hypoglycaemia. It results from an imbalance between glucose intake, endogenous glucose and glucose utilisation.

A decrease in the blood glucose level normally leads to stimulation of catecholamine secretion. Identify 5 causes.

Insufficient carbohydrate intake
Excessive carbohydrate utilisation (exercise)
Intercurrent acute illness
Overdose of insulin
Other illnesses (viz glycogen storage diseases)
Alcohol

Name 8 clinical features that the patient experiences.

Pallor

Shaking

Perspiration

Fatigue

A feeling of weakness

Rapid heartbeat (Tachycardia)

Hunger

Agitation

Difficulty concentrating

Irritability

Blurred vision

Temporary loss of consciousness

Confusion

Convulsions

Coma.

What would be given in order to treat it?

Depending on severity. If minor, warm sweet (glucose containing) drinks

If major, IM Glucagon. Monitoring essential until fully recovered.

What is ketoacidosis?

A clinical condition almost invariably associated with low insulin levels. As a result, the blood glucose levels rise and the intracellular glucose levels fall. This requires the metabolism at a cellular level to be fuelled with fat derivatives rather than carbohydrates and this produces acidic ketones. These ketones normally require the presence of insulin for their catabolism. In its absence, they build up causing a metabolic acidosis and spill over into the urine when the concentration is high enough.

Identify 5 causes

Fluctuations in insulin regime
Intercurrent illness
Trauma
Reduction in carbohydrate intake
Dehydration +- severe exercise

State 10 clinical features of this clinical state

High blood sugar levels

Frequent urination (polyuria) and thirst

Fatigue and lethargy

Dry skin

Facial flushing

Nausea

Vomiting

Abdominal pain

Fruity odour to breath

Rapid, deep breathing (Air hunger)

Muscle stiffness or aching

Coma

The principals of management are:-

Prompt administration of insulin (usually on a sliding scale) to reduce the hyperglycaemia and ketonaemia

Replacing fluid loss (from polyuria and vomiting) usually by intravenous fluids

Restabilising electrolyte imbalances secondary to dehydration, metabolic acidosis and hypokalaemia.

Treatment for any underlying cause such as infection.

LONG TERM COMPLICATIONS

There are 10 steps that the diabetic patient can take to reduce his chances of developing complications.

Regular screening of BP and maintain at 140/80 or lower.
Regular HbA1c testing.
Maintain blood glucose levels between 4-7mmols/L before meals.
A

Health and Social Policy

Introduction:

In this essay we will discuss the health care plans and objectives, beginning with the definition of health and an analysis of the Constitution of the World Health Organization highlighting which are the areas of health care policy that seems to have received greatest attention. Health relates to physical and emotional well being and this is emphasized even further in the British idea of a welfare state were health relates to social policy and serves as one of the most important areas of governmental concerns. The health care sector of the UK government represented by the NHS and department of health is discussed extensively with health care programs, implementations of change within the health care settings, modernization, collaborative working approaches and a general improvement of health care services being emphasized as essential to realization of a successful health care policy in the UK. We also discuss obesity and smoking related problems within this general context of health care and social policy to show how polices or administrative aspects are related to health care services implementation in general

Defining Health and Healthcare

The World Health Organization defines Health as a state of complete mental, physical and social well-being and not just a condition free from disease and abnormality. The Constitution of the WHO is given as follows: Source: WHO constitution, 2005

THE STATES Parties to this Constitution declare, in conformity with the Charter of the United Nations, that the following principles are basic to the happiness, harmonious relations and security of all peoples:

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, and political belief, economic or social condition.

The health of all peoples is fundamental to the attainment of peace and security and is dependent upon the fullest co-operation of individuals and States.

The achievement of any State in the promotion and protection of health is of value to all.

Unequal development in different countries in the promotion of health and control of disease, especially communicable disease, is a common danger.

Healthy development of the child is of basic importance; the ability to live harmoniously in a changing total environment is essential to such development.

The extension to all peoples of the benefits of medical, psychological and related knowledge is essential to the fullest attainment of health.

Informed opinion and active co-operation on the part of the public are of the utmost importance in the improvement of the health of the people.

Governments have a responsibility for the health of their peoples, which can be fulfilled only by the provision of adequate health and social measures.

Worldwide Health Policies:

The legislative and administrative measures on health policy within the divisions of WHO are carried out by Health Policy Analysis Programme (HPA) which is now fully integrated into that of the European Observatory on Health Systems and Policies. Among the Health policies, the Health Impact Assessment (HIA) program adopted by the WHO is a major opportunity to integrate health concerns into all other related policies. HIA influences the decision-making process, and addresses all determinants of health, providing a new direction for participation and empowerment in health related issues and decisions. The overall aim of health policies is to track the use of HIA and to evaluate its effectiveness identifying what are the factors that can help in successful implementation. Along with the Health impact assessment which serves as a decision making tool, the health targets are instruments that can facilitate achievement of certain health policies as they represent commitments of reaching or fulfilling specified outcomes in health care objectives within a defined time frame. Health targets have been identified by the member states of the WHO European Union and OECD countries as tools for both policy formulation and implementation. Health targets have been the focus of several health related discussions and have contributed substantially to national and sub-national health polices (WHO report on Health Policy, 2005). In order to maintain the effectiveness of health target programs and health impact assessment, the European Observatory on Health Systems and Policies launched a three year multi-country project on the effectiveness of HIA in August 2004, and this was co-funded by the European Commission under the Public Health Programme. As far as the WHO Environmental Health Policy is concerned, most European countries have addressed national health policies through the national environment and health action plans (NEHAPs). The WHO reports that Poor environmental quality contributes to 25 -33% of global ill health. Environmental health policy involves collaborative working different sectors and ministries, and the policy-making procedure itself involves many stakeholders in the phases of planning and consultation (WHO report, 2005).

One of the important health policies is the evidence on health needs and interventions (ENI) Programme at the WHO Europe committee which helps assure staff and programmes which uses available evidence in providing advice and recommendations to member states. One of the goals of WHO is to ensure that there is a link between potential interventions programmes or policies and improvements in public health for the primary areas of advice and recommendations. The ENI programme is an important part of the European Advisory Committee on Health Research (EACHR)and is a division of the WHO advisory mechanism on health research, the primary role of which is to advise the WHO regional director for Europe on priorities and policies for development of research. WHO/Europe defines evidence as follows:

findings from research and other knowledge that may serve as a useful basis for decision-making in public health and health care. (WHO report, 2005)

The ENI policy makes WHO/Europe accountable toWHO’s Member Statesas WHO is expected to make use of best available evidence to provide advice and recommendations for health policies to member states and it would be unethical if WHPO could not keep up to the requirement.

Health and Social Policy in the UK

A Policy has been defined as:

‘The process by which governments translate their political vision into programmes and actions to deliver ‘outcomes’ – desired changes in the real world’

Modernizing Government White Paper (2001) – See DH report 2005, Health Policy

A more working definition for policy is as follows:

“A course of action with general applicability, requiring agreement at ministerial or ‘top of the office’ level”

(Professor Mike Richards 2003) See DH report 2005, Health Policy

The Department of Health suggests a Policy is usually developed within complex systems and with many deadlines and pressures; the DH Policy Collaborative is a unique collaborative approach in which health professionals and administrators need to work within the constraints of this restrictive and complex health environment and despite this be able produce benefits to the teams involved. In this period when the Department of Health (DH) is undergoing major organizational changes the Policy Collaborative complements the downsides of organizational change through promoting learning of new and innovative ways of addressing health issues.

With public demands up for a faster and better NHS and social service, and for improved levels of public safety, the health department is working towards developing the right leadership for the whole healthcare system and also to secure delivery (Stephens 2004; Castledine 2004).

The different health policy teams involved in health care implementation plans in different departments and their foci of work are given below:

Source: DH report on Health Policy, 2005

Policy teams involved in phase 1 of the DH Policy Collaborative

Policy team

Focus of the work as part of the Collaborative

Envisaged distinctive learning

Transplant team

Policy regarding tissue banking and the development of EU legislation

Working with the NHS and other stakeholders on a high-risk, esoteric issue with a European dimension

Cancer team

The introduction of the NHS Bowel Cancer Screening Programme

Developing a bowel cancer programme fit for implementation, whilst taking account of the issues for symptomatic services

Older people’s NHS/social care policy teams and workforce team

To ensure the availability of an integrated health and social care workforce to help older people to maintain their independence

Integration of workforce and service policy making and health and social care expertise

NHS Standards team

The preparation and publishing of statements of standards in relation to the provision of healthcare by and for English NHS bodies and cross-border SHAs

Policy making around a ‘bright idea’ with urgent deadlines and devil in the detail

Within the UK the NHS and Department of Health including the NHS executive set a national framework within which healthcare services are delivered and implemented. The health department uses several different policy measures and tools such as legislation, circulars and guidance, corporate contracts, financial levers and review meetings. Many national level departments and organizations such as the Audit Commission, Clinical Standards Advisory Group, parliamentary committees, the royal colleges and specialist associations, and the Mental Health Act Commission have an impact on research implementation (Klein 1989). As the DH reports, policy measures can have unanticipated consequences and can conflict with policy goals and their may be many obstacles to evidence based practice. There is a growing awareness for the need to identify solutions to problems within the NHS ad health policy initiatives and certain reforms on evidence based care also need evaluation.

The aims of the DH policy for improvement of healthcare services are given as follows (DH report on Health Policy, 2005)

• To support the policy teams in reaching their objectives set within a specified time period
• To include wider stakeholder involvement in the process of developing health policy further
• To make implementation the primary measure of the DH policy making process
• To help project teams and wider stakeholders with handling of issues relating to implementation throughout the policy development process.
• To ensure a coherent, integrated set of policies supporting an agreed strategy.
• To take learning and experiences from the policy implementation programme and use that learning to develop an improved policy development and management process
• To improve ways of working and learning from experiences within DH
• To be informed of the ‘policy management toolkit’
• To involve participation and support of colleagues in managing change in policies within the DH
• To develop measures that can demonstrate real progress of the ‘Excellence in Policy Making’ criteria set out in the NHS management objective.
• To give time for creative thinking and implementation of policies, testing small changes, using examples of best practice and achievement
• To be brave in testing new ways of working and striving for excellence in policy making and challenging the ‘status quo’.
• To take measured risks in the quest for continuous improvement in policies and to achieve an excellent policy.

Health policy within the UK is incorporated within the concept of a British welfare State. The concept of a welfare state refers to government policies and objectives that strive for an ideal model of provision where the state accepts responsibility for providing comprehensive welfare in all areas to its citizens (Brown, 1995). Within the UK, the idea of a welfare state suggests government objective to provide its citizens with guaranteed minimum income, social protection and provision of healthcare and other services at the best possible level. The health care sector of the UK government is largely controlled by the Department of Health with the policy decisions taken by the DH and implemented in association with the NHS. The key elements considered within a welfare state framework are Health, Housing, Welfare, Employment and Social Security.

Healthcare Management in the UK – Evidence and Studies

Eccles et al (2005) suggested behavioral changes of health care professionals as an important factor of policy implementation. They write that routine healthcare is a haphazard and unpredictable process and the usefulness of results of implementation is quite limited. Their study explored the role of a theory based framework and suggests that some methods that could be used to operationalize the framework in the context of designing and conducting interventions which are aimed at improving the use of research findings by individual healthcare professionals or teams. This particular research aims o understand the importance of theory based research of health care services and emphasize on the role of behaviors and attitudes of health care professionals in successful implementation of health care plans.

Cauchi (2005) highlights the challenges of integrated governance in the NHS with emphasis on collaborative and multi-agency working beginning from April 2005 and this according to him poses a challenge for all medical personnel with the nurses being given a leading and more responsible role in the management of clinical cases.

Glen (2004) offers a wide ranging analysis and scrutiny of roles of professionals in the medical, nursing and healthcare sectors. Glen suggests that a coherent vision of the future is needed to shape the future of the health workforce and also argues that this requires moving beyond the presumption that medical reforms are primarily focused on shifting the responsibilities of doctors on to the nurses. The paper claims that the implications of changes in health care roles and the ability of existing professionals to function effectively in the future will require education, training and human resource investments which are supportive of these changes implied. The need to have a clear definition of competence and a national standard to practice has been recognized as essential especially as nurses work in acute critical care settings. A correlation between levels of practice, education ad remuneration has been suggested as important in management of health care. The author suggests that educational programmes for senior nurses should be in coherence with educational programmes required for modernizing medical careers. The paper also suggests that the NHS modernization agenda and government’s health services improvement require certain changes within the culture at higher educational institutions, professional organizations, workforce development agencies and NHS trusts.

The NHS healthcare policy on obesity have made several suggestion on whether junk food advertisements should be banned (Patchell and Paterson 2004) to spreading awareness on the need to have a balanced diet (Price, 2005). A balanced healthy diet cuts down on risks of obesity, diabetes and heart diseases and keeps the citizens healthy and active if it is also combined with a healthy and active lifestyle and this approach has been taken up by the Department of Health to promote awareness and reduce health problems.

For reducing other problems such as smoking, several measures have been taken up by the DH and NHS and these policies and initiatives range from community interventions using co-ordinated, widespread, multi-component programmes to try and influence behavior that would help in preventing smoking in young adults (Sowden et al., 2003) to effectively addressing tobacco control within health promoting NHS trusts as part of its network of health promoting hospitals (HPH) (Quinn et al, 2001).

Conclusion:

In this paper approached the problem of health and health care implementation program using worldwide and British perspectives of welfare and discussed related social policies and plans for implementation of these policies. We discussed in brief, the objectives of the WHO and the NHS, the different departments involved in a new collaborative framework of healthcare within the NHS, the aims of health care policy and the associated problems and obstacles in implementation of these policies. In this context we discussed specific cases of health care policies related to two major problems of obesity and smoking. We suggested along with evidential studies that maintaining modernized health care services and collaborative approach in the NHS are key elements of future health care improvement plan and also involve promoting awareness of the needs of an active and healthy lifestyle in individuals. Thus along with governmental efforts, individual awareness are key to better health and future well being and seem to form an obvious part of social policy.

Bibliography

Annandale, Ellen. The sociology of health and medicine :a critical introduction /Ellen Annandale. Cambridge :Polity Press,1998.

Brown, John, The British welfare state :a critical history /John Brown. Oxford :Blackwell,1995.

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Patchell C, Paterson M. Should junk food advertisements be banned? Nurs Times. 2004 Jan 20-26;100(3):19.

Quinn J, Sengupta S, Cleary H. The challenge of effectively addressing tobacco control within a health promoting NHS Trust. Patient Educ Couns. 2001 Dec 15;45(4):255-9.

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Websites:

www.who.org

http://www.euro.who.int/healthtopics/HT2ndLvlPage?HTCode=health_policy

www.nhs.uk

www.dh.gov.uk – for DH reports

http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/MentalHealth/MentalHealthList/fs/en?CONTENT_ID=4031694&chk=87%2BXMM

A Critical Discourse Analysis of an article on the Israeli-Palestinian conflict

With increasing global media synergies, media studies seems to be gaining popularity in academia. One part of this discipline involves the close examination of media texts, be they written, spoken, or symbolic. To analyse texts linguistically, two dimensions are often considered: that of coherence, involving semantics or the construction of meaning, and that of cohesion, or syntax. This analysis can be done through various types of frameworks, including grounded theory, narrative semiotics, conversation analysis, and critical discourse analysis (CDA).

According to Barthes (1994), texts are always multi-dimensional and their meanings are uncovered differently depending on the reader, context and setting. Particularly in the media, they are interconnected to other texts, through means such as quotations, indirect or direct references, photos or historical facts; thus, it could be said that the media produce and reproduce not only texts, but from these, social meaning, which is then further reinforced through subsequent intertextuality (Ibid). Baudrillard (2000) adds that language itself is not necessarily powerful; what makes it more so is its use by powerful people—in today’s society, this being epitomised by the globalised media.

Critical discourse analysis is also sometimes referred to as critical linguistics (Wodak and Busch, 2004). Its roots lie in classical rhetoric, sociolinguistics and applied linguistics, and it is often used to illustrate the relationships that power, hierarchy, race and gender have with language (Fairclough, 1995). CDA is especially used today by academics that regard the discursive unit of a text to be one of the most basic units of communication. In fact, it is so widely used within scholarly environments that its legitimacy as a tool for examining power imbalances has been called into question by some, such as Billing (Wodak and Busch, 2004). He claims that because CDA has become so entrenched in academic discourses, it is thus subject to the same rituals and jargon as institutionalized knowledge, thus negating its potential to demystify the functions and intentions of CDA research. While these points are interesting and worthy of further exploration, the scope of this paper will not allow such examination, and furthermore, the assumptions of this paper are that CDA does, in fact, provide useful tools for critical analysis of media texts.

Thus, this paper will apply CDA to one article by Rory McCarthy in the Guardian newspaper, dated Wednesday, December 12^th, 2007. CDA will be employed to illustrate overt and underlying assumptions and beliefs, as well as the construction of social meaning.

Wodak and Busch (2004) claim that all texts can help reproduce and produce unequal relationships in power between men and women, racial groups, social classes, ethnicities, and nations. This can be done through the creation of the Other, which involves the textual representation of a group as being ‘perpetrators and agents’ operating outside the law (Ibid, p. 99). They further claim that after the terrorist attacks of September 11, anti-Islamic prejudices became more pronounced in the media, which characterizes Muslims in anonymous and criminal terms (Ibid). Additionally, ‘strategies of generalization, blaming the victim, and victim-perpetrator reversal are increasingly prominent’ (Ibid, p.100).

Analysing the text in the Guardian, these strategies do indeed seem to be in place. For example, actions attributed to Palestinians in the article often involved negative activities, whereas verbs related to the Israelis were more neutral:

Palestinian actions: firing rockets, accused, complained, fired back, were detained, were reported, appeared to be

Israeli actions: mounted an incursion, said, issue tenders for

It is only when the voice of the article shifts from the writer to a direct quote from a Palestinian official that any harsher activities are attributed to the Israelis: sabotage, place obstacles

The first sentence of the article is also interesting:

Israeli troops in tanks and armoured vehicles mounted an incursion into Gaza yesterday, killing at least six Palestinians….As many as 30 tanks and vehicles were involved in the operation……

Although the facts in the article imply that the Israeli army killed several Palestinians, it is important to note the syntax of the sentence removes direct responsibility from the army and pins it on ‘the incursion’. What is more, semantically, Israeli activity is never referred to as an ‘invasion’ or an ‘attack’ but is referred to as a mere ‘incursion’ or ‘operation’, or in the title, ‘Israeli tanks enter Gaza’. The Israelis have neutral ‘troops’ which are seeking ‘members of Islamic Jihad’ ‘a hardline Palestinian militant group’ or ‘Palestinian fighters’. These phrases imply that Palestinians are the only ones operating outside the law.

