Changing Nature of Journalism Essay Example | Topics and Well Written Essays - 250 words

Changing Nature of Journalism - Essay Example One of the main themes of modern day journalism is ‘information’. New information continuously emerges through the prevailing news networks and journalists are faced with the challenging task of filtering out the most relevant and authentic information to present the most reliable information to their audience. Information flow has become so rapid that it is almost impossible to ascertain with confidence the true nature of any evidence that emerges. For this reason, journalists have to rely on their experience and knowledge to prevent spread of false information. A recent phenomenon that has shaped journalism is the development and spread of social networks that utilize internet. Since this is a two-way channel of information, journalism and journalists are faced with a novel situation. The older notion of ‘teaching’ the audience has transformed into the concept of ‘discussion’ that takes place between people and the journalists. This direct interaction has become a cause of concern for those journalists who were previously biased in their opinions or interpretations. Hence, the modern day journalism demands a high degree of impartiality on part of the journalists; a trend that should be

Portfolio Management Statistics Project Example | Topics and Well Written Essays - 2250 words

Portfolio Management - Statistics Project Example The stock returns values experience wide variance due to the fluctuation in portfolio weights across the period. From the set of 28 stocks, the time series was filtered on the criteria of performance to retain the 11 stocks shown in the time series as the most efficient portfolio. The process of refining the investment involved ignoring the portfolio with low weights and retaining the high weight portfolio. The selection aimed at picking 3 stocks with the best returns to represent the high efficiency required in the pool decision. The high efficiency stocks were found to be IBM and MMM. The decision was made on the values based on the original currency returns. The time series for the refined investment pool carries the following stock: The major reason for reducing the number of stocks in the refined investment is that many assets have caused a wide variation of the portfolio weights and return on investment (Tobin 1958, p. 65). The analysis sets up individual each of the assets independently to as to classify them as either risky assets or risk free assets using the correlation projections. The refinement judges the investment by their return, hence; it operates with the few selected manageable stocks to reduce the portfolio size by ignoring the low return stocks. The tangent portfolio was constructed using the Matlab program. The program uses the data entries from the covariance matrix with the new weights of portfolios. The mean return values and the optimal portfolio variances are shown with the least variance portfolio return averaging approximately 14.6%. After making the entry of the matrix, the exercise is repeated for the reduction of the variance to show the restricted efficient frontier as shown in figure 6 below. The assumption made in the construction of the frontier is that investment can run on negative portfolio weights, even though the current weights are positive. The

Law of Obligations(Tort) LLB Essay Example | Topics and Well Written Essays - 1000 words

Law of Obligations(Tort) LLB - Essay Example Frances (and his parents), depending upon the effect of the incident on the child, may also have a claim for psychological damage against the nursery brought about by the latter's negligence. In the recent case of Jones v BBC, 2007 WL 2187023 (QBD), where Jones, a freelance sound recordist for defendant BBC claimed that he suffered personal injury when a windmill rotor fell onto his back causing severe spinal injury rendering him paraplegic. In ruling for the claimant, the court stated that since BBC's safety crew had identified a risk of the falling mast, a discussion before filming should have been made to warn the crew not to go beneath it. But the safety crew did not give the warning. Such failure of BBC, through the safety crew, is considered negligent which caused Jones' accident. Thus, the BBC was liable for Jones' injuries. Also, the cameraman and Jones worked as a team because their equipment was linked. Jones with his equipment was following the cameraman who had decided to pass beneath the mast thereby leading Jones into the hazardous area. The cameraman was then in breached of his duty of care and the BBC was vicariously liable for that negligence. In Wilsons & Clyde Coal Company, Limited v English, [1938] A.C. 57, the House of Lords stated as follows: " primarily the master has a duty to take due care to provide and maintain a reasonably safe system of working in the mine, and a master, who has delegated the duty of taking due care in the provision of a reasonably safe system of working to a competent servant, is responsible for a defect in the system of which he had no knowledge" By the Jones and Wilsons cases, it is clear that the employer is under a duty of care to provide the employee with competent fellow employees including a qualified medical personnel, properly maintained site and facilities, and to provide a safe place and system of work. The question of whether the employer breached that duty of care depends on the standard of care owed by the employer to its employee and whether it has taken reasonable steps considering the circumstances. (Latimer v A.E.C. Ltd.[1953]) In Jones, the breach of the employer's duty consists in B BC's failure (through its safety crew) to discuss with the cameraman and Jones the risk of the falling mast and to warn the cameraman and Jones in unequivocal terms that they must not go beneath it. In Wilsons, the breach by the employer consists of its failure to provide competent fellow employees, properly maintained mine and equipment, and to provide a safe place and system of work. In the case of Ina here, the failure of the employer to provide competent fellow employees and to properly provide and maintain a safe place and system of work which caused the employee's disability to work for three (3) months constitute a breach of the standard of care required of the employer. Jack's negligence in leaving the drill on the floor in a place where thirty (30) toddlers freely roam about constitutes a negligent act for which the employer must be held vicariously responsible. The nursery cannot invoke the defence that Jack is merely a hired self-employed carpenter because as the court st ated in the Jones case the BBC had clearly assumed a responsibility for the health and safety of freelancers when they were working on BBC productions that was equivalent to that of an employer to a direct employee. Jack should have been more careful with his tools because it can reasonably be expected

