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Background The BNT162b2 mRNA vaccine has been shown to be effective at preventing serious COVID-19 events in clinical trials. There is less evidence on effectiveness in real-world settings, especially for older people. Here, we aimed to estimate vaccine effectiveness in the context of the rapid NHS mass-vaccination programme in England, exploiting age-based vaccination eligibility thresholds to minimise and correct for selection bias. Methods We studied 170,226 individuals between the ages of 80 and 83 years from community settings outside care homes who received one dose of BNT162b2 mRNA between the 15 and 20 December 2020 and were scheduled a second dose 21 days later. We matched these vaccine recipients to slightly younger (aged 76–79 years) persons not yet eligible to receive the vaccine on gender, area of residence, area deprivation, health status, living arrangements, acute illness, and history of seasonal flu vaccination. We compared their rates of COVID-19 positivity and hospitalisation in the subsequent 45 days. We adjusted for the increasing concentration of COVID-19 positivity in the control population caused by the requirement to have no COVID-19 symptoms prior to vaccination. Results Emergency hospital admissions were 51.0% (95% confidence interval 19.9 to 69.5%) lower and positive COVID-19 tests were 55.2% (40.8 to 66.8%) lower for vaccinated individuals compared to matched controls 21 to 27 days after first vaccination. Emergency admissions were 75.6% (52.8 to 87.6%) lower, and positive COVID-19 tests were 70.1% (55.1 to 80.1%) lower 35 to 41 days after first vaccination when 79% of participants had received a second dose within 26 days of their first dose. Conclusions Receipt of the BNT162b2 mRNA vaccine is effective at reducing COVID-19 hospitalisations and infections. The nationwide vaccination of older adults in England with the BNT162b2 mRNA vaccine reduced the burden of COVID-19.

Analyses of an individual's sexual orientation over time are desirable for policy evaluations and in estimating causal effects. We explore whether accounting for those who change sexual orientation over two time points, to create a measure of fluidity, produces substantially different results compared to sexual orientation measured at one time point and extrapolated to subsequent survey waves. We use seven waves of the UK Household Longitudinal Study which asked sexual orientation identity questions at two time points: waves three (2011-2013) and nine (2017-2019). Using the relationship with sexual orientation and various health outcomes as an empirical example, via a correlated random effects estimation approach, we find that the infrequent reporting of sexual orientation could over-estimate the negative impact for lesbian, gay and "other" individuals and under-estimate the negative impact for bisexuals. We further test the feasibility of the fluidity measure by examining attrition by sexual orientation identity and find small but statistically significant probabilities of attrition. Correction for attrition bias through inverse probability weighting makes little difference to the results. These results highlight the importance of accounting for changes in sexual orientation in empirical analysis and that doing so is feasible.

Aims: To estimate how a scheme to pay substance misuse treatment service providers according to treatment outcomes affected hospital admissions.Design: A controlled, quasi-experimental (difference-in-differences) observational study using negative binomial regression.Setting: Hospitals in all 149 organisational areas in England for the period 2009-10 to 2015-16.Participants: 572,545 patients admitted to hospital with a diagnosis indicating drug misuse, defined based on ICD-10 diagnosis codes (37,964 patients in 8 intervention areas and 534,581 in 141 comparison areas)Intervention and comparators: Linkage of provider payments to recovery outcome indicators in 8 intervention organisational areas compared with all 141 comparison organisational areas in England. Outcome indicators included: abstinence from presenting substance, abstinent completion of treatment, and non-re-presentation to treatment in the 12 months following completionMeasurements: Annual counts of hospital admissions, emergency admissions, and admissions including a diagnosis indicating drugs misuse. Covariates included age, sex, ethnic origin, and deprivation. Findings: For 37,245 patients in the intervention areas, annual emergency admissions were 1.073 times higher during the operation of the scheme compared with non-intervention areas (95% CI [1.049; 1.097]). There were an estimated additional 3,352 emergency admissions in intervention areas during the scheme. These findings were robust to a range of secondary analyses. Conclusion: A program in England from 2012-2014 to pay substance misuse treatment service providers according to treatment outcomes appeared to increase emergency hospital admissions.