Although it is clear from the facts stated in the article that Israel is the aggressor in this particular case: (tanks enter Gaza, killing at least six Palestinian militants) the writer felt it was necessary to include the feeble reaction of the Palestinians to this ‘incursion’ even though no Israelis were killed or even injured by the Palestinian action: ‘Palestinian fighters fired back’. This structure implies a fair battle, although it is abundantly clear that Israel is the only party here with fierce military power.

The body count is kept low in the piece, which claims ‘at least six Palestinian militants’ were killed, rather than emphasizing a larger number, such as ‘about ten’ or even ‘half a dozen’ even though it seems certain that more than six were killed. Importantly, only the deaths of the ‘militants’ are mentioned here: it could be quite possible, then, that several hundred civilians were also killed.

Although ‘as many as 30 tanks and vehicles’ seems a high number, the fact that these machines, and not people, were semantically involved in the invasion diminishes personal, human responsibility for the invasion and deaths. The sentence: ‘most of the dead appeared to be members of Islamic Jihad…’ only slightly suggests the possibility that ‘innocent civilians’ were also killed in the attack, and the words ‘appeared to be’ mean that there was no firm confirmation that the dead were, in fact, members of Islamic Jihad. ‘Several Palestinians were reported injured’ is another vague sentence which refuses to offer quantitative data regarding how many were injured, or give information about who, exactly, gave this report, which makes it sound dubious. The simple use of Palestinians is also vague and fails to clearly state the possible injury of ‘innocent civilians’.

The situatedness of this text historically and politically supports Barthe’s claim that social meaning is reinforced through intertextuality. There is no mention or even implication that the Palestinians are, in fact, fighting to free their homeland from an illegal oppressor, and there is also no overt mention of the illegitimacy and illegality of Israel’s acts: for example, by choosing the word ‘settlement’ in the sentence: ‘…an Israeli decision…to issue tenders for more than 300 houses in the East Jerusalem settlement of Har Homa’ allows for a form of Israeli ‘newspeak’ to whitewash what is essentially an illegal occupation that has destroyed the natural environment of the Abu Ghneim forest and stolen more land from the Palestinians (poica.org) . Moreover, there is no mention of how Israel has repeatedly been condemned by the United Nations for its illegal ‘settlements’ such as that in Har Homa (Ibid). In fact, after reading such an article as the one in the Guardian, readers could well be left wondering just why the Palestinians have been ‘firing rockets’ or why they have been ‘detained’ or have become ‘militants’, although the article makes Israeli grievances easier to understand by employing the very lexis just mentioned previously (as well as: Islamic Jihad, accuse, complain). Thus, victim-perpetrator relationships are skewed by the semantics and syntax used in the article.

There is no doubt that Israel is an oppressive power and disturbing presence in the Middle East, yet it is rarely portrayed as such in the media. There could be several reasons for this, but one may reside in Foucault’s notion of discourse, which states that discourse is an institutionalized way of thinking about something, or in other words, it defines the limits of what constitutes acceptable speech on a topic. Discourse is thus related to power, and defining discourses are often taken to be defining of reality itself (Foucault, 1997).

Wodak and Busch (2004) state that the dominant discourse on Israel generally supports this state, possibly as a kind of backlash after the blatantly anti-Semetic propaganda that was once so common in Europe before and during the Second World War, but also because power relationships have shifted: Israel is a key ally to the most powerful nations in the world, including the United Kingdom and the United States, and as mentioned by Baudrillard (2000), the powerful use language to keep power structures intact.

The final sentence of the article illustrates this point well:

Although Israeli and Palestinian leaders and negotiators have been meeting regularly for months, today’s meeting marks the beginning of talks intended eventually to bring the creation of an independent Palestinian state.

This paragraph implies that talks to create a Palestinian state are just beginning, and that a Palestinian state could possibly be created for the first time. Both of these assumptions are erroneous. Without delving too deeply in the politics of the Middle East, it is generally known by most that shortly after Israel’s inception, talks to negotiate Arab/Jewish territory have gone on almost continually.

Secondly, in 1919 Palestine was provisionally recognized as an independent nation by the League of Nations in League Covenant Article 22(4) as well as by the 1922 Mandate for Palestine that was awarded to Great Britain. This recognition continues today due to the conservatory clause found in Article 80(1) of the United Nations Charter (Boyle, ) . Thus, ‘the creation of an independent Palestinian state’ negates the fact that such a nation has already existed. Incidentally, legally, Israel does not have fixed and permanent borders (except most recently with respect to Egypt) and yet it is generally considered by the media to be a legitimate state (Ibid).

What is important to note here is that history is practically being rewritten in the Guardian text. Van Djik’s (1990) explanation as to how this is possible is closely connected to Barthes (1994) and Baudrillard’s (2000) ideas mentioned above. He claims that journalists and media consumers own ‘mental models of the world’ and thus any text that is understood contains only the ‘tip of an iceberg of information’ (Ibid, p.6). The tip is expressed through syntax and semiotics, but the rest is assumed to be supplied by the underlying knowledge of previous texts. For this reason, Van Djik states that ‘the analysis of the implicit…is very useful in the study of underlying ideologies’ (Ibid, p.6).

In conclusion, this paper has illustrated how critical discourse analysis can be a useful tool for unearthing implicit meanings in text, through the analysis of syntax, semiotics, and assumptions implicit through intertextuality. Furthermore, it has given examples of how current discourses of power can influence the content of media texts. There is no doubt that after several years of exposure to standard news formats, broadcasters and audiences alike are prone to overlooking the covert messages in news content. For this reason, a critical perspective is certainly important, and furthermore, if news texts are assumed to be a system of encoding reality, then the agendas of the encoders must be understood before a thorough deconstruction of their messages can be possible.

Appendix 1

Israel tanks enter Gaza on eve of peace talks

Rory McCarthy, Jerusalem

Israeli troops in tanks and armoured vehicles mounted an incursion into Gaza yesterday, killing at least six Palestinian militants on the eve of a new round of peace talks. As many as 30 tanks and vehicles were involved in the operation in southern Gaza, near the Sufa crossing and close to the town of Khan Yunnis. Several Palestinians were reported injured.

The Israeli military said it was a routine operation against militants, but Palestinian officials accused Israel of trying to disrupt the peace talks. Israeli and Palestinian negotiators were to meet today at the King David hotel in Jerusalem to start a new process of talks in the wake of the Middle East conference in Annapolis late last month.

Palestinian officials have already complained about an Israeli decision last week to issue tenders for more than 300 houses in the East Jerusalem settlement of Har Homa. ‘The Israeli policy of escalation aims to sabotage and place obstacles before the negotiations even before they start,’ said Nabil Abu Rdeneh, a spokesman for the Palestinian president, Mahmoud Abbas.

Most of the dead appeared to be members of Islamic Jihad, a small but hardline Palestinian militant group which ahs been responsible for firing makeshift rockets from Gaza into Israel. Around 60 Palestinians were detained in what was the largest Israeli operation in months. Palestinian fighters fired back and hit one Israeli tank.

Although Israeli and Palestinian leaders and negotiators have been meeting regularly for months, today’s meeting marks the beginning of talks intended to eventually bring the creation of an independent Palestinian state.

References

Barthes, R, (1994) Mythologies, Hill and Wang, London

Baudrillard, J, (2000), Routledge Critical Thinkers, Routledge Publishing, London

Boyle, F, (2007) Elements of Palestinian Statehood, in The European Journal of International Law, Vol.18 No 3

Fairclough, N (1995) Critical Discourse Analysis, Longman, Harlow.

Foucault, M (1997) The Politics of Truth, Semiotext(e), France

McCarthy, R, Israel tanks enter Gaza on eve of peace talks, in the Guardian, December 12, 2007

Van Djik, T. A. (1990). Discourse & Society, in Van Djik, T. A (ed.), (2007) A New Journal for a New Research Focus, Volume 18 No 2, Sage Publications, London

Wodak, R and Busch, B, (2004) Approaches to Media Studies, in Downing, J, The Sage Handbook of Media Studies, Sage, London

http://www.poica.org/editor/case_studies/view.php?recordID=1207

Major depressive disorders destroy a person’s ability to enjoy many ordinary parts of life. All of the activities which many consider normal such as eating, sleeping, working and playing, become empty for the depressed individual. Research has attempted to address the prevalence of depression and pharmacological treatments have often been the first line of defence in its treatment. Medications, however, usually have unpleasant side-effects and so psychological or talking therapies are often preferred by patients. One type of therapy that has been found to be effective in the treatment of depression is cognitive-behavioural therapy (CBT). This essay will first address the basic features and use of CBT in the treatment of depression before moving on to behavioural activation therapy which effectively uses a subset of the approaches used in CBT, finally the approaches will be compared and contrasted.

CBT is often referred to as though it was a single treatment, but it actually comprises a number of approaches from both the cognitive and behavioural theories. Aaron Beck, the grandfather of cognitive therapy, describes the cognitive aspect of the approach as targeting the way that people interpret the events around them (Beck, 1991). In depression, within the theory, people are seen to have beliefs that are essentially maladaptive to the world around them. Their powers of interpretation have a number of significant biases which contribute towards their depression. In order to treat depression, then, cognitive therapy attempts to challenge the way that patients interpret the world. This is done by working through the various beliefs which are considered maladaptive by the therapist and testing them against the real world.

Along with the cognitive aspects of CBT, behavioural approaches are also used. The behavioural aspect is based on ideas put forward by behaviourist psychologists such as B. F. Skinner, which describe people’s behaviour in terms of whether it is encouraged or discouraged by the environment. Hollon, Thase & Markowitz (2002) point out that one of the assumptions of the therapy is that people who are depressed receive a high degree of reinforcement for their depressive thoughts and a low degree for their non-depressive thoughts. Behavioural strategies are particularly useful in CBT for allowing the patient to carry out behavioural experiments in which they are encouraged to try out different types of behaviour and check how the outcomes marry with their beliefs. The aim in CBT is that the evidence of these experiments will help to convince the patient that, through testing their contact with reality, they will come to adjust those maladaptive beliefs. The typical belief that a depressed person has is that they are unlikely to succeed in many activities because of their have low expectations of their own abilities.

Hollon et al. (2002) emphasise that the aim of CBT is not to think ‘happy thoughts’, but rather to try and encourage the patient to become more accurate in the way they perceive the world. One of the most important aspects of CBT is encouraging the patient themselves to continue to use the strategies learned in CBT after the therapy has finished. Compared to psychodynamic therapies, CBT is relatively brief at around 14-16 one-hour sessions, and so these learned strategies and changed beliefs need to be maintained after the contact with the therapist is finished.

A large range of different studies have been carried out into the effectiveness of the use of CBT. Gloaguen, Cottraux, Cucherat & Blackburn (1998), for example, used a meta-analytic approach to examine the evaluation of cognitive therapy (CT) in 78 studies between 1977 and 1996. Overall this meta-analysis showed that CT was effective in cases of mild to moderate forms of depression when compared to placebo or control conditions. There was even some evidence that the use of CT produced a better outcome than the use of anti-depressant medications and other psychotherapies. Criticisms of this research were aimed at the fact that this meta-analysis amalgamated wait-list groups with placebo groups, which, Parker, Roy & Eyers (2003) argue, are not equivalent. Further, the effectiveness of the ‘other therapies’ category to which CT was compared, was weakened by the inclusion of weaker types of intervention such as ‘bibliotherapy’. This research has also been questioned by Wampold, Minami, Baskin & Tierney (2002) who, in reanalysing the meta-analytic data taking into account the control treatments, found that CT was not superior but equivalent to other forms of psychological therapy.

The results discussed so far were mainly obtained for the treatment of mild to moderate depression. In the treatment of severe depression, however, the use of CT compared to pharmacological interventions has been questioned. Elkin, Gibbons, Shea, Sotsky, Watkins, Pilkonis & Hedeker (1995) carried out a large study and found that CT was less effective than medication and only as effective as the placebo combined with clinical management. Hollon et al. (2002), however, point out that this, despite being a large influential study, was one of the only published studies that questioned the effectiveness of CT. Hollon et al. (2002) argue that the results were weak because of the lack of therapist training in two of the three sites at which the CT was given. In comparison, Jarrett, Schaffer, McIntire, Witt-Browder, Kraft & Risser (1999) in a placebo-controlled, double-blind study looked at the use of CT compared to the most effective medication in the treatment of atypical depression. This study found that CT was as effective as the medication and better than the placebo in the treatment of atypical depression. The criticism of this study is that not all of the patients selected were suffering from severe depression, although many were.

DeRubeis, Gelfand, Tang & Simons (1999) carried out a mega-analysis^[1] of severely depressed patients using the data from sub-groups of studies already carried out. Included in the analysis was the data from the study carried out by Elkin et al. (1995). Aggregating the results they found that, in fact, in this patient group with severe depression, CBT was as effective as medication. Indeed there was a small, but non-significant advantage for CBT over medications. This backed up findings from Hollon, DeRubeis, Evans, Wiemer, Garvey, Grove & Tuason (1992) who had found a small, although non-significant, advantage for CBT over a pharmacological intervention. Hollon et al. (2002) argue that it is the expertise of the therapist that is most important, and those studies that do not support the use of CT or CBT tend not to involve the best trained therapists.

So far, the way in which the studies have been discussed has treated depression as though the only variable in its makeup is its severity. Parker et al. (2003) point out that many of the studies report headline findings of the overall efficacy of the treatment of depression by CBT rather than examining the gradations in between. In fact, instead of talking about the severity of depression, Parker et al. (2003) suggest it is better to consider the different types of depression. Parker et al. (2003) split depression into psychotic, melancholic and other non-melancholic depressive disorders. The first two categories, Parker et al. (2003) argue, are considered more biological in origin and are, therefore, more responsive to pharmacological treatment. It is suggested that the last, more heterogeneous group of those with severe non-melancholic depression, are more responsive to psychotherapies, especially CBT.

Taking a closer look at the way in which CBT works reveals a more ambivalent picture. MacLeod (1988) points to the distinction in psychotherapies between what are called common and specific factors. The common factors that have been found to be effective in all types of therapy include the therapist’s warmth, acceptance and empathy. Examining this idea, Strupp (1996) found that across different psychotherapies, as much as 85% of the variability could be accounted for by common factors. In other words, it doesn’t matter which therapeutic modality is used, the simple fact that someone is taking an interest and being supportive has a beneficial effect. In addition, Ilardi & Craighead (1994) point out that many of the major improvements during CBT occur before cognitive restructuring techniques are introduced. This also suggests that the importance of non-specific factors of the psychotherapy is paramount.

A further factor which needs to be considered in the efficacy of CBT is the prevention of relapses. While patients often show good response to CBT, the suggestion is that, once the therapist’s support has been removed, a patient can easily regress. Gloaguen et al.’s (1998) study suggested only tentatively that, when followed up, patients who had been treated with CBT were better able to maintain their gains than those treated with pharmacological treatments. Fava, Rafanelli, Grandi, Canestrari & Morphy (1998) examined a relatively small sample of patients (40) in a follow-up study to compare the standard clinical management^[2] with CBT. After 4 years, the CBT was shown to have a significant preventative effect against depression; however, this had faded at the 6 year follow-up. In similar work, Scott, Teasdale, Paykel, Johnson, Abbott, Hayhurst, Moore & Garland (2000) looked at the effect of using CT on those with residual depressive symptoms and compared it to clinical management. The authors found that CT did significantly reduce residual depressive symptoms although there were some methodological problems with the study including the fact that the patient’s response could be a placebo effect as well as the authors suggesting that the effects seen might not have clinical significance – in other words, they might not be practically useful. Parker et al. (2003) argue that, overall, these studies show only limited support for CT in the prevention of relapses and, in any case, do not provide the most useful comparisons as they do not compare CT to other psychotherapeutic or psychopharmacological approaches.

Overall, Parker et al. (2003) argue that the efficacy of CBT and/or CT for all types of depression has yet to be established definitively, despite major positive findings in much of the research. Despite their critical approach to CT, Parker et al. (2003) do admit that CT is useful in certain situations. The problem for the research is identifying the situation – specifically those with what is labelled ‘depression’ do not represent a homogenous group and therefore when interventions are tested, it is not surprising that the results are equivocal.

All of the research discussed so far has addressed cognitive behavioural or purely cognitive models of treatments for depression. The behavioural components of this type of therapy are normally used to augment the cognitive approach, with purely behavioural approaches having lost favour after the 1970s. As Parker et al. (2003) point out, though, there are problems with a reliance on cognitive strategies. They find little evidence for some of the basic assumptions of cognitive therapy, such as the centrality of global negative views of self and the world (Beck, Rush, Shaw & Emery, 1979). One example of this is the work of Ingram, Miranda & Segal (1998) who failed to find any support in the literature for cognitive vulnerability, an important factor in the model. While this does not disprove the model, Parker et al. (2003) argue that, overall, the evidence is somewhat inconclusive. For this reason and because of the increasing pressure to provide brief cost-effective interventions for depression, there is now an effort to examine the efficacy of more behavioural methods, specifically behaviour activation (BA) therapies.

As Hopko, Lejuez, Ruggiero & Eifert (2003) point out, the roots of BA come from the radical behaviourism of Skinner (1953) who argued that depression was caused by those reinforcements that encourage healthy behaviour being, for one reason or another, interrupted in the social environment. At its most fundamental, then, those behaviours that are seen as ‘healthy’ are not reinforced, or may even be punished, while ‘unhealthy’ behaviours are reinforced. Jacobson, Martell & Dimidjian (2001) claim that it is possible that CT and CBT do also tap into these ideas (as discussed earlier) but also place considerable emphasis on cognitive models. Jacobson, Martell & Dimidjian (2001) see BA theories as concentrating more on the environment than the internal processes of the individual, and therefore aid in the de-medicalisation of depression. The empirical roots of BA can be seen in the Harmon, Nelson, and Hayes (1980) who found that they could prompt depressed patients into activity using a beeper and increase their activity by more than double. Similarly, Zeiss, Lewinsohn & Munoz (1979) found that depression could be alleviated to a similar level as comparable interventions through the increasing of patient’s activity levels.

