BackgroundNHS expenditure has stagnated since the economic crisis of 2007, resulting in financial pressures. One response is for policy-makers to regulate use of existing health-care technologies and disinvest from inefficiently used health technologies. A key challenge to disinvestment is to identify existing health technologies with uncertain cost-effectiveness.ObjectivesWe aimed to explore if geographical variation in procedure rates is a marker of clinical uncertainty and might be used by local commissioners to identify procedures that are potential candidates for disinvestment. We also explore obstacles and solutions to local commissioners achieving disinvestment, and patient and clinician perspectives on regulating access to procedures.MethodsWe used Hospital Episode Statistics to measure geographical variation in procedure rates from 2007/8 to 2011/12. Expected procedure numbers for each primary care trust (PCT) were calculated adjusting for proxies of need. Random effects Poisson regression quantified the residual inter-PCT procedure rate variability. We benchmarked local procedure rates in two PCTs against national rates. We conducted rapid systematic reviews of two high-use procedures selected by the PCTs [carpal tunnel release (CTR) and laser capsulotomy], searching bibliographical databases to identify systematic reviews and randomised controlled trials (RCTs). We conducted non-participant overt observations of commissioning meetings and semistructured interviews with stakeholders about disinvestment in general and with clinicians and patients about one disinvestment case study. Transcripts were analysed thematically using constant comparison methods derived from grounded theory.ResultsThere was large inter-PCT variability in procedure rates for many common NHS procedures. Variation in procedure rates was highest where the diffusion or discontinuance was rapidly evolving and where substitute procedures were available, suggesting that variation is a proxy for clinical uncertainty about appropriate use. In both PCTs we identified procedures where high local use might represent an opportunity for disinvestment. However, there were barriers to achieving disinvestment in both procedure case studies. RCTs comparing CTR with conservative care indicated that surgery was clinically effective and cost-effective on average but provided limited evidence on patient subgroups to inform commissioning criteria and achieve savings. We found no RCTs of laser capsulotomy. The apparently high rate of capsulotomy was probably due to the coding inaccuracy; some savings might be achieved by greater use of outpatient procedures. Commissioning meetings were dominated by new funding requests. Benchmarking did not appear to be routinely carried out because of capacity issues and concerns about data reliability. Perceived barriers to disinvestment included lack of collaboration, central support and tools for disinvestment. Clinicians felt threshold criteria had little impact on their practice and that prior approval systems would not be cost-effective. Most patients were unaware of rationing.ConclusionsPolicy-makers could use geographical variation as a starting point to identify procedures where health technology reassessment or RCTs might be needed to inform policy. Commissioners can use benchmarking to identify procedures with high local use, possibly indicating overtreatment. However, coding inconsistency and limited evidence are major barriers to achieving disinvestment through benchmarking. Increased central support for commissioners to tackle disinvestment is needed, including tools, accurate data and relevant evidence. Early engagement with patients and clinicians is essential for successful local disinvestment.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

The use of name spotting and 'snowball' sampling proved the most productive. The Electoral Register was preferred to the Family Health Services Authority lists. Interviewers must be carefully selected and adequately trained to work in this difficult area. The questionnaire must be culturally and linguistically acceptable across all the ethnic groups.

Demand for surgery to treat morbid obesity outstrips supply. Amanda Owen-Smith and colleagues find regional commissioning policies are not consistent with NICE guidance and provision of surgery varies widely Amanda Owen-Smith research fellow

This paper discusses some of the findings of the Bristol Black and Ethnic Minority Health Survey, especially in relation to local plans to improve opportunities for South Asian women to become more physically active. Low levels of participation in exercise sessions were reported in the survey, particularly among Pakistani women. Many of the South Asian women whom we interviewed have poor self-assessed health and limited knowledge of English; they are also economically disadvantaged. It seems likely that exercise sessions outside the home will not reach many of these women. A project has been funded to discuss the research with local women, to identify exercise facilities and improve opportunities for South Asian women to become more active. In what follows we discuss findings relating to all South Asian women but subsequently with particular regard to Pakistani women, the largest single group.A note on ethnic origin terminology Difficulties in the construction and use of terminology of ethnic identity or ethnic origin, and inconsistent use of descriptive terms such as 'Asian' in health and epidemiological research have been discussed in detail'. There are difficulties both in the construction of the categories themselves and in their use and application. In this paper the work reported stems from the Bristol Black and Minority Ethnic Health Survey. In that research a question and a set of categories closely approximating to those in the 1991 UK census were employed. The census categories were themselves a mixture of race/colour designations (Black) and national origin designations (Pakistani). In the parts of our research reported in the present article we focus on people who at Mount Royal University on June 13, 2015 hej.sagepub.com Downloaded from

In the Bristol Black and Ethnic Minority Groups Health Survey more than 500 interviews were completed. The study made it possible to measure the health status of a range of groups. The interview schedule was translated into seven languages; the main groups interviewed were 'Indian', 'Pakistani' and 'Black Caribbean'. Ethnic groups differ from each other quite markedly in socio-economic profile, and within any given ethnic group there is differentiation. In the present article, we suggest that research reports about health and ethnicity may be misleading if they simply present inter-group differences in health status, showing differences within and between groups. Socio-economic variables influence self-assessed health; in particular the unemployed and those with housing difficulties report significantly poorer health. The 'Pakistani' group have the poorest self-assessed health and the poorest socio-economic status. However, standardising for gender, age and material factors, differences in self-assessed health between ethnic groups persist.