Aim To compare drug recovery outcomes in commissioning areas included in a ‘payment by results’ scheme with all other areas. Design Observational and data linkage study of the National Drug Treatment Monitoring System, Office for National Statistics mortality database and Police National Computer criminal records, for 2 years before and after introduction of the scheme. Pre–post controlled comparison compared outcomes in participating versus non-participating areas following adjustment for drug use, functioning and drug treatment status. Setting Drug services in England providing publicly funded, structured treatment. Participants Adults in treatment (between 2010 and 2014): 154 175 (10 716 in participating areas, 143 459 non-participating) treatment journeys in the 2 years before and 148 941 (10 012 participating, 138 929 non-participating) after the introduction of the scheme. Intervention Scheme participation, with payment to treatment providers based on patient outcomes versus all other areas. Measurements Rate of treatment initiation; waiting time (> or

Pharmacogenomics, ie, the study of how an individual’s genomic profile influences his or her response to drugs, has emerged as a clinical tool to optimize drug therapy. Certain variants in some genes increase the risk of severe, life-threatening adverse effects from certain drugs. Integrating pharmacogenomics into clinical practice to assist in drug selection and dosing has the potential to improve the outcomes of treatment, reduce the risk of drug-induced morbidity and death, and be cost-effective.

The teaching and learning of English as a second language have always been emphasized by the Ministry of Education (MOE). In the Malaysia Education Blueprint (2013–2025), among the many goals is to produce learners who can comprehend the language for various purposes, including for information and enjoyment. Over the years, the teaching and learning of English have changed from conventional chalk-and-talk methods to modern methods that involve various platforms such as Quizizz, which is free and easy to use. This systematic literature review focuses on teachers’ perception on the use of Quizizz in the teaching and learning of English. Using the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) review methodology, a total of 45 articles related to the use of Quizizz in the English language classroom were identified from the ERIC and Google Scholar databases. Based on the articles from the year 2017 to 2021, the results show that the mixed-method research design was most used to gather teachers’ perspectives on the use of Quizizz in the teaching and learning of English. Overall, the results of this study show that Quizizz is accepted positively among teachers due to its effectiveness, feasibility, ease of use, and motivating nature for learners. As a suggestion for future research, more focus can be put on investigating the effectiveness of Quizizz from the perspective of parents and issues related to the implementation of gamified learning, such as Internet connection and device availability.

Health care decision makers are required to make planning decisions over a medium to long term planning horizon. Whilst population ageing is an important consideration for planners, age-stratified demographic models may produce misleading estimates of future resource requirements if the actual relationship between age and health is not fixed. We present a methodology which tests whether the assumption of a fixed age-health relationship is valid and estimate the magnitude of planning errors using a long time-series of measures of chronic health and service utilisation (N = 2419) taken from the Great British General Household Survey (1980-2008). We find that age-only models contain significant omitted variable bias, and that the relationship between age and health varies significantly across birth cohorts. Chronic sickness has fallen across birth cohorts born between 1890 and 2008, particularly before birth year 1930. Generational health improvements have mitigated the effects of population ageing, meaning that the population rate of sickness fell between 1980 and 2008. Planning based only on age leads to overestimation of the population level of health care need if successive cohorts are becoming healthier. Many alternative approaches exist which allow planners to relax the assumption of a fixed relationship between age and health.