BA concentrates, then, on behaviour, returning to formulations developed earlier, but with some modern enhancements. At heart, though, BA relies on some basic behaviourist principles. Extinction is used to attempt to remove those behaviours that lead to depressive feelings through the encouragement of approach behaviour (Hopko et al., 2003). At first, in BA, rigid structures are used to attempt to inculcate new behaviours but over time fading is used to minimise these structures as new behaviours become embedded. Shaping is also used in BA, although to a lesser extent than either extinction or fading. The reason it is not seen as shaping in BA is that the new target behaviours that the therapist hopes to embed in the patient are considered to already be there within the client. Shaping is sometimes required to reach more difficult goals that require a number of steps.

Many of the ideas used in BA rely on classical behaviourism, but there are a number of major differences that Hopko et al. (2003) identifies. Firstly, BA approaches concentrate more on the functional aspects of a person’s behaviour, i.e. those aspects of their environment that reinforce the depressive state. Secondly, close attention is paid in BA to the ongoing assessment of whether particular behaviours are related to depressive symptoms. Thirdly, instead of targeting thoughts, BA targets behaviours specifically and places this as the focus of change for the patient, with the assumption of the model being that these changes will flow back into affective states as well as thoughts. Finally, BA affects the environmental component of depression by influencing a person to change their behaviour and so experience positive consequences.

Early work examining the efficacy of BA as a treatment for depression produced some encouraging results. Jacobson, Dobson, Truax & Addis (1996) attempted to separate out the BA aspects of CT and compare them with each other. The results showed that there was little difference between the groups that received just the BA aspects of CT and those that received the full CT treatment. What was also encouraging for the researchers was that although the BA treatment did not specifically address the idea of negative automatic thoughts – an extremely important component of the cognitive model of depression – they showed the same levels of reduction across both the BA and CT treatment groups.

Hopko and his colleagues went on to develop a specific manualised intervention aimed at depression called the Behaviour Activation Treatment for Depression (BATD) (Lejuez, Hopko & Hopko, 2001). At heart this method uses the matching law developed by Hernstein (1970). This states that the amount of behaviour a person tends to give to a particular activity is directly proportional to the amount of reinforcement they receive while conducting that activity. The therapist therefore encourages the patient to change their behaviour, with much of the expected change happening outside the therapy sessions. The advantage of this type of treatment is that it is generally delivered over 10 to 12 sessions and is therefore shorter than CBT. In addition, sessions are often reduced in length towards the end of the intervention (Lejuez, Hopko & Hopko, 2001).

In this technique, once the baseline levels of activity and depression have been assessed, the patient moves on to look at the possible activities that could be targeted for increase. Examples provided are such things as the improvement of family and social relationships or courses of education or training that might be embarked upon. The emphasis at all times is focussing on those activities that the patient would find pleasurable and then these are ranked in order of difficulty. The patient also provides them self with rewards if their targeted behaviours have been completed (Lejuez, Hopko & Hopko, 2001). Week by week the patient, with the help of the therapist, moves up through the hierarchy of activities, as they slowly get more and more difficult. The extra exposure to positive reinforcement for healthy behaviours is, within the theoretical model, supposed to encourage them to continue performing these behaviours and so decrease their depression.

Hopko, Lejuez, LePage, Hopko & McNeil (2003) used BATD in a small sample of 25 patients at a psychiatric in-patient facility. BATD was compared to the standard supportive treatments that the in-patient hospital provided. The results showed that, with the BATD requiring fairly low levels of training to implement, significant reductions in depression as measured on the Beck Depression Inventory (Beck & Steer, 1987), such that the effect size and also the clinical significance of the intervention were substantial. In work that looked at both depression and anxiety in a case study, Ruggiero, Morris, Hopko & Lejuez (2005) also found support for the use of BATD.

In their most recent research, Hopko, Bell, Armento, Hunt & Lejuez (2005) have examined the use of BATD in the treatment of depression in cancer patients in a primary care setting. This study was a preliminary clinical trial and therefore only included 6 participants. Each of these participants was suffering from major depression and being treated for cancer. After the BA intervention a variety of different measures showed considerable improvement with significant effect sizes. On top of this, the intervention was reported to be relatively easy to implement and did not require a large amount of resources. The advantages were maintained three months after the intervention and there was also an improvement in the amount of bodily pain.

BA, while being based on techniques that have been long-established, in its current formulation is actually a relatively new method. As such, the types of evaluation that have been carried out to assess its efficacy are, as yet, fairly limited. While the work of Hopko and colleagues certainly provides some interesting and encouraging results, there are not the same scale of studies carried out into BA that have been carried out into CT and CBT. The CT and CBT studies include more than a handful of controlled, double-blinded studies which are the gold-standard of health psychology research. In comparison, the studies into BA have mostly small numbers of participants and do not provide the same rigorous comparisons as those carried out into CT and CBT. The reason for this is that the research into BA is still at an early stage and consequently, even though it is encouraging, cannot hope to provide the same solid evidence base as is already available to CBT.

In conclusion, it can be seen that CBT and CT have a huge and growing evidence base that is largely positive. These cognitive based interventions have been repeatedly shown to be effective in the treatment of mild to moderate depression. For the treatment of severe depression there are some questions as to whether these cognitive methods are effective. Some researchers have suggested that the studies that have looked at CT and CBT have treated those with depression as though they are heterogeneous group – which they are not. Future research should aim to look at which types of intervention are best suited to which types of depression. In comparison, BA shares many roots with CBT but only pays attention to the cognitive component indirectly. In this intervention the changing of behaviour is paramount, and the cognitive changes are thought to flow from these. One of the strongest advantages for BA despite its relative lack of supporting evidence is the easy with which it can be implemented. The evidence base for BA is clearly not as strong as that for CBT and so it will require more research before it can be confidently endorsed.

References

Beck, A. T., Rush, A. J., Shaw, B. F., Emery, G. (1979) Cognitive Therapy of Depression. New York: Guilford.

Beck, A. T., & Steer, R. A. (1987). Beck Depression Inventory: Manual. San Antonio, TX: Psychiatric Corporation.

Beck, A. T. (1991) Cognitive therapy. A 30-year retrospective. American Psychologist, 46(4), 368-75.

DeRubeis, R. J., Gelfand, L. A., Tang, T. Z., Simons, A. D. (1999) Medications versus cognitive behavior therapy for severely depressed outpatients: mega-analysis of four randomized comparisons. American Journal of Psychiatry, 156(7), 1007-13.

Elkin, I., Gibbons, R. D., Shea, M. T., Sotsky, S. M., Watkins, J. T., Pilkonis, P. A., Hedeker, D. (1995) Initial severity and differential treatment outcome in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology, 63(5), 841-7.

Fava, G. A., Rafanelli, C., Grandi, S., Canestrari, R., Morphy, M. A. (1998) Six-year outcome for cognitive behavioral treatment of residual symptoms in major depression. American Journal of Psychiatry, 155, 1443–1445.

Gloaguen, V., Cottraux, J., Cucherat, M., Blackburn, I. M. (1998) A meta-analysis of the effects of cognitive therapy in depressed patients. Journal of Affective Disorders, 49(1), 59-72.

Harmon, T. M., Nelson, R. O., Hayes, S. C. (1980) Self-monitoring of mood versus activity by depressed clients. Journal of Consulting and Clinical Psychology, 48, 30-38.

Hernstein, R. J. (1970) On the law of effect. Journal of the Experimental Analysis of Behavior, 13, 243-266.

Hollon, S. D., DeRubeis, R. J., Evans, M. D., Wiemer, M. J., Garvey, M. J., Grove, W. M., Tuason, V. B. (1992) Cognitive therapy and pharmacotherapy for depression: singly and in combination. Archives of General Psychiatry, 49, 774–781

Hollon, S. D., Thase, M. E., Markowitz, J. C. (2002) Treatment and prevention of depression. Psychological Science in the Public Interest, 3, 39-77.

Hopko, D. R., Bell, J. L., Armento, M. E. A., Hunt, M. K., Lejuez, C. W. (2005) Behavior Therapy For Depressed Cancer Patients In Primary Care. Psychotherapy: Theory, Research, Practice, Training, 42(2), 236–243.

Hopko, D.R., Lejuez, C. W., LePage, J.P., Hopko, S. D., McNeil, D. W. (2003) A brief behavioral activation treatment for depression. A randomized pilot trial within an inpatient psychiatric hospital. Behavior Modification, 27(4), 458-69.

Hopko, D. R., Lejuez, C. W., Ruggiero, K. J., Eifert, G. H. (2003) Contemporary behavioral activation treatments for depression: procedures, principles, and progress. Clinical Psychology Review, 23(5), 699-717.

Ilardi, S. S., Craighead, W. E. (1994) The role of nonspecific factors in cognitive-behavior therapy for depression. Clinical Psychology: Science and Practice, 1, 138–156.

Ingram, R. E., Miranda, J., Segal, Z. V. (1998) Cognitive Vulnerability to Depression. New York: Guilford.

Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E. (1996) A component analysis of cognitive-behavioral treatment for depression. Journal of Consulting and Clinical Psychology, 64, 295-304.

Jacobson, N. S., Martell, C. R., Dimidjian, S. (2001) Behavioral activation treatment for depression: Returning to contextual roots. Clinical Psychology: Science and Practice, 8, 255–270.

Jarrett, R. B., Schaffer, M., McIntire, D., Witt-Browder, A., Kraft, D., Risser, R. C. (1999) Treatment of atypical depression with cognitive therapy or phenelzine: a double-blind, placebo-controlled trial. Archives of General Psychiatry, 56(5), 431-7.

Lejuez, C. W., Hopko, D. R., Hopko, S. D. (2001) A brief behavioral activation treatment for depression: Treatment manual. Behavior Modification, 25, 255–286.

MacLeod, A. (1998) Therapeutic interventions, In M. W. Eysenck, (Ed.), Psychology, an integrated approach. London: Prentice Hall.

Parker, G., Roy, K., Eyers, K. (2003) Cognitive behavior therapy for depression? Choose horses for courses. American Journal of Psychiatry, 160(5), 825-34.

Ruggiero, K.J., Morris, T.L., Hopko, D.R., Lejuez, C.W. (2005) Application of Behavioral Activation Treatment for Depression to an adolescent with a history of child maltreatment. Clinical Case Studies, 2(10), 1-17.

Scott, J., Teasdale, J. D., Paykel, E. S., Johnson, A. L., Abbott, R., Hayhurst, H., Moore, R., Garland, A. (2000) Effects of cognitive therapy on psychological symptoms and social functioning in residual depression. British Journal of Psychiatry, 177, 440–446.

Skinner, B. F. (1953) Science and human behavior. New York: Free Press.

Strupp, H. H. (1996). The tripartite model and the Consumer Reports study. American Psychologist, 51(10), 1017-1024.

Wampold, B., Minami, T., Baskin, T., Tierney, S. (2002) A meta-(re)analysis of the effects of cognitive therapy versus ‘other therapies’ for depression. Journal of Affective Disorders, 68, 159–165.

Zeiss, A. M., Lewinsohn, P. M., Munoz, R. F. (1979) Nonspecific improvement effects in depression using interpersonal skills training, pleasant activity schedules, or cognitive training. Journal of Consulting and Clinical Psychology, 47, 427-439.

COMMERCIAL LAW “where a person contracts as agent, the contract is that of the principal, and not that of the agent and prima facie the only person who may sue is the principal and the only person who may be sued is the principal….to that rule, there are of course many exceptions” Per Wright J in MONTGOMERIE V UNITED KINGDOM MUTUAL STEAMSHIP discuss the situations in which an agent may be liable to a third party.

A relationship of agency arises where one person, an agent, acts on behalf of another person, a principal, in making legal arrangements with third parties that confer rights and impose obligations on the Principal.

It is the Principal that can sue and be sued on the contracts made between itself and the Third Party (Richards, p.449)^[1]. However, in some cases, the Agent may be personally or jointly liable to the Third Party. Where there is joint liability, the Third Party must decide whether to sue the Agent, the Principal or both.

An agent will be liable when he intends to enter into an agreement as joint principal. This may be apparent from the express terms of the agreement, or from the way in which he signs it. An example of such arrangement can be found in a solicitor’s partnership, where each partner is an agent of the firm and any agreement entered into by them is as agent and joint principal (Denny, p.33)^[2].

The case of Shack v Anthony (1813)^[3] demonstrates that where an agent executes a deed on behalf of the principal in his own name, he will be held personally liable. For the Principal to take the benefit of the deed, he must be named on it and it is not enough that the Principal is simply disclosed.

In some cases, it is trade usage and custom that give agents liability under a contract. For example, insurance brokers take liability for non payment of premiums, and ship brokers accept liability for payment of charter parties (Fleet v Murton 1871)^[4]. In both examples, liability is joint with the Principal. A further commercial example is found with Del Credere agents, who take personal liability as surety for their Principal.

Several outcomes can follow from contracts made with a non existent principal. If the contract is made prior to the incorporation of a company as in Kelner v Baxter (1886)^[5], the Agent will be held personally liable. If the contract is entered into where the Principal is in fact fictitious, again the Agent will incur personal liability, and the same applies where the agent uses someone else’s name. If however the identity of the other person is material to why the third party entered into the contract, the agent will be liable for misrepresentation (The Remco 1984)^[6].

An agent will incur liability to a third party if by his conduct he indicates that he intends to be liable to that party. He may, for example, enter into an agreement where there is no reference made to an agency, and which is signed in his own name or profession. In this scenario, he is jointly liable with the Principal. A further example of such liability that might arise can be found in Sika Contracts Ltd v B L Gill and Closeglen Properties Ltd (1978)^[7], where an agent acting on behalf of a disclosed but unnamed principal signed contracts in his own name and profession, and was held to be personally liable. This situation could have been avoided had the agent added “as agent” after his signature, although the mere use of the word “agent” may indicate either a description or qualification and is not therefore conclusive (Gadd v Houghton (1876)^[8], Halsburys s.184)^[9].

The agent will always be jointly liable to the third party when acting for an undisclosed Principal because, for all intents and purposes, he appears to the third party to be the Principal (Halsbury’s s.183^[10], Saxon v Blake (1861)^[11]. Although it is the contract that the Agent has entered into that the Principal is entitled to enforce, the Third Party retains the right to elect to sue either the Agent or the Principal if he subsequently becomes disclosed (Bradgate, p.169^[12], Richards p.456). The agent is not however liable where the contract is entered into with an unnamed (but disclosed) Principal, unless there is evidence of intention to be personally liable (Benton v Campbell, Parker & Co Ltd 1925^[13]).

The above examples consider where the agent has found himself either jointly liable under the original contract, or personally liable and in fact, he becomes the principal and takes on all rights and liabilities of that contract, which is binding.

However, the case of Collen v Wright (1857)^[14] establishes that where an agent enters into a transaction as if he were acting for a Principal and by implication, he warrants that he has the Principal’s authority to act in the matter, if the third party acts in reliance on his representation and it transpires that he has no such authority he may be liable to the third party for breach of warranty. This principle is based on an implied unilateral contract which is formed when the agent, by implication, promises that he will warrant he has authority if the third party enters into a contract with the principal. By entering into the contract with the principal, the third party accepts the offer of the agent and provides consideration for the agent’s promise. This brings about a collateral contract between the third party and the agent. Where the Principal remains liable under the main contract, the agent is not liable as the third party has suffered no loss despite the agent’s lack of authority (Richards, p.457).

Liability under this principal can be extended to warranting the authority of a fellow agent, as was the case in Chapleo v Brunswick (1881)^[15]. The agent may also find themselves liable to any third party in the transaction – for example, the mortgage company in a property transaction (Penn v Bristol and West 1997)^[16].

The third party may claim damages under the usual principals of contract law, being all damages that flow naturally and directly from the breach (Hadley v Baxendale (1854)^[17], the aim being to put the third party back in the position he was in had the breach not occurred (Suleman v Shahsavari 1989^[18], Nimmo v Habton Farms 2003^[19]). Liability is strict and there is no defence in saying that the agent acted innocently in the matter (Yonge v Toynbee 1910^[20]). However, the amount that can be recovered is limited by the amount the third party would have been able to recover from the Principal so if, for example, the Principal becomes insolvent, the amount is limited to how much the third party could have claimed from the Principal’s insolvency.

In addition to liability for breach of warrant of authority, if an agent deliberately or recklessless misstates his authority he will be liable to the third party in the tort of deceit (Derry v Peek 1889^[21], Richards p.200). However, fraud is very difficult to prove and rarely gives right to recovery against an agent. He can also be liable for negligent misstatement under the principle in Hedley Byrne & Co v Heller & Partners (1963)^[22] if it can be shown that there is an assumption of responsibility by the Agent to create a special relationship between the Agent and the Third Party, giving rise to a duty of care. The Agent, in failing to exercise due and reasonable care in representing the extent of their agency or the fact of its existence, breaches that duty. The Third Party would also need to show that they had suffered loss as a result of breach of that duty (Bradgate, p.175).

In conclusion, although an agent is not generally liable to the third party where both the existence and name of the Principal have been disclosed, there are many exceptions to the statement of Wright J in Montgomerie v United Kingdom Mutual Steamship (1891)^[23] that only a principal can sue and be sued where an agency exists. The law of agency protects third parties who must be able to rely on an agent’s assertion of authority as a matter of commercial convenience, and where that assertion is incorrect, the agent may find himself jointly or personally liable to the Third Party. As can be seen, it is preferable to explore contractual remedies including breach of warrant of authority rather than negligence or deceit, as these carry with them the strict liability inherent to the law of contract.