A qualitative and quantitative evaluation of the Advancing Quality pay-for-performance programme in the NHS North West Ruth McDonald,1* Ruth Boaden,2 Martin Roland,3 Soren Rud Kristensen,4 Rachel Meacock,4 Yiu-Shing Lau,4 Tom Mason,4 Alex J Turner4 and Matt Sutton4 1Manchester Business School and Centre for Primary Care, University of Manchester, Manchester, UK 2Manchester Business School, University of Manchester, Manchester, UK 3Institute of Public Health, University of Cambridge, Cambridge, UK 4Manchester Centre for Health Economics, University of Manchester, Manchester, UK *Corresponding author ruth.mcdonald@mbs.ac.uk Background: Advancing Quality (AQ) is a voluntary programme providing financial incentives for improvement in the quality of care provided to NHS patients in the north-west of England. Objectives: (1) To identify the impact of AQ on key stakeholders and clinical practice; (2) to assess its cost-effectiveness; (3) to identify key factors that assist or impede its successful implementation; and (4) to provide lessons for the wider implementation of pay-for-performance schemes across the NHS. Design: We tested whether or not the financial incentives of AQ had an impact on mortality using two methods: a between-region difference-in-differences analysis comparing the North West region and the rest of England for the incentivised and non-incentivised conditions and a triple-difference analysis comparing performance on the incentivised conditions, as well as the non-incentivised conditions, in the North West region and the rest of England. A cost-effectiveness analysis of AQ based on the first 18 months of the programme was also undertaken. We used interviews and observation to explore how and why changes occurred. Results: Risk-adjusted mortality rates for all three of the conditions we studied (pneumonia, heart failure and myocardial infarction) decreased in both the North West region and the rest of England during the first 18 months of the scheme. The reduction in mortality for incentivised conditions was greater in the North West region than in the rest of England. Compared with non-incentivised conditions within the North West region, there was a significant reduction in overall mortality for incentivised conditions, comprising a statistically significant reduction in pneumonia and non-significant reductions in the other two conditions. Comparing mortality for the incentivised conditions with mortality for these conditions in other regions, there was a significant reduction in overall mortality in the North West region, again made up of individually significant reductions in pneumonia and non-significant reductions in the other two conditions. The reduction in mortality over the 18-month period studied for non-incentivised conditions was not significantly different between the North West region and the rest of England. The between-region difference-in-differences analysis after 42 months showed that risk-adjusted mortality for the incentivised conditions fell in the rest of England and the North West region. This reduction in the rest of England was significantly larger than in the North West region and was concentrated in pneumonia. However, the reductions in mortality were larger for the non-incentivised conditions in the North West region than in the rest of England between these periods. DOI: 10.3310/hsdr03230 HEALTH SERVICES AND DELIVERY RESEARCH 2015 VOL. 3 NO. 23 © Queen’s Printer and Controller of HMSO 2015. This work was produced by McDonald et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. v For incentivised conditions, the triple-difference analysis shows a larger reduction in mortality for the rest of England than in the North West region between the shortand long-term periods. Conclusions: Based on the first 18 months, the AQ programme was a relatively effective and cost-effective intervention. However, findings at 42 months are open to interpretation. One interpretation is that the short-term improvements were not sustained and that the observed improvements in mortality in the non-incentivised conditions within hospitals participating in AQ were unrelated to the programme. An alternative interpretation is that these improvements are related to the positive spillover effect of AQ. Further research should be undertaken to determine the explanation for the findings. Funding: The National Institute for Health Research Health Services and Delivery Research programme. ABSTRACT NIHR Journals Library www.journalslibrary.nihr.ac.uk vi

This research examines mother-daughter conflict in freshmen/first-year female students (18 - 21 years) enrolled at the Faculty of Social Sciences (FSS), University of the West Indies (UWI), St. Augustine, Trinidad. The concentration on mothers in full or part-time paid employment is reinforced by Pickhardt [1] who argued that mothers are more comfortable than fathers in family conflict. The purpose of the study was to describe the structure of a typical mother-daughter conflict by examining its causes and management. Using a sample of 23 (sociology and psychology) students, 10 open-ended questions were posed. The major questions were: Why do you get into conflict with your mother? What or who is to blame? What is a typical conflict like? What effects does conflict have on you? How are these conflicts resolved or managed? A phenomenological approach was adopted. Purposive sampling was employed by recruiting only females (18 - 21) involved in at least one family conflict in the last month (September, 2014). First the findings indicate five (5) features of mother-daughter conflict: Conduct (act or speech), Response, Reaction, Intensification and Containment (CRRIC). The second is that issues of home and school are the main sources of conflict and that at the end daughters fare less well compared to mothers. Future research includes mother-son conflict and the parenting adolescent/young adult children.

This paper explores how 'place' is conceptualised and mobilized in health policy and considers the implications of this. Using the on-going spatial reorganizing of the English NHS as an exemplar, we draw upon relational geographies of place for illumination. We focus on the introduction of 'Sustainability and Transformation Plans' (STPs): positioned to support improvements in care and relieve financial pressures within the health and social care system. STP implementation requires collaboration between organizations within 44 bounded territories that must reach 'local' consensus about service redesign under conditions of unprecedented financial constraint. Emphasising the continued influence of previous reorganizations, we argue that such spatialized practices elude neat containment within coherent territorial geographies. Rather than a technical process financially and spatially 'fixing' health and care systems, STPs exemplify post-politics-closing down the political dimensions of policy-making by associating 'place' with 'local' empowerment to undertake highly resource-constrained management of health systems, distancing responsibility from national political processes. Relational understandings of place thus provide value in understanding health policies and systems, and help to identify where and how STPs might experience difficulties.