Bibliography:

Richards, P (2006) Law of Contract, Pearson, Essex
Denny, R (2002) Commercial Law, ITC, Bedford
Halsbury’s Laws of England : Agency
Bradgate, R (2000) Commercial Law, Butterworths, United Kingdom
Sealy, L.S, Hooley, R, Berwin S.J (2003) Commercial Law: Text, Cases and Materials Lexisnexis UK, England

Title: Discuss the nurse led intervention in relation to secondary prevention for COPD

Chronic Obstructive Pulmonary disease (COPD) is a growing health concern today all over the world. The World health Organization predicts that by 2020 COPD will rise from it’s current ranking of 12^th most prevalent disease worldwide to 5^th and from 6^th most common cause of death to 3^rd.(Murry 1997) Another study by WHO(2002) states that COPD is the third largest cause of respiratory death and account for 20% of respiratory mortality. According to research conducted in UK, around 900000 patients are suffering from COPD in England and Wales currently (NICE 2004). Numbers of patients affected by COPD are increasing in UK and it has taken over the place of heart diseases as one of the major killer diseases leading to 30000 deaths per year. (Gibson 2003). Reason for dramatic increase in COPD includes reduced mortality from other diseases like heart diseases in industrialization countries and infectious diseases in developing countries with marked increase in cigarettes smoking and environmental pollution all over world.

COPD is a chronic progressive disorder characterized airway obstruction with little or no reversibility. COPD affects bronchi, bronchioles and lung parenchyma with predominance on distal airways. It involves two clinical condition- chronic bronchitis and emphysema. Most patients with COPD have both pathological condition but relative extent of emphysema and chronic bronchitis is variable in individual patient.

Chronic Bronchitis and Emphysema

Chronic bronchitis is defined as a cough productive of sputum on most days for 3 months for successive 2 years. Cough is due to hyper secretion of mucus not necessarily accompanied by air flow obstruction.

Chronic bronchitis is characterized by enlargement and multiplication of mucus glands, resulting increased airway mucus production. Evidence suggests that apart from quantity, quality in the form of composition of mucus is also altered becoming more viscous.

Mucus is one of the important component in pathophysiology of COPD. Increased secretion of mucus is the result of goblet cell hypertrophy on exposure to various noxious stimuli. This mucus affects pulmonary function in various ways. Increased secretion for prolong period leads to decrease in FEV1 which is promotional to degree of hyper secretion .Excess mucus causes airway obstruction by accumulation in peripheral airways and increased airway resistance.

Additionally, there is thickening of airway wall and infiltration with lymphocytes, neutrophils and macrophages leading to fibrosis. In contract to asthma, infiltration of lymphocytes and neutrophils are found in greater number in airway lumen. In the event of exaggeration of COPD, Eosiniphils are also observed in airway lumen. Inflammatory process in COPD is powered by interaction of proteolytic enzymes and several chemokines, as sputum of patients with COPD shows increased amount of Leucotriene B4, interleukin- 8 and tumor necrosis factor.

Emphysema is defined as enlargement of airspaces distal to terminal bronchioles with destruction of alveolar wall resulting loss of elasticity of lung and closure of small airways. Elastic recoil of alveolar attachment helps to maintain the patency of airway lumen especially during expiration. With destruction of connective tissue matrix of alveolar walls by proteolytic enzymes called proteases, released by inflammatory cells in the alveolar wall causing destruction of elastin, affects structural integrity of alveolar wall. Pathological changes in emphysema are related to proteolytic activity of these enzymes.

In peripheral airways of patients with COPD, there is airflow limitation due to loss of alveolar attachments, inflammatory obstruction of airways and luminal obstruction with mucus. The airway narrowing in COPD is the end result of combination of structured inflammatory narrowing, loss of elastic recoil and loss of alveolar attachments.

One of the important effects of risk factors of COPD is abnormality in ciliary function. Airway wall is lined by cilia which act as a force to propel mucus or foreign body towards trachea for coughing it out. Mucociliary function is affected by thick and tenacious mucus. It also increases the risk of infection due to accumulation in airway causing recurrent infection in lungs and further lung damage. Mucus plugging and pulmonary infection contributes to V/Q mismatch and hypoxia eventually. Acute hypoxia caused dyspnoea affecting other systems of the body. Chronic hypoxia leads to pulmonary hypertension and right sided failure. Other pathophysiological consequences of COPD include abnormalities in pulmonary function, the mechanism of gas exchange.

Risk factors for COPD

There are several factors responsible for development of COPD called risk factors.

Smoking cigarettes, both active and passive, is considered the major causative factor in development of COPD. More than 80% of COPD patients are or were smokers (Gibson 2003).

Air pollution, industrial smoke and chemicals used in industry are responsible for development of COPD. Exposure to industrial dust is a causative factor in diseases like asbestoses, mesothelioma and black lung disease. Infection especially in early childhood and frequent exposure to allergens leading to changes in airway are contributing factors in development of COPD. People with Alfa -1 antitrypsin deficiency are more likely to develop COPD due to genetic defect in production of enzyme alfa-1 antitrypsin. It is believed that patients having periodontal diseases are more likely to develop COPD as the bacteria casing periodontal diseases travel to lung and cause infection and inflammation.

Babies with low birth weigh have shown increase incidence of COPD and poor nutrition during fetal development leading to small dysfunctional lung is considered the responsible factor for development of COPD. COPD in more common in men, over sixty years of age. At this age it is at its highest level of development, which started in young age.

Out of all the risk factors discussed smoking cigarettes is most important factor in causing COPD. Effects of smoking cigarettes on human body are due to nicotine present in a cigarette. Nicotine molecule was produced over 60 million years ago by tobacco plant to overcome insect herbivores. Tobacco introduced in Europe in 1492 when Christopher Columbus sailed to America and its cultivation then spread to many parts of world (Corti 1931). Today tobacco is widely prevalent in society in the form of cigarette smoking. Typical cigarette contain 9 mg of nicotine of which 1 mg is absorbed by smoker.

Burning tobacco produce a complex mixture of compounds divided in gas and particulate phase components. In gas phase component, carbon monoxide (4%) forms the significant amount in concentration in addition to nitrogen, oxygen and carbon dioxide. The particulate phase component is consisting of aerosol of tar. Tar is the sticky, brown, residual substance left after removal of nicotine and moisture. Both gas and particulate phase are responsible for COPD

Delivery of smoke compound is variable according to type of tobacco used in cigarette, addition of filter and the vigor with which an individual smokes cigarette. Smoking affects lung at the level of bronchi, bronchiole and lung parenchyma. Tobacco smoke affects structure and function of bronchial mucous gland. Number and size of mucus secreting glands increase due to smoking leading to more production and deposition of mucus in airway. Tobacco smoke also produces structural changes in airway cilia. These changes are related to dose and duration of smoke exposure. It also affects the function of cilia with abnormal clearance of secretion. Additionally, it also cases narrowing of small airways with inflammation and fibrosis. Apart from this, smoking has some short term effects like increase in carboxyhaemoglobin, decreased appetite and emotional dependence on nicotine.

COPD is treated with elimination of risk factors, bronchodilators such as beta-agonists and anti-cholinergic, corticosteroids, low concentration of oxygen and mucus thinner like guaifenesic. The cost of COPD is enormous as economic burden on health care system, society, patients and their family is significant. An audit of 1400 patients admitted in a hospital revealed that 34% patients readmitted and 14% had died within 3months. (Roberts 2002)

It is imperative to act upon risk factors responsible for COPD. Smoking is major risk factor for development of COPD and it is never too late to stop smoking and benefits starts immediately. (Price 2004).Usually smoking starts in teen age and continues for long time, but those who have never smoked remain non-smoker for many years.

Study indicated decline in number of male smokers in UK from 70% in 1950 to 28% in 1998 (Macfadyen 2001).More positively, men are giving up smoking in increasing number. These changes in behavior of people in society towards smoking are the result of implementation of health promotion strategies in communities. Health promotion is the science and art of helping people changing life style to move towards the state of optimum health. Optimum health is defined as a balance of physical, emotional, social, spiritual and intellectual health (Irwin 2005)

Health promotion is directing the plan to foster communities’ abilities to take effective actions at local level. It covers the methods to map and mobilize local resources, to activate citizens, government for management of positive changes, and transform institutions into health promoting environment. It involves the actions to improve ability of health care system for primary and secondary prevention and assist citizens in taking control and improve their own health by behavior and lifestyle changes. Life style changes can be facilitated with combination of enhanced awareness and creating environment that support good health practice.

Health promotion is that element of public health that focus on social conditions for maintenance and development of better health for productive society. Evaluation of health education programmes reveled that change in knowledge did not result in action and improved health. Knowledge alone is not sufficient but people need the confidence that they can change their lives.

Hubley (2002) explained that health empowerment has two components self efficacy and health literacy. Self efficacy implies feeling of power and control and confidence of taking action. Health literacy is related to ability to communicate health related issues.

.Health literacy is achieved only by means of health education leading to understanding of health issues and application of it in decision making. Many traditional health education methods rather disempower person by creating more dependency on health professionals. Important element in health promotion is to provide cognitive input through educational process which will not undermine community confidence. Health education using participatory learning methods creates a way forward for heath literacy and self efficacy.

Nurses in health care set up facilitate these components of health promotion by helping smoking cessation in society and directing health care for secondary prevention of COPD. Nurses as health care professionals act by providing information and support to smokers either by telephone contact or nurse led clinic to obtain objective of reducing smoking in communities. There are clear objectives for nurses in smoking cessation programmes of advocating positive social and environment changes for health promotion and organizing supporting activities that leads to secondary prevention of health related morbidity and mortality. It is important for nurses to educate the people to influence the positive behavior changes in health related issues. Apart from providing information, it is important for nurses to use the information to bring change by communicating and convincing smokers and organizing individual action. Government says that smokers are four times more likely to quit smoking using NRT with local NHS stop smoking programme than if they only rely on their will power. (DH 2004)

Smoking is seen in three phases: initiation, maintenance and cessation. Initiation occurs in early teens and begins with experimentation with cigarettes. There is evidence that adolescent of more rebelling or risk taking, out going nature are more likely to take up cigarettes. Individuals of more neurotic personality are also more prone to take up cigarettes. Some degree of genetic predisposing has also been observed, which not particularly specific to nicotine but also for alcohol and caffeine. High status individuals in media also have great influence in initiation of smoking. Maintenance of smoking is promoted by direct and indirect effect of nicotine releasing central dopamine, noradrenalin and opiate peptides. It helps in coping with stress and also improves performance due to its tranquillizing effect, in a variety of tasks but it eventually leads to dependence, addiction and withdrawal symptoms.

On initial contact with patient, nurse establishes that the person is a smoker and obtains informed consent from person. Nurse gives a questionnaire to patient to know smoking history of patient in the form of numbers of cigarettes smoked in a day by a person. It also includes disclosure of information about duration and pattern of smoking.

Nurses then assess the willingness of the person to stop smoking. By asking smoker to rate the importance of quitting on a scale one to ten, with one number having least importance. Smokers are also asked to rate their confidence in their ability to quit. This gives an idea to nurse about the readiness of a smoker for quitting.

Nurse also assess level of breathlessness in patient with COPD, which is graded as follows (Gibson 2003).

Not troubled by breathlessness on strenuous exercise.
Breathlessness when walking uphill
Walks slower than counterpart on the level because of breathlessness
Stops to take a breath after 100m or a few min on the level
Too breathless leave the home or breathless on dressing.

After initial assessment, nurse counsel patient to educate and prepare him/ her to take action to quit smoking. Nurse explains the benefits of smoking cessations with emphasis on the explanation that a person starts getting benefits immediately after stopping and set a quit day with explanation of problem they may come across.

In clinic, most patients say they would like to give up and also tried to stay away from cigarette (Percival 2004).A study indicates that long term success of smoking cessation depends on several factors like low daily cigarettes and delayed first cigarette of day; low consumption of alcohol or caffeine, high socioeconomic class; non smoking spouse and less neurotic or depressive personality. Some evidence also suggests that women find it difficult to give up. It is important for the nurses to now the degree of self confidence from the outset that the goal will be achieved and absence of stressful episodes during the therapy as contributing factors for long term abstinence from smoking. Study suggests that, persons usually give up smoking after five to six trial and error sequences. (Gibson 2003)

The duration of therapy is usually six weeks. Nurses lead session either in a group or one to one and manage for regular follow up. After initial contact, nurses remain in contact with person by telephone or in clinic at 2 days, one week, three weeks and three months interval. Patients are given booklet about COPD and disadvantages of smoking. Booklet also contains the benefit s of quitting smoking. It also explains the patient about how to quit smoking, how to cope with withdrawal symptoms like need to smoke, depression, irritability, insomnia, difficulty in concentration, restlessness and increased appetite… Patients with strong withdrawal urge are explained about NRT. At the end of six weeks patients have consultation with nurses. Those who continued smoking or relapsed are offered additional support.

Anti smoking public health campaign helps smokers by drawing attention more frequently and pushing them to take action. It also helps nurse in facilitating their advice. Self reported motivation of smokers, wish to avoid further health problem and in some cases actual ill health are important factors in giving up smoking. For example, a pregnant lady is inclined to give up smoking to avoid harm to her baby. Smokers receiving advice from hospital physician specially after admission for myocardial infarction had quit rate of 50%, compared to success rate for advice by physician in general practice of around 5% in unselected patients.(Pety 2000 ) Concern of passive smoking and many times social pressure by family and friends also contributes in moving forward for help in smoking cessation clinic. Rising price of cigarettes and ban or restriction of smoking in public places also tend to discourage smokers. Socioeconomic model suggest that for every one percentage rise in cigarette price leads to 0.5 % drop in consumption (NICE 2004).Smoking advertisements and perceived status of smoking from them are significant factors in encouraging people to become smoker.

Nurse encourages person in finding alternate source of enjoyment and different coping strategies in the event of stress leads to successful outcome on long term. Nurse also takes help of specialist in search for other ways of mastering concentration during sustained task. Nurse also asks spouse to quit smoking to create the environment for behavior change. Many smokers have poor central control system for arousal reward and punishment, and then alternative strategies may involve physical sports, mental relaxation, assertiveness techniques and different scheduling for work activities. Nurses help smokers understanding and reducing the image smoking as’ something exciting and sophisticated’.

Most smokers give up with the help of their own efforts but those who cannot manage themselves nurses propose specific methods with the social support. For those , who will not give up in immediate future some damage limitation can be achieved by production of safe cigarettes; transfer to pipe or cigar or chewing tobacco; other formulation of tobacco like nicotine gum, nasal spray, transdermal patch inhalable aerosol- called nicotine replacement therapy (NRT). Before starting medication nurse rules out contraindication for medication like severe cardiovascular diseases, recent MI, severe cardiac arrhythmia, recent CVA, transient ischemic attack, pregnancy and breast feeding. Variety of other drugs apart from medications used for NRT are also used in practice which counteract unpleasant aspects of nicotine withdrawal, includes amphetamine, benzodiazepines, ACTH, vasopressin, clonidine, fluoxetine, bupropion and naloxone. Mecamylamine (nicotinic antagonist) is another important medication used in smoking cessation.

Nicotine replacement therapy in the form of nicotine gum or patch is better than smoking and decrease health risk. NRT and bupropion are prescribed to those who have set a date as a target to stop smoking. Transfer to pipe decrease the risk of lung damage, but can not protect upper oesophageal tract. With nicotine nasal spray, absorption from mucosa is much faster than gum and the blood level achieved are comparable with cigarette smoking. Nicotine aerosol has irritant sensation in nose but it is still the attractive option in switching from cigarettes. Nicotine patches application on skin promotes slow absorption of nicotine from the skin .It is devoid of sufficient sensory stimulation involved in smoking. It has limitation in alleviating withdrawal symptoms during smoking cessation therapy.

Practically more useful are nicotine gum, transdermal nicotine patch, nasal spray and antidepressant bupropion. They are equally effective and safe, doubling quitting rate. Study indicates less than 5% drop out rate due to adverse effects if these drugs, but combination is superior in effects compared to single drug (Gibson 2003).Combining medication with counseling by nurse boost the quit rate. Nurse explains side effects of NRT like headache, nausea, dizziness, palpitation, dyspepsia, hiccups, insomnia, myalgia, anxiety, and irritability to patients before starting it.

For many novice ex-smokers major difficulties emerge after initial euphoria of successfully having overcome the first week of withdrawal symptoms. The more complex task then begins to manage and overcome withdrawal symptoms for longer term for successful outcome. NRT forms the mainstay of management of withdrawal symptoms. There are differences in response from various types of NRT .In case of heavy smokers( more than 20 cigarettes a day) 4mg nicotine gum is more effective than 2mg. In medium to heavy smokers standard patch of 21 mg is more effective than lower dose patch. Treatment with NRT is continued for 10 to12 weeks with gradual withdrawal. If person is unsuccessful in quitting after 3 months, the treatment is again reviewed. (West 2000)

Addition to anti-smoking measures, nurse should check effectiveness of inhaled drug, it’s technique and if they are symptomatic despite short acting bronchodilators.

Nurse also takes care of nutrition and vaccination in COPD case.

Nurse led clinic for smoking cessation is a part of pulmonary rehabilitation program which involves exercise and education over 6to 8 weeks to anyone who feels that COPD is affecting quality of his or her life. It is closely related to health promotion by creating an environment and providing education for improving personal and community health.

Educating people to change behavior and empowering them to take actions leading to smoking cessation are essential elements of smoking cessation clinics.

References

Corti C., (1931). A history of smoking. London: George G. Harrap
Department of health, Office of National statistics, (1997). General household survey. London: HMSO
Gibson g., Duncan G., costabel U., Sterk P., Corrin B.,( 2003). Respiratory medicine, 3^rd edi, vol. 1 p 645. London: Elsevier
Hubley J (2002). Health empowerment, health literacy and health promotion putting it all together. http://www.hubley.co.uk/1hlthempow.htm (Accessed on May 14, 2005)
Irwin J (2005). Health promotion theory in practice: an analysis of Co-Active Coaching. International Journal of Evidence Based Coaching and Mentoring ,vol-3, no-1.http://www.brookes.ac.uk/schools/education/ijebcm/vol3-1-a-morrow&irwin.html! (Accessed on May 14, 2005)
Macfadyen L., Hastings G., Mackintosh A., ( 2001). Cross sectional study of young people-awareness and involvement with tobacco markets. BMJ. 322, pp 512-517.
Murry C., Lopez A., (1997). Alternative projections of morbidity and disability by cause, 1990-2020: Global burden of diseases study. Lancet: 349. 1498-1504
NICE guidelines (2004). Management, treatment and cure of COPD. British journal of nursing ,vol.13, no18, pp1100-1103
NICE; (2004). Guidelines to improve patients with COPD. London : NICE
Percival J. (2004).Make use of all resources to quit smoking. http://www.professionalnurse.net/nav?page=pronurse.article&resource=1454302&fixture_article=1454302&category=RESPIRATORY_CARE. (Accessed on May 14 , 2005)
Pety R., Darby S., Deo H., (2000). Smoking, smoking cessation and lung concern in UK since 1956.Combination of national statistics with two cases control studies. BMJ, 321, pp 323-324
Price D., Foster J., Scullion J., Freeman D., (2004). Asthma and COPD. London: Elsevier
Roberts M., Lowe D., Bucknell C., (2002). Clinical audit indicator of outcome following admission to hospital with acute exacerbation of COPD. Thorax, 57, pp 137-141
West R., McNeill a., Raw a., (2000) .Smoking cessation guidelines for health professionals: – an update. Thorax, 55, pp 987-999
WHO, (2002), reducing risks, promoting healthy life. Geneva : WHO

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CASE STUDY: SEBASTIAN AND BELLE YANOVSKY

This essay examines the legislation, policy and care practice relevant to the case study of Sebastian and Belle Yanovsky, and their parents Ms. Jo Butler and Mr. Zalman Yanovsky. The main issues for discussion are: the legislation relevant to the case study, the role of the family court system, the role of the ‘looked after’ children review system, child protection case conferences, the criminal justice system, and the practical issues which arise from these. The purpose of the essay is to analyze each of these areas to see how they are intended to contribute to the protection and welfare of Sebastian and Belle Yanovsky. The essay also examines closely how the various agencies and services involved in the care of Sebastian and Belle maximize inter-agency communication so as to reduce the risks and maximize the protection available to the children.

The four principal pieces of legislation relevant to the Yanovsky children’s case are the Children Act 1989, the Protection of Children Act 1999 the Adoption and Children Act 2002 and the Children Act 2004. The Children Act 1989 sought to carry into legislation the belief that where possible ‘… children are generally best looked after within the family, with both parents playing a full part and without resort to legal proceedings. The welfare of the children is the paramount consideration.’ (Children Act, 1989). Thus the Children Act sought where possible to protect children within a family environment. Thus the act introduced a number of provisions designed to protect children by improving their home and family environment. The report stressed the need for various care agencies to increase inter-communication so as to best determine the risks posed to a particular child or children and so to most effectually provide the protection from abuse that they required. Sections 27 and 47 of the Act – significantly titled ‘Co-operation Between Authorities’ and ‘Local Authority’s Duty to Investigate’ – sets out the governments demands for closer agency communication. Section 27: 4 for instance defines the need for agencies to co-operate on educational care, stating ‘Every local authority shall assist any local education authority with the provision of services for any child within the local authority’s area who had special educational needs’. The relevance of this act to the Yanovsky case will be shown shortly. The main themes of the Children Act 2004 were an emphasis upon ‘integrated planning’, ‘delivery of services’, ‘multi-disciplinary working’, ‘increased accountability’ and, especially, more provision for those children with ‘special needs’. The Protection of Children Act 1999 and the Adoption and Children Act 2002 will be discussed in the forthcoming paragraphs.

This legislation provides the following short term and long term solutions for the Yanovsky children’s case. In the short term, the Children Act 1989 states that, where possible, the welfare of the children must be attempted inside the family environment. Thus the Children Act allows for various professional carers (social workers, mental health practitioners, police etc.,) to monitor the home situation of the Yanovsky children. The Child Protection Act 1999 makes provision for Child Protection Conferences (discussed later in this essay) and a conference for the Yanovsky children would be an important short term measure to assess the risk to the children and to co-ordinate a Child Protection Plan for them. Earlier legislation also allows social workers to put the Yanovsky children on the Child Protection Register if they feel it necessary. If these short term measures prove unsuccessful, then it may be necessary to bring a public law case (family court) against the Yanovsky’s as set out in the Children Act 1989. If the court thinks it necessary to remove custody from the Yanovsky’s then the Adoption of Children Act 2002 makes provisions for the long term care of the children under the status of ‘looked after’ children. Thus, both long term and short term, there is a comprehensive range of legislation to protect the Sebastian and Belle.

The role of a family court in child protection cases is to make rulings about the rights to custody of the child or children involved in a particular case. A family court can be convened under two sets of circumstances as outlined in The Children Act 1989: in the first instance are private law cases where two parents dispute in court rights to custody of a child or children. The second instance is that of public cases where the state on the advice of care agencies seek custody of a child or children. In both public and private law cases the responsibility of the court is to decide who is most fit to care for and support the child or children in question. In public cases the family court hears evidence and recommendations from social service workers, doctors, mental health workers and other professionals. This evidence is intended to evince the potential risk that the child or children are exposed to. If the family court finds that the potential risk to the child or children is too high then the court may rule that custody should be removed from the parents and given – either temporarily or permanently – to the State (Schepard, 2004). Such children are referred to as ‘looked after’ children, and provision for such children has been the subject of much recent government discussion and legislation. Family courts have recently been the subject of much controversy and criticism. The ‘Fathers 4 Justice’ campaign has been particularly prominent and is scarifying of the tendency of family courts to seemingly always grant custody to mothers and to neglect the human and legislative rights of fathers. The group has even published the ‘Blueprint for Family Law in the 21^st Century’ towards this end. Andrew Schepard, amongst many others, has written of the need for radical revision of the family court system so as to promote parity of rights between fathers and mothers. Only when this happens, it is argued, will family courts be able to make rulings that ensure the best and fairest outcome for the welfare of the child or children involved.

The case of Sebastian and Belle Yanovsky has not yet reached the point where a family court has been convened. Mr. Yanovsky and Ms. Butler are still together and so there has been no private application by either parent for sole custody of Sebastian and Belle. Nonetheless, given the seriousness of Sebastian’s and Belle’s physical and emotional abuse, it may be that care services feel it necessary to recommend in future that custody be removed from both parents. If such a recommendation were made then Mr. Yanovsky and Ms. Butler would have to attend a family court to decide whether they were fit to have the custody of their children.

The basic function of the ‘looked after’ children review system is to maximize the government’s provision of care for ‘looked after’ children. The government has pledged to ensure that ‘looked after’ children receive exactly the same opportunities for education, healthcare, social experience and security as other children. There should be no discrimination or prejudice against ‘looked after’ children. The government has made several legislative and policy requirements of local government with respect to ‘looked after’ children. For instance, a review of existing ‘looked after’ children provision is integral to the Children and Young People Plan (CYPP) which every local authority is obliged to have begun by April 2006. Local government implementation of the Adoption of Children Act 2002 is also vital to boost rates of adoption for ‘looked after’ children and to increase the likelihood of such adoption succeeding. Integral to the view is the Every Child Matters ethos, whereby the government seeks to guarantee equal opportunities for all children in the United Kingdom. The government’s proposed package for improving the provision for ‘looked after’ children includes some of these features: a national helpline to recognize carer help, the introduction of minimum allowances, increasing training chances for foster workers, the introduction of a reward scheme and so on. These measures are all intended to improve the lives and educational and social opportunities for ‘looked after’ children. This educational responsibility of local government was set-out in the Protection of Children Act 1999. The Choice Protects scheme was also introduced in March 2002 to ensure that ‘looked after’ children find more secure homes and have a greater choice over their own lives. The government’s 2003 Social Exclusion Unit Report: A Better Education for Children in Care made numerous recommendations about possible improvement to the educational provision for ‘looked after’ children. Perhaps the most important of these measures were the introduction of explicit guidelines for school governors as to the educational needs of ‘looked after’ children, and, secondly, advice for foster carers about the educational needs of the children under their protection.

Sebastian and Belle Yanovsky are not yet ‘looked after’ children, since Ms. Jo Butler is their biological mother. As such, the above provisions for ‘looked after’ children are not directly relevant to Sebastian and Belle. Nonetheless, given the seriousness of the risks posed to Sebastian and Belle there is a strong chance that these children will become ‘looked after’ children in future. If this happened then clearly all of the above provisions and changes to provisions featured in the Adoption of Children Act would affect the Yanovsky children directly.

The purpose of a child protection conference is to convene in one place and at one time all the relevant people interested in the care of a particular child: care professionals, medical practitioners, police, lawyers and so on. Before the introduction of child protection conferences the child protection system was often highly inefficient and ineffectual since various agencies worked independently of each other and had little or no communication between themselves. This confusion increased a child’s risk of abuse since there was little or no sharing of information between the various relevant agencies. Child protection conferences aim to increase communication between child protection agencies and therefore reduce the risk of abuse to the child. Child protection conferences are convened when care services have made an initial assessment of the risk to a particular child and then decide that further investigation is necessary. The professionals who attend child protection conferences must make an evaluation of the welfare of the child, determine the likelihood of physical or emotional abuse to the child, and decide whether that child ought to be placed on the Child Protection Register. Care professionals must also decide whether legal proceedings ought to be brought on behalf of the child, and whether there ought to be a criminal investigation also. If these professionals think it necessary to place a child on the Child Protection Register then they must also design a Child Protection Plan to control future proceedings towards ensuring the safety of the child. These plans clearly define what duties each care agency has for the protection of the child, and ensure that there is coherent and productive communication between these individual agencies. After the initial conference a further meeting can be convened after three months and then further six monthly conferences if felt necessary.

Applied to the Yanovsky and Butler case study, a child protection conference might have the following consequences. The Yanovsky’s social worker (no name), Mrs. Wilma Connelly (the health visitor), a representative from the Garthdee Family Centre, the police and other professionals would meet to discuss the risk posed to Sebastian and Belle Yanovsky. These professionals would use various criteria to produce a total risk assessment posed the Yanovsky children. In this instance, the risks to the Yanovsky children might appear to be very high. There are serious questions the risk Mr. Yanovsky poses as a sexual predator: he offended a seventeen-year-old child in 1992 and he was recently arrested for a Breach of the Peace for an incident in a womens’ public toilet. Moreover, Mr. Yanovsky and Ms. Butler admitted to police incidents of ‘mutual violence’ between themselves. The medical reports for Sebastian and Belle are also extremely concerning. Belle was recently admitted to Royal Aberdeen Children’s Hospital because of vomiting; upon inspection she was found to have a fractured right leg, three similar injuries and two cracked ribs. The medical staff thought these highly unlikely to be caused by accident. A further risk for consideration by the conference might be the quality of housing of the Yanovsky children. Based upon these various risk factors the members of the conference might decide to place both Sebastian and Belle on the Child Protection Register. The conference would also need to produce a Child Protection Plan; this plan might stress the need for greater care provision for Ms. Butler, and counseling for both Mr. Yanovsky, Ms. Butler and, separately, their children. Given the particularly harrowing details of the case, the conference might recommend that Sebastian and Belle be removed from their parents for their protection. The conference might also recommend criminal proceedings against the Mr. Yanovsky and Ms. Butler on account of the injuries caused to their children.

The criminal justice system, under the Child Protection Procedures of the Children Act 1989, allows and sets out guidelines for the prosecution of particularly serious offences against children. The Child Protection Team (CPT) has the responsibility to investigate allegations of abuse against vulnerable children. In the Yanovsky case, the injuries against Sebastian and Belle were thought by Dr. R. Williamson and Police Surgeon Dr. Mike Heron to be ‘obviously inflicted upon the child’ – they were deliberate. The police felt that both Mr. Yanovsky and Ms. Butler had failed to offer plausible explanations for the injuries to Belle. Given the seriousness of the injuries to Belle, the Child Protection Team might decide to recommend that charges of abuse be brought against either Mr. Yanovsky or Ms. Butler, or both. If it became so serious that charges of sexual abuse were deemed necessary by the CPT then these would be issued under the Sex Offenders Act 1997.

In conclusion, the main practical issues to be addressed in the case of the Yanovsky children are as follows. Paramount, of course, is the issue of the safety and welfare of Sebastian and Belle. Clearly there is a high risk of continued physical and emotional risk against both children. Temporarily and short-term, the Yanovsky’s social worker has recommended that Jo Butler receive extra care provision for Sebastian. The professionals involved in the case may decide to convene a Child Protection Conference, where after Sebastian and Belle may be placed on the Child Protection Register and have a Child Protection Plan drawn up to determine how they should be cared for in the coming months and years. The suggestions of abuse against Belle are so serious that the State may decide to seek to remove custody of the children from Mr. Yanovsky and Ms. Butler. The Child Protection Team may also consider it necessary to bring criminal charges against the parents for physical abuse. If custody were removed, then, under the Adoption of Children Act it would be necessary to give Sebastian and Belle the status of ‘looked after’ children and so to implement the provisions that are joined to this status.

BIBLIOGRAPHY

— Booth, M. (1996). Avoiding Delay in Children Act Cases. Routledge & Paul Kegan, London.

— Hanson, R.K. (1997). What Do We Know About Sex Offender Risk Assessment. Psychology,

Public Policy and Law, 4.

— Holder, W & Corey, M. (1986) Child Protective Services Risk Management: A Decision

Making Handbook. Action for Child Protection, Charlotte, N.C.

— Rushton, A. (2003). The Adoption of Looked After Children. Social Care Institute for

Excellence, London.

–– Schepard, A. I. (2004) Children, Courts and Custody. Hofstra University, New York.

— Warman, A. Adoption and Looked After Children: International Comparisons. Family Policies

Study Centre, Oxford.

* * * * * *

— The Children Act (1989), Her Majesty’s Government. www.dfes.gov.uk/publicaions/childrenactrepor

— The Children Act (2004), Her Majesty’s Government.

www.dfes.gov.uk/publications/childrenreport

— The Protection of Children Act (1999), Her Majesty’s Government.

www.dfes.gov.uk/publications/protectionofchildrenact

— The Adoption and Children Act (2002), Her Majesty’s Government.

www.dfes.gov.uk/publications/adoptionofchildrenact

— The Sex Offenders Act (1997), Her Majesty’s Government.

www.dfes.gov.uk/publications/sexoffendersact

Chapter 1: Directors’ Duties

Formulating a system for holding directors accountable has never been easy. As Roach put it, directors’ duties must be gleaned from “a confusing and compendious mass of case law and the occasional statutory measure.”^[1] Given the vast variations in the types of companies that exist, and the types of directors that exist, a universal approach has not always been easy to apply. Nevertheless, the law sometimes seeks to impose a single standard of conduct on all directors, regardless of the nature and characteristics of the company, and the level of involvement of the director. While recent statutes have started to distinguish between private and public companies, and may vary the duties of a director depending on which type of company is concerned, the vast majority of the case law on directors’ duties makes no such distinction and is of general application. There is therefore a complex body of statutory and case law which attempts to both define the duties that a director owes to the company, as well as the level of care that must be exercised when performing such duties.^[2]

As well as statute and case law, a number of standards and codes of practice have also been formulated which seek to define the nature of the duties owed by directors to companies. The first of these to be considered here is the Cadbury Committee, which was established in 1991 following a number of financial scandals that occurred during the previous decade. It was widely acknowledged that reform was needed in company law to allow shareholders and other stakeholders to hold directors more directly accountable for the consequences of their actions. The Cadbury Committee focused on financial control mechanisms to be used by the Board of Directors, and on auditing procedures, and published its report at the end of 1992.^[3] The report focused mainly on larger listed companies and its main conclusion was that a Code of Best Practice should be drawn up and which the Boards of Directors of such companies would be obliged to follow. For smaller companies, it would not be obligatory to comply with the code, but if they chose not to, they would have to publish the reasons why they had chosen not to.^[4] Adherence to the Code would be made a listing requirement, which would help ensure compliance among listed companies.

The benefits of the Code would be to make corporate governance more open and transparent, would make the equities markets more efficient, would make boards more accountable and also more responsive to the needs of the company, and would allow shareholders to exercise greater control and scrutiny over boards. The report was an early supporter of the importance and need of non-executive directors^[5] and recognised that executive and non-executive directors play very important complimentary roles. This area proved to be controversial as many saw the creation of two classes of directors as a threat to the traditional unitary nature of boards. However, the report found that non-executive directors could play a vital role in “reviewing” the performance of the executive directors, as well as taking measures to avoid and deal with “potential conflicts of interest”^[6].

While the report emphasised the importance of financial auditing of companies, it did not go into detail on what should be disclosed in such audits, nor did it consider the controversial area of auditor liability. These were issues which would later become the subject of heated debate.

The Report was also an important element in the growth of shareholder activism in the UK, and it concentrated on the steps that institutional shareholders could take to ensure compliance with the Code. In response to the issues raised in the Report, the Institutional Shareholders Committee^[7] published its own paper, “The Responsibilities of Institutional Shareholders in the UK”^[8] which dealt with many of the issues raised in the Cadbury report. The paper stated that “Because of the size of their shareholdings, institutional investors, as part proprietors of a company, are under a strong obligation to exercise their influence in a responsible manner.” This paper marked a new era in UK shareholder activism and promised to make shareholders more involved in making boards more accountable. The paper went so far as to recommend “regular, systematic contact at senior executive level to exchange views and information on strategy, performance, Board Membership and quality of management”^[9]. Regarding the composition of boards, the paper recommended that institutional investors look carefully at “the concentration of decision-making power not formally constrained by checks and balances” and “the appointment of a core of non-executives of appropriate calibre, experience and independence.”^[10] Therefore, this new investor oversight was taken for granted in the Cadbury report as another force that would improve the governance of large companies.

The Cadbury Report has not been without criticism. Many feared that its recommendations, which put a strong influence on non-executive board members, would lead to the creation of a two-tiered board, a development that was seen as unnecessary and inefficient.^[11] The voluntary nature of the Code has also been criticised. As a listing requirement, the Code also drew some criticism on the London Stock exchange which was given the task of enforcing and implementing the Code. Concerns led to the establishment of a follow up report prepared by the Hampel Committee, which re-examined the issues at stake, the criticisms which had been raised, and the conclusions reached in the Cadbury Report. The conclusions of the Hempel Committee were strongly supportive of the Cadbury Report and it was not long before the ‘Combined Code’ was drawn up, and implemented by the London Stock Exchange which listed companies were bound to implement, or give reasons for not doing so.

The Combined Code now requires that boards implement a “sound system of internal control” which must consider all significant risks facing the company, the effect they might have on the company, and the costs and advantages of various means of dealing with such risks. The Code also deals with the terms and conditions on which directors are employed, including their pay packages incentive schemes, and termination payments.