Background: The limited number of existing previous studies of the distribution of quality under NHS Pay-for-performance (P4P) by income deprivation have not analysed the relationship at the individual level and have been restricted to assessing P4P in the primary care setting. In this study, we set out to examine how achievement of P4P 'quality measures' for which NHS hospitals were paid was distributed by income deprivation. Methods: Design: Retrospective analysis of performance data reported by hospitals, examining how the probability of receiving 23 indicators varied by patients' area deprivation using logistic regression controlling for age and gender. Sample: We use anonymised observational data on 73,002 patients admitted to hospitals in the North West of England between October 2008 and March 2010 for the following five reasons: acute myocardial infarction; coronary artery bypass grafting; heart failure; hip and knee replacement; and pneumonia. Results: The relationship between quality and deprivation varies depending on the point of delivery in the treatment pathway, and on whether delivered for conditions in scheduled or unscheduled care. For diagnostic tests on arrival, receipt of quality was: pro-rich in scheduled care and pro-poor in unscheduled care. Receipt of quality was pro-poor for pre-surgery measures in scheduled care. Receipt of quality at discharge was pro-rich. Conclusion: Unlike in primary care, in secondary care quality is not systemically distributed by income deprivation under P4P. Whilst improvements in health inequalities are important system objectives; they may not necessarily be achieved by the adoption of P4P schemes in hospitals.

T Allen, T Mason, W WhittakerManchester Centre for Health Economics, University of Manchester, Manchester, United KingdomAbstract: Increasingly, financial incentives are being used in health care as a result of increasing demand for health care coupled with fiscal pressures. Financial incentive schemes are one approach by which the system may incentivize providers of health care to improve productivity and/or adapt to better quality provision. Pay for performance (P4P) is an example of a financial incentive which seeks to link providers' payments to some measure of performance. This paper provides a discussion of the theoretical underpinnings of P4P, gives an overview of the health P4P evidence base, and provide a detailed case study of a particularly large scheme from the English National Health Service. Lessons are then drawn from the evidence base. Overall, we find that the evidence for the effectiveness of P4P for improving quality of care in primary care is mixed. This is to some extent due to the fact that the P4P schemes used in primary care are also mixed. There are many different schemes that incentivize different aspects of care in different ways and in different settings, making evaluation problematic. The Quality and Outcomes Framework in the United Kingdom is the largest example of P4P in primary care. Evidence suggests incentivized quality initially improved following the introduction of the Quality and Outcomes Framework, but this was short-lived. If P4P in primary care is to have a long-term future, the question about scheme effectiveness (perhaps incorporating the identification and assessment of potential risk factors) needs to be answered robustly. This would require that new schemes be designed from the onset to support their evaluation: control and treatment groups, coupled with before and after data.Keywords: pay for performance, primary care, financial incentives, quality of health care

Every court is the product of its time and reflects the predilections of fallible men in black robes. Whatever the orientation of conflicting values, judicial activism involves a paradox at the heart of constitutional orthodoxy: the Supreme Court considered as the mouthpiece of self-interpreting, self-enforcing law.1 While wearing the magical habiliments of the law, Supreme Court justices take sides on controversial issues. In a moment of judicial candor, Justice Robert H. Jackson remarked: "We are not final because we are infallible, but we are infallible only because we are final."2 Even those inclined to think of the Supreme Court as "brushed with divinity" do not accept constitutional theology at face value. Few Americans were shocked in 1968 when the GOP presidential candidate made the Court a major political issue, and bluntly announced his determination to restore "law and order" by changing

In 1974, two years before the bicentennial of America's birth as a nation, free government experienced a crisis comparable only to the Civil War. Thoughtful Americans gravely wondered whether there would be anything to celebrate in 1976. Confronted with unprecedented betrayals, the institutions of free government-press, Congress, and courts-responded. Without loss of a drop of blood, America ousted from the highest office in the land a rebellious conspirator to obstruct justice.1 To rid themselves of Britain's tyrannical rule, the colonies resorted to revolution. Thanks to the Founding Fathers' constitutional handiwork that was not necessary on the eve of America's bicentennial. No happenstance, this timely tribute to the resilience of eighteenth-century institutions was the result of careful planning. James Madison, "Father of the Constitution," boasted that the American people "accomplished a revolution which has no parallel in the annals of human society. They reared the fabrics of government which have no models on the face of the globe. They formed the de

1 Chief Justice Marshall in Osborn v. U.S. Bank, 9 Wheat. 738, 866 (1824). Symbolism and magic are, of course, useful in the governing process. But judges tend to insist on their impotence when they are making almost brazen use of their power. "Professions of automatism are most insistent," Professor Thomas Reed Powell observed, "when it is most obvious that they are being honored in the breach rather than in the observance." T. R. Powell, Vagaries and Varieties in Constitutional Interpretation (New York, 1956), 43. See my "Myth and Reali