When speaking of the duty owed by directors to a company therefore, this includes the legal duties imposed on directors by the case law and statutes dealing with the subject, as well as the soft-law measures implemented in the Combined Code. Such duties may be owed to the company itself, or to shareholders or other stakeholders such as shareholders, employees, creditors, and the general public.

That said, it must be remembered that in a legal sense, the duties owed by directors is to the company as a legal person, and not shareholders or other stakeholders. The case of Percival v Wright [1902] 2 Ch 421 established beyond a doubt that the duties of directors is to the company. This case concerned a transaction in which a number of directors purchased shares personally from shareholders at a price of ?2 10s. The directors knew that another purchaser wanted the shares and was willing to pay a substantially higher price. The shareholders sought to have the transaction set aside as a breach of duty to the company. Swinfen-Eady J found that the directors had breached no duty to the company, and that no such duty was owed to the shareholders qua shareholders.^[12] The case of Scottish Co-operative Wholesale Society Ltd v Meyer [1959] AC 324 also illustrates the point. In that case, a parent company appointed some of its directors as directors of a subsidiary. These directors proceeded to act in the best interests of the parent, but Lord Denning pointed out the directors “probably thought that ‘as nominees’ of the [parent company] their first duty was to the [parent company]. In this they were wrong.” The duty of directors is always to the company they are acting for, regardless of the external relationships that the company, or they personally, may have with other persons. Currently there are proposals afoot to allow directors to act in the interests of a group of companies, as this is what happens in reality in many cases, especially where the shareholders and directors of the various companies are identical.

Without shareholders seeking a profit from a company, it can be argued that a company is a meaningless concept, or a piece of paper without a purpose. The law therefore recognises that in most cases, the interests of the company, will be closely connected to the interests of the members of the company, the interest of both being to make a profit. However, as shown above, the interests of the members are not paramount, and difficulties will always arise in equating the interests of the company with the interests of the members due to the fact that in many situations, the members will have different opinions and conflicting interests which cannot all be met. Section 172 of the Companies Act 2006 also adopts the ‘enlightened’ approach which calls for the interests of the company to be interpreted widely and not only as the maximisation of profits at a cost to all other considerations. Employees are one group whose interests the directors must “have regard” to under section 172. This is part of the general duty owed to the company and as such, must be enforced by the company, and not the employees. Many have criticised this provision as meaningless, as employees cannot enforce it, however, given that it is a requirement of the Companies Act, it must be expected that the majority of boards will consider the impact their decisions will have on employees, and such consideration will be minuted. While the provision may not prove capable of persuading callous directors to act other than in the interest of profit maximisation, it will certainly support the efforts of directors who do wish to improve conditions for employees. It also remains to be seen how this provision will be enforced by companies and it may transpire that a strong line of case law will develop which will persuade directors to give genuine consideration to the interests of employees.

Another group whose interests must be considered under section 172 is creditors. In Lonrho v Shell Petroleum [1980] 1 WLR 627 Lord Diplock stated, at page 634, that the best interests of the company “are not exclusively those of its shareholders but may include those of its shareholders.” Since it is the members who appoint directors, it would be tempting for directors to seek to promote only their interests, however, as the court recognised, it is often the case that creditors have put significant money into a company and their interests must be taken into account. Lonrho concerned a company that was solvent at the relevant time. The position regarding an insolvent company arose in The Liquidator of the Property of West Mercia Safetywear Ltd v. Dodd and Another [1988] BCLC 250. In this case the Court of Appeal confirmed that when a company was insolvent, its interests include those of its creditors. In Winkworth v Edward Baron [1987] BCLC 193 Lord Templeman found that the duty was owed directly to the creditors and in Brady v Brady [1989] 1 AC 755 Nourse LJ stated that where a company was insolvent, or its solvency was at risk, the interests of the company and its creditors were identical. According to Finch therefore, the creditors interests must always be taken into account to a limited extent, but as the company approaches insolvency, the interests of creditors must be given greater weight, until the interests of both groups coincide on insolvency.^[13]

The full extent of the “success of the company” as it is termed in section 172 of the 2006 Act includes a duty of directors to have regard to “(a) the likely consequences of any decision in the long term, (b) the interests of the company’s employees, (c) the need to foster the company’s business relationships with suppliers, customers and others, (d) the impact of the company’s operations on the community and the environment, (e) the desirability of the company maintaining a reputation for high standards of business conduct, and (f) the need to cat fairly as between members of the company.”

It can be seen that there has been a steady broadening of the concept of the interests of the company to include more and more interests that a pure profit motive would fail to embrace. In March 2000, the DTI Company Law Review Committee stated that an “inclusive approach” should be adopted.^[14] They pointed out that society’s interest in company law was that it promote “wealth generation and competitiveness for the benefit of all”, and that this can better be achieved if directors are forced to take into account “all the relationships on which the company depends.” The approach adopted in the Companies Act 2006 towards the creation of a statutory “general duty” owed by directors to the company is a progression of this concept with section 170(3) stating that “The general duties are based on certain common law rules and equitable principles as they apply in relation to directors…” At subsection (4) it states “ The general duties shall be interpreted and applied in the same way as common law rules or equitable principles”. This is clearly maintaining the case law that has built up over the past centuries as the framework on which the new statutory general duties are based. It remains to be seen what effect the new statutory duties contained in section 172 of the 2006 Act will have on this case law. Therefore, in looking at the duties owed by directors, it is necessary to read both the statutory provisions and the pre-existing case law together. These both make a distinction between the ‘fiduciary’ duties that directors owe the company, and their duty to act with ‘reasonable care, skill and diligence.’

Under section 174 of the 2006 Act a director “must exercise reasonable care, skill and diligence.” The content of this duty has been long ago established by the courts and in The Marquis of Bute’s Case [1892] 2 Ch 100 the limits of the duty were clearly set out. That case concerned the Cardiff Savings Bank, which allowed by tradition the Marquis of Bute to inherit the presidency of the bank from his father. The Marquis in question became president at the age of six months, and in the following 38 years, he attended only one board meeting. He therefore had no awareness of the business or involvement in it, and the court found that he was not expected to be involved. When financial irregularities by the board were uncovered, the court found that the Marquis was not liable due to his remoteness from the business, despite his formal position on the board. However, it appears as if the courts quickly grew stricter and in Dovey v Cory [1901] AC 477 a director escaped liability for malpractice but only because he had relied on information given to him by the chairman and general manager of the company, and his decision to do so was reasonable and not negligent. The extension since the Marquis’ case therefore, was the application of a reasonableness test.

The standard was further developed in Re City Equitable Fire Insurance [1925] Ch 407 in which three rules were established. These were that: a director must show the skill and diligence that could be expected from a person with his knowledge and experience; his duties are intermittent, and exercised only at board meetings where he participates in decision making; where reasonable, a director is free to delegate tasks and responsibilities to other employees. These rules were affirmed in Dorchester Finance Co. Ltd v Stebbing [1989] BCLC 498 which stated that they applied equally to executive and non-executive directors.

One of the features of the standard set out in Re City Equitable Fire Insurance is the fact that the standard is not that of the professional man, but the reasonable man with the skill and experience that the director in question subjectively possesses. This subjective test is useful for most companies as the more complicated the operation and the more money that is at stake, the more qualified the director is likely to be and the higher the standard. The standard will fall short in cases such as the Marquis of Bute, but this is more to do with the fact that a woefully unsuitable candidate has been appointed to the board, such as a six month old baby. In all but such extreme cases therefore, the subjective case set out in Re City Equitable will be sufficient. The second rule only requires the director to attend meetings and make himself aware of the business of the company “whenever in the circumstances he is reasonably able to do so.” Again this approach gives the law flexibility to allow for very different types of director, depending on the nature of the business. So for example, you could have an elderly family member sitting on the board because he knows the history of the business, and he will not be required to pay constant attention to the business, but simply offer his guidance when reasonably practicable. You could also have, as most companies do, full time salaried directors who are paid to spend all of their time and attention on the affairs of the company. As both types of director will be useful in various circumstances, the law allows for both, and requires each of them to be as aware of the dealings of the company as is reasonable in the circumstances.

The third rule allows directors to delegate responsibility to others, and it might be feared that this will be used by directors to avoid responsibility. However, when taken together with the other rules of the test, it is apparent that a director cannot delegate all of his responsibilities and disallow all awareness of the dealings of the company. He will still be required to be reasonably aware of what is going on and only to delegate tasks which it is reasonable for him to do so, taking into account the nature of business and the circumstances of the case.

However, there are many instances in which these three rules will not protect investors or other stakeholders, for example in the Marquis of Bute case, and there have been calls for some time for an objective standard to be introduced into the law. The DTI Company Law Review Committee, in the 2000 report mentioned above, pointed out that an objective standard has been adopted for the protection of creditors by section 214 of the Insolvency Act 1986^[15] and in the case of Re D’Jan of London Ltd [1993] BCC 646 Hoffman LJ found that the objective standard set out in section 214 of the 1986 Act reflected the standard that all directors were bound to meet when upholding their general duty. Therefore, the objective standard first set out in the insolvency context became the general standard owed by directors in all cases, and section 174 of the 2006 Act affirms that both the objective and subjective standards apply. At section 174(2) the 2006 Act states that the standard required is that which may be met by a “reasonably diligent person with (a) the general knowledge, skill and experience that may reasonably be expected of a person carrying out the functions carried out by the director in relation to the company, and (b) the general knowledge, skill and experience that the director has.” Therefore, as a minimum, the director will be required to demonstrate the care and skill that a reasonable director of a company of that type and standard would be expected to demonstrate. This allows for some flexibility as this minimum standard can still vary depending on the business, so that the director of a small family business will have a lower standard than the director of a FTSE 100 company. At the same time, if a director is chosen because of his particular characteristics, which make him qualified above and beyond what one might expect, he will be held to this higher, subjective standard.

This standard, which upholds an objective minimum standard, which may be increased if the director in question is unusually highly qualified, seeks to strike a balance between protecting the interests of the company, and allowing directors to feel relatively at ease with the personal liability they have taken on board. A different approach was adopted in the USA, where the Supreme Court of Delaware, in Smith v Van Gorkom [1985] 488 A.2d 858 found the ten directors of Trans Union Corporation liable in the sum of $23.5 million for agreeing to a takeover without first valuing the shares of the company. While this failure seems fundamental, the sale of the company’s shares was set to take place at a price significantly higher then the quoted price of the shares on the stock exchange, and the takeover would undoubtedly have benefited the company. The massive liability was imposed without any allegation of fraud or breach of fiduciary duty and resulted in a marked unwillingness of qualified persons taking on the role of non-executive director, at least for a time. It also resulted in a number of states, including Delaware where the decision was made, enacting legislation which allowed companies to exclude or limit the liability of directors for negligent breach of their fiduciary duties. Such a situation has not occurred in English company law, and the standard adopted in section 174 is measured to avoid the need for such a development.

The second main area of directors’ duties falls under the heading of fiduciary duties. At its most simple, this covers the requirement that directors act bona fides in respect of the company. The case law that developed however sets out a number of common instances in which directors are in danger of breaching this duty, and the 2006 Act has proceeded to specify these situations explicitly. While it is not set out as such, the duty to act bona fides can be seen as an overriding interest, which cannot be breached, even when authorised by the shareholders in general meeting. For example, in the case of (Re Attorney-General’s Reference (No. 2 of 1982) [1984] 2 ALR 447 the directors of the company were the only shareholders. They took money from the company and the interpretation given was that the directors had taken the money with the authorisation of the shareholders. Nevertheless, the court found that this was breach of the overriding duty to act bona fides. The case of R v Phillipou [1989] Crim LR 559 found the same overriding duty and these cases were upheld by the House of Lords in R v Gomez [1992] 3 WLR 1067. Therefore, it can be said that there is an overriding duty to act in good faith and even if a majority of the shareholders approve of the action, the directors may not breach it, and a minority of shareholders, or creditors, and possibly employees and other stakeholders, would be able to have the action set aside.

However, it is also possible for directors to breach one of the explicit fiduciary duties, such as using powers for one purpose to achieve a different purpose, which are not dishonest or mala fide. In such cases, the court can find that the breach of the particular fiduciary duty does not place the directors in breach of their overriding duty of good faith, and a majority of the shareholders can vote to authorise such acts. Section 239 of the Companies Act 2006 allows shareholders to ratify breaches of a fiduciary duty, but subsection (7) states “This section does not affect any other enactment or rule of law imposing additional requirements for valid ratification or any rule of law as to acts that are incapable of being ratified by the company”. Therefore, the previous case law which was upheld by the House of Lords in Gomez still limits the ability to ratify. In fact, the specific fiduciary duties have been described as “disabilities” and in Movitex Ltd v Bulfield and Others [1988] BCLC 104 it was upheld that companies could alter their Memorandum and Articles to amend the nature of any fiduciary duty owed by the directors to the company, subject always to the requirement that nothing purported to allow dishonesty. Movitex concerned the concept of self-dealing, which is ordinarily presumed to be a breach of duty. In this case, the company was able to remove this presumption, so that the director was able to engage in self-dealing, but subject to the requirement that he did in fact act in the best interests of the company. A simple example of this would be if a cheese producing company sought to appoint the owner of a supermarket as a director. Self dealing would disable the director from selling cheese to the supermarket he owned, as it would be self-dealing, and very easy for the director to breach his fiduciary duties to the cheese producing company. However, the company could authorise the director to sell to the supermarket concerned, on condition that he did not abuse this ability and breach his duty of good faith. An ordinarily disallowed activity would be allowed, but would still be subject to the requirements of good faith.

The explicit fiduciary duties of the director set out in the 2006 Act are: the duty to act within powers^[16]; the duty to exercise independent judgment^[17]; the duty to avoid conflicts of interest^[18]; the duty to declare interests in proposed transactions or arrangements^[19]; and the duty not to accept benefits from third parties^[20].

Section 171 requires that the director “(a) act in accordance with the company’s constitution, and (b) only exercise powers for the purpose for which they are conferred.” This is an area where the courts have been quite willing to excuse directors if they have used a power for a collateral purpose and a majority of shareholders have been in favour of it. For example, in the cases of Punt v Symonds & Co [1903] 2 Ch 506 and Piercy v S Mills & Co [1920] 1 Ch 77, the court allowed the issue of shares by directors to prevent a hostile takeover and to dilute the influence of hostile shareholders, because the majority of shareholders approved. This was despite the fact that the power had been granted solely to allow the raising of capital. However, in Howard Smith Ltd v Ampol Petroleum Ltd [1974] AC 821 the Privy Council held that where there were two purposes for issuing shares, to raise capital and to prevent a takeover, the proper purpose of raising capital had to be the dominant purpose. In Re Looe Fish Ltd [1993] BCC 368 the directors were disqualified under section 8 of the Company Directors Disqualification Act 1986 for allotting shares for an improper purpose.

Section 173 requires the directors to exercise independent judgment. This is a restatement of the common law duty on directors not to ‘fetter their discretion’. This has acted to reduce the risk of directors being in a conflict of interest situation be disabling them from entering agreements which might prevent them from acting in the best interests of the company in the future. In Fulham Football Clun and Others v Cabra Estates Plc [1994] 1 BCLC 363 the company was paid money in exchange for not opposing property development plans. As the planning process drew out, the question arose of whether the directors had fettered their discretion by agreeing never to oppose such plans. However, the Court of Appeal stated that where a “contract as a whole [was] bona fide for the benefit of the company” it was valid and the directors could bind themselves to do whatever was required to fulfil it.

Section 175 prohibits directors from entering a position where his interests actually or potentially conflict with those of the company. If the constitution of the company permits, the directors can authorise a conflicting situation to be entered into, so long as the relevant director does not vote. Section 175 also requires the director to declare their interests in any contracts, and under section 170, this duty extends after the director has ceased to hold office. The declaration is made to the board. The potential complexity of such situations can be seen in Menier v Hooper’s Telegraph Works [1874] LR 9 Ch D 350 in which the James LJ held that a majority shareholder could not prejudice the interests of the company because of its own conflicting interests. Similarly, in Cook v Deeks [1916] 1 AC 554 the directors sought to conclude the final round of contracts in a large railway development programme in their own names. The court held this was clearly in breach of their duty. In Scottish Co-operative Wholesale Society Ltd v Meyer [1959] AC 324 the directors say on the boards of both a parent and subsidiary company, and as soon as it emerged that the interests of the two companies were conflicting, the directors could not longer remain in that position. As Lord Cranworth said in Aberdeen Railway Co v Blaikie Bros (1854) 1 Macq 461 (HL), “it is a rule of universal application that no one, having [fiduciary] duties to discharge, shall be allowed to enter into engagements in which he has or can have a personal interest conflicting or which possibly may conflict with the interests of those whom he is bound to protect.” One area that the courts have found difficulty with is when a director comes across a profitable opportunity as a result of his position as director. This situation arose in Regal (Hastings) Ltd v Gulliver [1942] 1 All ER 378 in which a cinema company sought to lease two other cinemas. A subsidiary was formed for the purpose, but the owners of the two cinemas would only agree to the lease if the authorised share capital was paid up. As the parent could not afford to do so, some directors personally purchased shares in the subsidiary. When it came time to sell the shares in the subsidiary, the company demanded that the directors account to the company for the profits they had made, and the House of Lords held that they were liable to do so. This was despite the fact that the company would have been unable to exploit the situation because of its own lack of funds. The same principle was applied in Industrial Developments v Cooley [1972] 1 WLR 443 in which a director learned information which would have been profitable to the company and kept it to himself. He then used the information to secure a position at a rival firm and left his present company. His present company could not have secured this position itself and so could not have benefited in the manner in which the director had. Nevertheless, the court found that the director had to account to the company for the profit he had made as a result of information gleaned in the course of his directorship. Gencor ACP Ltd v Dalby [2000] 2 BCLC 734 affirmed that it is no defence that the company would not have exploited the opportunity, although the shareholders can approve of the action and this would justify the director.