One does not speak of the rights of American trade unions glibly or in off-hand fashion. Unlike the English policy of defining the rights of labor by legislative enactment, our legislatures, both federal and state, have been particularly slow to make such definition. Such predicability as the labor law has thus far assumed has been largely the work of the courts. Here, in other words, we discover the rights of trade unions in the opinions of the courts; in England, we have been accustomed to look to the statute-book rather than to judicial opinions. Comparatively, English labor law has at least enjoyed the merit of being reasonably predicable. The acts of 1859, 1871, 1875, 1906, and 1913 were all designed either to make the existing law more definite or to overturn a judicial interpretation of the law adverse to labor. Thus, by the year 1927 the law was rather definite. The statutes contained statements of what labor could or could not do. A reading of the recent Trade Disputes and Trade Unions Act of July 29, 1927, raises the question whether this legislation marks a change in the English policy of fixing the rights of labor by legislative definition.The immediate occasion for the recent act was the general strike of May, 1926. Introduced and rushed through Parliament by the present Conservative government, this measure failed to receive the preliminary study and consideration that preceded the introduction of the acts of 1871 and 1906.

President Truman's stubborn determination to build on the New Deal's embattled foundations an imposing edifice called the Welfare State is stirring the business community and its spokesmen to renewed and outwardly bold hostilities. This present outcry for “welfare,” it seems, is not what it used to be: “The irresponsible clamor of the mob for bread and circuses.” “Welfare” is now recognized as “a justifiable demand, consonant with the necessities of social evolution,” and in keeping with our political tradition. The old jungle economy, at long last, must be discarded. All this is now cheerfully conceded. But whose responsibility is it to bring order out of chaos, whose business is it to formulate and administer the welfare program? There is the rub. Certainly not government's, business leaders assert, for ultimately that would spell not a glorious welfare society but an inglorious welfare state. This ignominious prelude to statism, to totalitarianism, to despotism, must be avoided at all cost. That is why certain publicists, ex-New Dealers, industrial leaders and university officials are alerting the business community to a fresh responsibility, the unique venture of capitalism today—“the greatest opportunity in the world,” Russell Davenport calls it, and peculiarly the concern of Free Enterprise.Harvard's Business School Dean, Donald K. David, also points ominously at “The Danger of Drifting,” and sharply differentiates between “freedom to” and “freedom from,” between “equality of opportunity and equality of results,” etc., etc. These refinements are important, Dean David decides, because in them lies the crucial difference between welfare society (which he approves) and welfare state (which he deplores). How easy it is, he warns, to drift into the lethal arms of the welfare state. To foil the octopus of welfare, businessmen must be vigilant and aggressive. “Responsibility for this program,” Dean David concludes, “is going to be placed in the hands of the businessman, because we have, whether some people like it or not, an industrial civilization; and the businessman, whether he likes it or not, has to assume new responsibilities.”

'The roots of Massachusetts Savings Bank Life Insurance are in the scandals of insurance high finance that were exposed in I905. The Big Three (Equitalble, Mutual, and New York Life) were notorious, and the Armstrong Committee had been appointed by the New York Legislature in I905 to investigate the insurance companies. But, as a matter of fact, in the field of industrial insurance, the Metropolitan, Prudential, and John Hancock were guilty of even greater abuses. The Armstrong Committee recognized the grave social and moral evils of industrial insurance, but left these unremedied. In I905 Louis D. Brandeis was already a well-known Boston lawyer. The Armstrong Committee's neglect of industrial insurance, together wiith Brandeis's deep concern for the workingman, led him to study this aspect of the insurance problem. Specific results are the test of statesmanship. In no field did Brandeis ever demonstrate his analytical power, his superb mastery of fact and detail, his unusual ability in constructive economic and social statecraft, his devotion to the democratic process, more strikingly or more effectively than in his surgical exposure of flagrant insurance abuses and his proposals for a comprehensive remedy. The provisions of his Massachusetts Savings Bank Life Insurance law of i907, under which savings banks are authorized to write insurance policies in limited amounts, and receive and invest premium income, were not the result of happy chance. Brandeis did not

"Neither the common law nor the Fourteenth Amendment confers the absolute right to strike." 2 Such is the recent authoritative declaration of the United States Supreme Court. And what is perha.ps more surprising, these are the words of Mr. Justice Brandeis, a liberal who holds progressive views on industrial questions. Well known for his advocacy of the Oregon Minimum Wage Law and legislation limiting hours of labor, to say nothing of his now famous dissenting opinions in Dutplex Printing ConmpaHy v. Deering 3 and other important labor cases, Mr. Justice Brandeis enjoys a reputation among labor leaders that has served to deny the publicity to this case that usually follows decisions that affect adversely the rights of organized labor.4 Although fully appreciating the broad scope of the Court's declaration, the legal information btureau of the American Federation of Labor comments, quite submissively, on the decision as follows