As a result of the case law and the wording of the relevant provisions of the 2006 Act, it can be concluded that a director is disallowed from entering a position where one of his person

This brief critically considers the empirical literature on asthma care. Emphasis is on UK studies although research from the USA (and other countries) is also considered. It is argued that both environmental and genetic factors are implicated in asthma onset, based on epidemiological evidence. Deficits in care provision persist: these gaps in care may be attributable to a wide range of modifiable factors, including unsatisfactory health professional (GP, nurses) input, limited use of care plans, and patient unawareness. Overall, however, conclusive inferences about asthma care provision are hampered by:

A preponderance of retrospective/correlational studies, and a paucity of randomised control trials, which demonstrate causality;
A paucity of research on particular gaps in asthma care;
Failure to account for third-variable moderator effects.

The Office for National Statistics (2004) publishes comprehensive statistics on asthma-related mortality, morbidity, treatment, and care, collapsed by demographic categories. Data is collected from the General Practice Research Database (GPRD). Issues addressed include mortality, prevalence, time trends, patients consulting general practice, incidence of acute asthma, and hospital inpatient admissions.

Research suggests that health care providers often fail to agree on the precise criteria for diagnosing asthma, whether mild or severe (e.g. Buford, 2005). Severe asthma is often defined based on pulmonary function measurements, such as forced expiratory volume in 1 second, and hospitalisation. However, neither of these indicators reliably predicts asthma severity (Eisner et al, 2005).

Eisner et al (2005) evaluated the efficacy of a method for identifying a cohort of adults with severe asthma based on recent admissions to an intensive care unit (ICU) for asthma. Four hundred adults with severe asthma enrolled at seventeen Northern Carolina hospitals were surveyed. A control group of patients hospitalised without ICU unit admission was also recruited. The study examined whether admission to an ICU unit is in itself a reliable indicator of asthma severity.

Asthma patients with a recent ICU admission generated higher asthma scores (based on the frequency of current asthma symptoms, use of steroids and other medications, and history of hospitalisations/intubations), and poorer quality of life, were more likely to have been hospitalised, visited an asthma specialist in the previous twelve months, been in an asthma-related emergency department, and received inhaled corticosteroids in the past year. Data analysis controlled key background variables (e.g. demographic factors), increasing confidence in the reliability of the findings. However, this study was based on quasi-experimental design and hence may be confounded by sampling bias.

Trends in annual rates of primary care consultations, mortality, and hospital visits/admissions were monitored for children under 5 years and 5-14 year olds. For children aged <5, weekly general practice consultations rose during the early 1990s, peaked around 1993 (circa 150/100,000 children), then began to decline. This decrease persisted through the 1990s, falling to about 70/100,000 by 2000. Annual hospital admissions have also declined through the 1990s, falling from circa 100/10,000 in 1990 to approximately 50/10,000 by 2000. By contrast the number of patients treated for asthma has increased marginally albeit year-to-year change may be insignificant. Mortality rates decreased steadily, from around 10 million in the 1960s to approximately 2 million the year 2000.

For 5-14 year olds, weekly general practice visits rose in the early 1990s (circa 70/100,000 in 1990), showed a fluctuating pattern through the mid 1990s, but has declined steadily since 1997 (about 50/100,000 by 2000). The number of patients treated annually for asthma has risen slowly but steadily, although this increase seemed to level out by the mid/late1990s. Both mortality rates have dropped steadily since the early 1990s, from about 14 million in 1990 to circa 2 million by 2000. Annual hospital admissions has also fallen steadily, from just under 30/10,000 in 1990 to about 15/10,000 by 2000. These patterns suggest an increase in self-management (e.g. action plans) that obviates the need to visit a general practice, and that asthma care overall is having the desired effect on mortality.

The prevalence of wheezing and asthma in children has generally increased during the last 40 years. Although there is a paucity of reliable national statistics, data is available from specific parts of the UK, notably Leicester, Sheffield, and Aberdeen (see Figure 1).

The prevalence of wheezing increased from 12% (1990) to 26% (1998) in Leicester, and from 17% (1991) to 19% (1999) in Sheffield. The prevalence of asthma showed a similar pattern in both cities, rising from 11% (1990) to 18% (1998) in Leicester, and from 18% (1991) to 30% (1999) in Sheffield. Wheezing incidence rates for Aberdeen increased from 10% (1964), to 20% (1989), 25% (1994), and 28% (1991).

Data from national birth cohorts suggests a sharp increase in the average weekly GP consultations for hay fever/allergic rhinitis from 1991 to 1992. The rates rose from circa 13/100,000 (0-4 year olds) and 40/100,000 (5-14 years olds) in 1991 to about 25/100,000 (0-4 year olds) and 76/100,000 (5-14 year olds) as 1992 approached. Trends subsequently dropped off slightly but then started to show an increase again around 1998. By the year 2000 the figures were roughly 20/100,000 (0-4 year olds), and 56/100,000 (5-14 year olds).

Data from a nationally representative sample of schools across the country suggests that the prevalence of asthma was fairly even across different regions. However, Data for England suggests a higher prevalence outside big cities. The greatest proportions of wheezing was found in the South West, while the highest proportion of asthma cases was found in East Anglia and Oxford (see Figure 2).

In a recent Annual Report, Asthma UK (2003/2004) noted that one child in 10 has asthma and a child is admitted to hospital every 18 minutes due to an asthma attack. Over 600 copies of Asthma in the Under Fives are downloaded from the UK Asthma website monthly and on average every classroom in the UK has at least 3 children with asthma.

The impact of acute asthma can be debilitating. Around 5.2 million people in Britain are presently being treated for asthma, and asthma prevention/care costs the NHS on average almost ?900 (i.e. ?889) million per year. GPs across the country treat over 14,000 new episodes of asthma each week, and UK Asthma met almost 25,000 requests for health promotion documents and other materials.

About 40% of workers who have asthma find that working actually exacerbates their asthma, and 1 in 5 asthmatic people feel excluded from areas of the workplace in which people smoke. Over 12.7 million working days in the UK are lost as a result of asthma, and it is estimated that the annual cost of asthma to the economy is ?2.3 billion.

Asthma UK also states that 82% of people who are asthmatic find that passive smoking triggers their asthma, and 19% of people with asthma indicate that their medical condition makes it difficult for them to play with children in their family. One in 3 children has had their routine daily activities disrupted due to asthma and 39% of asthmatic people are badly affected by traffic fumes (which stop them exercising). About 500,000 people have asthma that is very difficult to control.

In 2003/2004 over 90 researchers worked on Asthma UK-funded projects and, Asthma UK spent ?2.5 million on asthma-related research. The group funded/is funding 63 research projects.

These statistics paint a rather bleak picture of asthma prevalence, incidence, and the effects on people’s lives.

Numerous epidemiological studies have been published that address the etiology of asthma in population groups (International Archives of Allergy & Immunology, 2000; Kitch et al, 2000; Schweigert et al, 2000; Tan, 2001; Court et al, 2002; Smyth, 2002; Weissman, 2002; Tan et al, 2003; Wenzel, 2003; Gibson & Powell, 2004; Barnes, 2005; Pinto & Almeida, 2005).

Barnes (2005) considered evidence on the role of genetic factors in resistance to atopic asthma, Studies which focus on the role of genetic factors in resistance to tropical/parasitic diseases (e.g. malaria) overlap with genetic associations found for asthma. It was concluded that genetic factors might be implicated in the development of allergic illnesses.

Pregnancy is thought to increase the probability of asthma attacks in about 4% of all pregnant women. Beckmann (2006) assessed eighteen pregnant women with asthma. The study was based on a longitudinal design. Participants were recruited from local prenatal clinics and private enterprises, and enrolled during the first trimester. Patients kept a daily log recording peak expiratory flow data until delivery. Three peak-flow assessments were recorded after which the best value was entered into the log. Asthma was diagnosed by a health professional. Participants were also required to record asthma symptoms, exacerbations, medications, and cigarette use. To increase participation, subjects were reminded by telephone to complete their log.

Data analysis showed that peak expiratory flow (PEF) was variable as a function of particular trimesters. Peak air flow was highest during the second trimester, with a statistically reliable difference between the second and third trimester. Unfortunately, the small sample size limits the generalisability of the findings. However, the study was based on a longitudinal design, allowing tentative causal inferences.

Schweigert et al (2000) reviewed the literature on the role of industrial enzymes in occupational asthma and allergy. Enzymes used by detergent manufacturing companies (e.g. amylases, cellulases) are toxicologically benign, with mild irritation effects on the body. However, these enzymes do affected asthma and allergy. Thus, the industry is required to adhere to exposure guidelines for these enzymes.

Kitch et al (2000) considered literature on the histopathology of late onset of asthma (i.e. onset in adulthood), and whether allergic exposure and sensitivity have the same impact on asthma development in adulthood as they do in children. Epidemiological studies suggest that the prevalence of asthma in older adults aged 65years or more is between 4% and 8%. The illness appears to be more common in women, especially those with a long history of smoking, and with respiratory symptoms (e.g. cough, wheeze, shortness of breath). Asthma in adulthood often developed before the age of 40, with maximum incidence occurring around early childhood.

Beyond the age of 20 years the incidence of asthma tends to remain stable through young, middle-aged, and older adulthood. Death rates in adults are generally lower than figures for children; “Mortality rates attributable to asthma among those aged between 55 and 59 years of age and 60 and 64 years of age were 2.8 and 4.2 respectively, per 100,000 people, the highest rates among all age groups” (p.387). However, as adults get older asthma is less and less likely to be identified as the main cause of death due to the increased incidence of other pathology.

Epidemiological research in Japan highlights a link with air pollution (International Archives of Allergy & Immunology, 2000). The prevalence of asthma among kindergarten and elementary school children has increased steadily since the early 1960s, rising from 0.5-1.2% between 1960 and 1969, to 1.2-4.5% (1970-1979), 1.7%-6.8% (1980-1989), and 3.9-8.2% (1990 onwards). By contrast, data indicates little or no change in asthma prevalence amongst adults. Figures range from 1.2% in 1950-1959 to 1.2-4.0% (1960-1969), 0.9-5.0% (1970-1979), 0.5-3.1% (1980-1989) the 1960s to 1.6-2.9% (1990 onwards) (see Figure 3).

Asthma in Japanese children is more common amongst boys than girls although this gender difference has diminished noticeably since the 1960s. Asthma usually appears in infancy or early in childhood but has been known to begin across all age groups. Inherited (genetic) dispositions to allergies have been implicated in the onset of asthma. There is normally a strong correlation between asthma onset and a family history of asthma.

Overall, asthma-related mortality in Japan has decreased since the mid 1990s. Delays in seeking treatment and rapid exacerbation of symptoms have been strongly implicated in asthma mortality. Unfortunately, this article offers little information about the designs of studies reviewed. Inferences regarding the possible causes of asthma morbidity and mortality may be inconclusive if much of the evidence is derived from cohort studies, rather than case control studies that more effectively eliminate alternative causes.

The premenstrual period in women has been implicated in asthma exacerbation. Tan (2001) reviews epidemiological literature suggesting that female sex-steroid hormones may be significant in understanding the premenstrual-asthma link, albeit the available evidence is tenuous. The luteal phase of the menstrual cycle is associated with airway inflammation and hyper-responsiveness, and hence may explain asthma exacerbation during the premenstrual phase. However, this increase in asthma severity can still be treated effectively using the normal drugs.

Studies suggest that premenstrual asthma affects the rate of hospital admissions – the majority of adults admitted are women, indicating that hormonal factors play an important role. Other evidence suggested that emergency presentations increased before ovulation. It is suggested that oral contraceptive pills or gonadotrophin releasing hormone analogues may be especially effective treatments. However, premenstrual asthma was rarely associated with serious mortality. Unfortunately, most of the studies reviewed were retrospective and questionnaire based, and hence subject to response bias. There was a paucity of randomised control trials, or pseudo experiments that may permit causal inferences.

Court et al (2002) considered the distinction between atopic (extrinsic) asthma, common in younger people, and non-atopic (intrinsic) asthma, found mostly in older groups. Additionally, they also considered whether identification of asthma cases in epidemiological research should be based on a doctor’s diagnosis or self-reported asthma symptoms. Nearly 25,000 people in England were surveyed. Data was collected regarding whether participants had experienced wheezing in the past 12 months and/or had been diagnosed as asthmatic by a doctor.

People with atopic asthma were more likely to have experienced wheeze and been diagnosed as asthmatic in the past, compared with the non-atopic group.

Logistic regression analysis showed that gender, social class, smoking status, living in an urban/rural area, and house dust mice (HDM), were all risk factors for the presence of wheeze both with (age not significant) and without (urban/rural area not significant) a diagnosis of asthma. Wheeze/asthma was more prevalent in women, younger people, lower social classes, previous/current smoking, living in an urban area, and greater HDM IgE levels. Smoking status, social class, and age were all risk factors for wheeze in both atopic and non-atopic cases. Gender was also a risk factor for atopic subjects, and urban living for non-atopics.

Other research has considered the epidemiology of severe or ‘refractory’ asthma, which is rather less well understood compared with milder forms of asthma. Wenzel (2003) reviews evidence indicating that severe asthma (defined as asthmatics requiring continuous high-dose inhaled corticosteroids or oral corticosteroids for over half of the preceding year) may account for circa ? 5% of asthma cases. Data from a large Australian-based study, which has followed a large cohort of asthmatics for over three decades, implicates childhood pulmonary problems with reduced lung function in adulthood.

Data suggests that over two-thirds of severe asthmatics were afflicted with asthma in childhood. Other risk factors implicated include genetic mutations (in the IL-4 gene and IL-4 receptor), and environmental factors (e.g. allergen, tobacco exposure, house dust mite, cockroach and alternaria exposures), respiratory infections (e.g. pathogens like chlamydia), obesity, gastroesophageal reflux disease, increased body mass index, lack of adherence to corticosteroid regimes, and poor physiological response to medication. Physiological factors are also implicated, notably structural changes in airway reactivity, inflammation of the peripheral regions of the lungs. Steroids are the main form of treatment.

Tan et al (2003) demonstrated the role of respiratory infection in patients with severe (i.e. near fatal) asthma, acute exacerbations, or chronic obstructive pulmonary illness (COPD). Participants had all been diagnosed as asthmatic by a physician and were undergoing treatment. All showed evidence of forced expiratory volume in 1 second (FEV1) increase of 200mL. COPD patients were suffering from chronic cough and dyspnea, with a predicted FEV1% 50%, with no ?-agonist reversibility. Near fatal cases were patients undergoing ventilatory support in the intensive care unit of a hospital (National University Hospital and Alexandria Hospital, Singapore) as a result of a severe exacerbation.

Acute asthma subjects were characterised by non-improvement following administration of ?-agonists, and/or severe exacerbation judging from clinical/blood data. Analysis showed that near-fatal cases were the least likely to have the influenza A + influenza B virus, but the most prone to have adenovirus and picornavirus, compared with the other two groups (see Figure 4). This suggests that viral infection may be a risk factor for severe asthma. However, due to sampling size/bias (n= 68), and failure to control for key background variables (e.g. asthma history, smoking history, prior medication use, and outpatient spirometry), the findings can be considered tentative.

Smyth (2002) reviewed epidemiological studies on asthma in the UK, and worldwide. The number of new asthma cases seen by GPs has increased noticeably since the mid 1970s. Nevertheless, asthma incidence has tended to decrease since the early 1990s, consistent with data from the Office for National Statistics (2004). By the year 2000 circa 60-70, 40-50, 20-25 new cases (per 100,000 of a given age group) were reported amongst, respectively, preschool children, 5-14 year olds, and people older than 15 years. Significant ethnic differences have been reported, with high asthma prevalence in Afro-Caribbean children. Since 1962, the number of preschool children hospitalised for asthma rose steadily, then peaked in the late 80s and early 90s, and has begun to decline since. The hospitalisation rates in 1989 were 90/10,000 (preschool children), 30/10,000 (5-14 year olds), and 10/10,000 (15 years or older). By comparison the rates for 1999 were 60/10,000, 20/10,000, and 10/10,000 respectively (see Figure 5).

The British Thoracic Society identifies specific benchmarks or ‘best practice’ which health professionals are required to meet when caring for asthma patients (BTS, 2004). These recommendations are mostly based on scientific evidence from RCTs, epidemiological studies (cohort and case-control), meta-analytic reviews, and other good quality research. The recommendations related specifically to the following topics:

Diagnosis and assessment in children and adults (e.g. key symptoms, recording criteria which justified diagnosis of asthma);
Pharmacological management (e.g. use of drugs [inhaled steroids, ?2 agonist] to control symptoms, prevent exacerbation, eliminating side effects, employing a ‘stepwise’ protocol for treatment);
Use of inhaler devices (technique and training for patients, agonist delivery, inhaled steroids, CFC vs. HFA propellant inhalers, suggestions on prescribing devices);
Non-pharmacological management (e.g. breast feeding and modified milk formulae for primary prevention, and allergen avoidance for secondary prevention, alternative medicines);
Management of acute asthma (initial assessment, clinical features, chest x-rays, oxygen, steroid treatment, referral to intensive care)
Asthma in pregnancy (drug therapy, management during labour, drug treatment in breastfeeding mothers);
Organisation and delivery of care (e.g. access to primary care delivered by trained clinicians, regular reviews of people with asthma, audit tools for monitoring patient care after diagnosis);
Patient education (e.g. action plans, self-management, compliance with treatment regimes).

Overall, despite these guidelines, recent research suggests that patients’ treatment needs are not being met. For example, Hyland and Elisabeth (2004) report data on the unmet needs of patients. Focus groups were organised between parents, patients, and clinicians. Patients and parents reported various needs that weren’t been met including frequent exacerbations, and a preference for less complex drug regimens (i.e. with fewer drugs). Many individuals had worries regarding treatment and experienced asthma symptoms 3 or more days per week. As Levy (2004) suggests, there is a need for health professionals to address these concerns, especially in relation to the BTS guidelines.

Levy, a GP and Research Fellow in Community Health, identified current deficiencies in the care of asthma victims. These comprised:

Higher than expected exacerbations (42/1000 patients per year);
Under-diagnosis: more patients presenting for treatment with uncontrollable asthma, who had not been diagnosed previously;
Deficiencies in treatment uptake: many patients fail to collect their prescriptions;
Many patients with symptoms delay presenting for treatment, until their medical situation becomes critical;
Health care professionals are failing to assess patients objectively (PEF, oximetry), both pre- and post-treatment;
Failure to adhere to national guidelines for the care of acute asthma (e.g. not enough oral steroids and ?-agonists are prescribed for patients presenting with asthma attacks.
Considerable variations across GPs, NHS Trusts, clinics, and other sources of care provision: patient follow-up appointments range from a few days to six months, in direct violation of standards set by the British Thoracic Society (BTS, 2004).

Levy suggests various strategies for improving asthma care including diagnosis criteria (e.g. “any patient with recurring or respiratory symptoms [cough, wheeze, or shortness of breath], or who has been prescribed anti-asthma treatment should be considered to have asthma” (p.44)), use of computerised templates, having systems or triggers in place for recalling patients (e.g. patients requesting more medication, or who have been seen out of hours), introducing more effective protocols for monitoring and informing asthma patients (e.g. using a checklist to ascertain various key information on patients status, such as effects of asthma on patients life, recent exacerbations), providing written self-management plans (e.g. how to detect uncontrolled asthma, using PFM charts), and having an agreed procedure for managing acute asthma attacks (e.g. selecting a low threshold for using oral steroids).

Currently there is a lack of research testing the value of these recommendations on asthma health outcomes. However various strategies are continually being implemented in various parts of the country to improve the quality of asthma care. For example,

Holt (2004) describes the effects of implementing the RAISE initiative, launched by the National Respiratory Training Centre, in a primary care setting. This scheme is designed to raise awareness of existing variations in standards of care, improve standards of care through education, support, and feedback, increase awareness and understanding of respiratory disease, use asthma as platform to demonstrate the value of shared experiences across different agencies/professionals, and augment the profile of primary care settings as the main source of asthma care and innovation. The RAISE led to various improvements, such as:

The use of ‘active’ and ‘inactive’ asthma registers, to distinguish patients who currently have asthma symptoms from those who don’t.
Introduction of computerised templates to improve accuracy and reliability of data recording during consultations (e.g. progressing sequentially from assessment of symptoms, to peak flow, inhaler, and advice stages).
Use of symptom questionnaires (e.g. handed out with repeat prescriptions) that help patients with well-managed asthma decide whether they can opt for a telephone consultation, rather than taking the trouble to visit the practice for a face-to-face consultation.

Haggerty (2005) identifies several factors paramount to effective care and management of asthma in UK patients. These comprise adequate patient education about the nature of asthma (e.g. number of asthma episodes, use of quick relief medicines, long term symptoms, restrictions on daily activities, and emergency visits), use of asthma action plans, and customised treatment plans (to achieve early control), and addressing patients own concerns and perception.

Treatment for asthma is usually in the form of regular inhaled corticosteroids (ICS), oral corticosteroids (OCS), and ? agonists. These treatments are usually administered by a health professional when symptoms manifest and/or become severe. However, since asthma can often exacerbate rapidly, before an individual can seek medical help, it is vital that asthma patients receive the necessary care from health professionals, and also self-management skills. GPs and nurses play a critical role.

Griffiths et al (2004) conducted a randomised control trial to assess the effect of a specialist nurse intervention on the frequency of unscheduled asthma care in an inner city multiethnic clinic in London. The role of specialist nurses in asthma care has been uncertain. Interventions in which specialist nurses educate patients about asthma, after hospital attendance with acute asthma, were shown to have inconsistent effects on unscheduled care. However, outreach initiatives to educate medical staff had shown no effect. Thus, an intervention was designed that combined patient education with educational outreach for doctors and practice nurses. It was suspected that such an integrated approach would benefit ethnic minority groups, especially given their higher hospital admission rates and reduced access to care during asthma exacerbation. The key research question was whether specialist nurses could improve health outcomes in ethnic minority groups.

Outcome variables were the percentage of patients receiving unscheduled treatment for acute asthma during a 12 month period, and time to first unscheduled attendance with acute asthma. The study was based on 44 practices in two east London boroughs. Participants comprised over 300 patients (aged 6 to 60) who were admitted to or attending the hospital, or the out of hours GP service with acute asthma. Half the sample were classified as South Asians, 34% were Caucasian, while 16% were Caucasian. The intervention was based on a liaison model. Practices were assigned to either a treatment or control condition.

Practices randomised to the treatment condition ran a nurse led clinic involving liaison with GPs and practice nurses, incorporating education, raising the profile of guidelines for the management of acute asthma, and providing on-going clinical support. In practice these practices received two one-hour visits from a specialist nurse who discussed guidelines for managing patients with acute asthma. Discussions were based on relevant empirical evidence. A computer template was provided to elicit patient information on various treatment issues, such as inhaler technique and peak expiratory flow, and offer self-management advice. By contrast, control practices received a visit promoting standard asthma care guidelines.

Data analysis showed that the intervention lengthened the time to first attendance (median 194 days for intervention practices, and 126 days for control practices), and also reduced the proportion of patients presenting with acute asthma (58% treatment practices versus 68% in control practices (see Figure 6). These effects were not moderated by individual differences in ethnicity, albeit Caucasians seemed to benefit more from the intervention compared with minority ethnic groups.

O’Connor (2006) noted that asthma care in the UK remains below the required standards. The majority of the 69,000 hospital admissions and circa 1400 deaths annually are attributable to poor patient adherence to treatment regimens. Nurses, it is argued, play an important role in promoting adherence. Additionally, use of a new inhaled corticosteroids – circlesonide – may also help increase adherence. Circlesonide is much easier to use than more established asthma drugs (e.g. it has a once-daily dosing). Evidence is reviewed suggesting that peak expiratory flow remains stable when patients are given circlesonide compared with a placebo.

Tsuyuki et al (2005) assessed the quality of asthma care delivered by community-based GPs in Alberta, Canada. They reviewed clinical charts for over 3000 patients from 45 primary care GPs. Of this number 20% had ever visited an emergency department or hospital, 25% had evidence that a spirometry had been performed, 55% showed no evidence of having received any asthma education, 68% were prescribed an inhaled corticosteroid within the past 6 months, while a very small minority (2%) had received a written action plan. Figure 6 shows percentage of participants receiving medication.

Sixty-eight percent were prescribed an inhaled corticosteroid, 11% were given an oral corticosteroid, and 80% received a short acting ?-agonist, while 8% were prescribed a long acting ?-agonist. Participants with an emergency room/hospital event were (marginally) more likely to be prescribed medication (no group differences in use of short acting ?-agonists). Regarding pulmonary testing, 25% had evidence of a pulmonary function test (not peak flow), 46% had peak flow monitored, 34% showed no evidence of pulmonary function tests, while 26% had an x-ray. Again individuals with an emergency room/hospital event were more likely to be tested (see Figure 7).

Data about education received by patients was also evaluated. Twenty-two percent received information about environmental triggers, 20% on inhaler use, 10% on how to perform a home PEF test, 2% on written action plans, while 55% received no education at all. Those with an emergency room/hospital event were more likely to receive education. Receiving asthma education, use of spirometry, and prescription of inhaled corticosteroids, were all predicted by number of asthma-related clinic visits (4 or more) and having an emergency room/hospital event. Additionally, asthma education was predicted by cormorbidities, and absence of documentation regarding asthma triggers, while use of spirometry was predicted by being a non-smoker, and symptoms or triggers. Finally, use of inhaled steroids was predicted by symptoms.

Overall, this study highlights numerous gaps in the care provided by GPs, partly echoing criticisms of GPs in the UK (Levy, 2004). For example, Levy (2004) cited ‘under

The modern meaning of the word ‘gender’ emerged in the 1970s. Its original purpose was to draw a line between biological sex and how particular thoughts and behaviours could be defined as either ‘feminine’ or ‘masculine’ (Pilcher & Whelehan, 2004). The reason for using the word ‘gender’ was to raise awareness of the exaggeration of biological differences between men and women. The popularity of this meaning for the word ‘gender’ resulted from the efforts of second wave feminism in the 1970s. This essay examines how second wave feminism attempted to construct a ‘grand narrative’ of women’s oppression. It then examines Judith Butler’s contribution to post-modern feminist theory through her performative theory of gender and how this fits into post-modern feminist debates.

A product of second wave feminism, which began around 1970, was the attempt to place women within a ‘grand narrative’ history of their oppression. One of the seminal writers on this narrative was Simone de Beauvoir. Her work in describing how women had become ‘the other’ in her book The Second Sex (de Beauvoir, 1961) laid the foundations for what was to come in the second wave of feminism (Gamble, 2002). De Beauvoir argues that the way in which men think about women is only in relation to their fantasies, that they have no substance of their own. Unfortunately, for de Beauvoir, women have come to accept men’s fantasies of womanhood as constituting their own conception of themselves. For de Beauvoir, it was for women to conceive of themselves in their own terms, to take back the power themselves.

A criticism of de Beauvoir’s approach was that it tended to blame women for their current condition (Gamble, 2002). The second wave feminists of the 1970s, however, such as Millet (1970), pointed to patriarchy as the root cause of women’s oppression. It is patriarchy, so Millet argued, that has become a political institution, and from this flows all the other forms of women’s oppression. Firestone (1970) also took a strong line against patriarchy, equating women’s oppression to a caste or class system. Ideological support for patriarchy, in Firestone’s view, has come from institutions such as the family, marriage along with romantic love.

These ideas are referred to as constructing a ‘grand narrative’, a way of charting the history and development of particular ideas, in this case women’s oppression (MacNay, 1997). One of the problems that much feminist thought has come up against in trying to provide a ‘grand narrative’ of women’s oppression is that it is difficult to effectively give all women a common identity (Whelehan, 1995). If the very idea of gender flows from cultural origins, then it is only natural to conclude that gender has different meanings in different cultural contexts. How then can a common identity be posited?

Other critics such as Richards (1982), examining second wave feminism from a liberal perspective, have seen it as a movement that has failed. Richards sees many of the feminist approaches as being extreme and unattractive, and not focussing, as she sees it, on rational debate. She criticises feminists for utilising ‘eccentric’ arguments which do not conform to the normative expectations of philosophical debate. Further, she criticises feminism for ignoring the obvious differences between men and women – such as women’s ability to have children – and thereby presenting an unrealistic picture of utopian gender relations.

Another vibrant stream of criticism against second wave feminism has been that it assumes that what is required is a reversal in the relative positions of men and women. In other words, if women can take the position of men in society then their oppression will finally be undone (Brooks, 1997). Instead, however, post-modernist forms of feminism have tended to criticise the placing of women and men in oppositional categories. Post-modernist writers, such as Judith Butler, Brooks argues, help the feminist debate move on from the grand narrative to the focussing on deconstruction and identity (Brooks, 1997).

Judith Butler’s work as a social theorist has been extremely influential. Some of the major themes of her work include important contributions to queer theory and her criticism of the way in which gender has been constructed (Clough, 2000). Her breakthrough work was Gender Trouble which strongly criticised existing feminist theory on gender such as the work of Firestone and Millet.

Butler (1990) points out that feminist approaches have tended to emphasise the difference between gender and sex. In these perspectives sex is seen as a biological fact, while gender is a cultural construction. The problem for Butler is that this split has gone too far, such that it is not possible to analyse how the sexed body is constituted (Salih & Butler, 2004). Rather than splitting gender and sex, then, Butler’s work has actually collapsed one into the other (Fraser, 2002). Sandford (1999) explains that this is achieved by showing that gender actually produces sex.

Butler (1990) asks whether it is possible to talk about the ‘masculine’ attributes of a man and then talk about their ‘feminine’ attributes and still be able to ascribe sensible meaning to the word ‘gender’. Butler (1990) argues that when the idea of ‘woman’ and ‘man’ are dispensed with, it is more difficult to see how these gendered attributes can still be viable. Butler (1990) states that gender cannot necessarily be referred to in terms of these attributes, or as a noun, a thing of itself, but rather as a verb. In this sense Butler considers gender to be performative, to be an act which constitutes itself rather than flowing from some other source.

The criticism aimed by Butler (1990) at feminist theory is precisely that it has argued there must be a source for actions. This means that gender cannot be ‘performed’ of itself; it must be performed by something. Butler (1990) provides an example in the relationship between sexual desire and gender. Freud’s explanation that attraction comes from biological sex is considered by Butler. She argues that sexual attraction, rather than coming from sex, is a process that is learned over time, that is a performance we work on, not something flowing directly from biological sex.

The political implications of this argument are vital, especially for homosexuality. Kirsch (2001) argues that some people in the queer movement have accepted the primacy of biology. This idea is related to essentialism which relies on factors such as the ‘gay gene’ to explain homosexuality. In contrast to this view, a constructionist approach concentrates on the ways in which society encourages certain types of behaviour through social norms. ‘Men’ and ‘women’, within Butler’s theory, are no longer essentialist universal categories but rather free-floating categories which are socially produced.

The norms to which Butler is referring are those which see the body as being directly related to the types of sexual desire and practices that are associated with it (Salih & Butler, 2004). Sexual desires and practices which do not fit within this matrix are ‘not allowed’. In order to understand how sexed bodies are produced, Butler uses Lacan’s reading of Freud (Salih & Butler, 2004). Lacan argues that it is through fantasy that the sexed body is created. Salih (2002) points out that it is Butler’s use of Freud that is one of her most important achievements. Here, she analyses Freud’s idea of the Oedipus complex. This is where the child is forced to give up its desire for its parents by the incest taboo. Butler reinterprets this by arguing that the child desires the parent of the same sex, but finds that this is taboo. Sex and gender identities are then formed from this taboo. Butler argues that everyone’s gender identity is formed from this homosexual taboo. Butler refers to the formation of gender identity in terms of melancholic identification (Salih, 2002). The place where this identification can be seen, according to Butler, is on the body in the form of gender and sex identities.

While Butler’s theory of performativity along with her work in post-modern feminist theory has been extremely influential, it has also provoked a fair degree of criticism. Benhabib (1995) has argued that the death of the subject, which is at the heart of Butler’s thesis, leads to an incoherent picture. Benhabib (1995) points out that it is difficult to believe there is nothing behind the mask of gender, that agency appears completely absent. In a parallel argument to Benhabib, Kirsch (2001) makes the point that this negation of the subject has negative consequences for ideas of identity and collective action. A sense of collectivity, in particular, is often seen by those ‘coming out’ as providing support. In Butler’s theory, however, there is only the focus on the individual. To Kirsch (2001) it seems that Butler’s theory tends to reduce the ability of the wider community to provide support to the individual.

A more generalised criticism of modern feminism, however it is labelled, is that there is a sense in which it is an exclusive club. Butler’s ideas relating to the performativity of gender are only available to a certain restricted group in society: white, middle-class, intellectual (Whelehan, 1995). Each feminist sub-movement implicitly creates its own lists of what can be done, and what cannot. Women, therefore, can find it difficult to label themselves as feminists as there are now many apparent bars to entry and negative associations with it (Whelehan, 1995).

Perhaps in this sense second wave feminism, as enunciated by Firestone and Millet, provided a vision with which it was easier to associate. In contrast, post-modern perspectives, a category in which Butler’s work has been put, provide a much more complex and illusory analysis of gender; even, as some critics would have it, making it harder for those attempting to live outside society’s norms.

It has been argued that theories such as those put forward by Butler have lead to the need for a new type of feminism (Pilcher & Whelehan, 2004). This is precisely because postmodernist thought has rejected the ‘grand narratives’ associated with second wave feminism. As a result, women may find it difficult to claim the identity ‘woman’ as its nature is so contested in postmodernist thought (Pilcher & Whelehan, 2004). This is part of the problem that so-called ‘post-feminism’ has attempted to address.

This leads to an attempt to answer the question: “What gender am I?” Viewed through the influence of Butler’s theories, it is increasingly difficult to provide a clear answer. The two answers that are most ‘natural’, male or female suddenly become obsolete expressions which appear devoid of their previous meaning. With the ‘subject’ apparently removed from the equation, it is difficult to lay claim to any particular gender. Certainly Butler’s theory does not imply that both men and women can travel without hindrance across the boundaries of gender, far from it. Naturally society’s norms still apply and even transgressions are carried out in relation to the norms themselves. Ultimately, though, the question comes back to the problem of agency. If it is up to me to choose my gender, as I wish, then who is doing the choosing? When Butler even rejects the idea of there being an actor at all, all meaning fades from the question “What gender am I?”

In conclusion, the second wave of feminism brought a grand narrative view of the history of women’s oppression. It pointed to oppression as a political institution enforced through social mechanisms such as the family, marriage and economics.

Critics of this approach, however, questioned whether it was possible to set women up in direct opposition to men. Judith Butler responded to the second wave view by collapsing the ideas of gender and sex into each other. Gender, she argues, is performed, and so the subject in feminist thought, was apparently destroyed. But, argued critics of Butler, these notions of gender appear to restrict the political power of feminism, to leave it toothless, without its subject. Attempting to answer the question “What gender am I?” when viewed in the light of Butler’s theory, leads to a sense of confusion. I could be both, I could be either, I could be neither. Is this freedom, or is it just too free-form?

References

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Brooks, A. (1997). Postfeminisms: Feminism, cultural theory, and cultural forms. Oxford: Routledge.

Butler, J. (1990). Gender Trouble: Gender and the Subversion of Identity. Oxford: Routledge.

Clough, P. T. (2000) Judith Butler. In: G. Ritzer (Ed.). The Blackwell Companion to Major Social Theorists. Oxford: Blackwell Publishing.

Beauvoir, S. (1961). The Second Sex. Translated by HM Parshley. New York: Bantam.

Firestone, S. (1970). The dialectic of sex: The case for feminist revolution. New York: William Morrow and Company.

Fraser, M. (2002). What is the matter of feminist criticism? Economy and Society, 31(4), 606-625.

Gamble, S. (2002). The Routledge companion to feminism and postfeminism. Oxford: Routledge.

Kirsch, M. (2001). Queer theory and social change. London: Routledge.

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Millet, K. (1970). Sexual politics. London: Ballantine.

Pilcher, J., & Whelehan, I. (2004) Key concepts in gender studies. London: Sage.

Richards, J. (1982). The sceptical feminist: a philosophical enquiry. London: Penguin.

Salih, S. (2002). Routledge critical thinkers: Judith Butler. Oxford: Routledge.

Salih, S., & Butler, J. (2004). The Judith Butler reader. Oxford: Blackwell Publishers.

Sandford, S. (1999) Contingent ontologies: sex, gender and “woman” in

Simone de Beauvoir and Judith Butler. Radical Philosophy 97, 18–29.

Whelehan, I. (1995). Modern feminist thought: from the second wave to post-feminism. Edinburgh: Edinburgh University Press.