Portfolio Management Statistics Project Example | Topics and Well Written Essays - 2250 words

Portfolio Management - Statistics Project Example The stock returns values experience wide variance due to the fluctuation in portfolio weights across the period. From the set of 28 stocks, the time series was filtered on the criteria of performance to retain the 11 stocks shown in the time series as the most efficient portfolio. The process of refining the investment involved ignoring the portfolio with low weights and retaining the high weight portfolio. The selection aimed at picking 3 stocks with the best returns to represent the high efficiency required in the pool decision. The high efficiency stocks were found to be IBM and MMM. The decision was made on the values based on the original currency returns. The time series for the refined investment pool carries the following stock: The major reason for reducing the number of stocks in the refined investment is that many assets have caused a wide variation of the portfolio weights and return on investment (Tobin 1958, p. 65). The analysis sets up individual each of the assets independently to as to classify them as either risky assets or risk free assets using the correlation projections. The refinement judges the investment by their return, hence; it operates with the few selected manageable stocks to reduce the portfolio size by ignoring the low return stocks. The tangent portfolio was constructed using the Matlab program. The program uses the data entries from the covariance matrix with the new weights of portfolios. The mean return values and the optimal portfolio variances are shown with the least variance portfolio return averaging approximately 14.6%. After making the entry of the matrix, the exercise is repeated for the reduction of the variance to show the restricted efficient frontier as shown in figure 6 below. The assumption made in the construction of the frontier is that investment can run on negative portfolio weights, even though the current weights are positive. The

Polysystem Theory and the 'Cultural Turn' Essay

Polysystem Theory and the 'Cultural Turn' - Essay Example Polysystem Theory means a "refocus on alternative experiences which are socially defined and can be classified as peripheral or marginal states of affair challenging some center of authority within a variety of cultural and social systems (literature, religion, politics, economy, historiography, etc)" (Munday 43). The value of polysystem theory is that it allows translators and researchers to analyze a literary text from multiple perspectives: different social discourses and voices. This theory demonstrates social order and highlights agonistic tension between different social and cultural agents. Polysystem Theory uses social-cultural instructions for explanation of phenomena and complexity of culture within one community. Polysystem Theory sees translation in terms of "saying," restating in the target language more or less precisely what the source author said in the source language, and performative linguists of translation as those who see translating as "doing," doing something to the target reader, then the contemporary scene comes to look rather different. Then, obviously, the politically engaged cultural theorists of translation-the postcolonialists and the feminists-become performative linguists: translating as colonizing, or as fighting the lingering effects of colonialism; translating as resisting global capitalism (Venuti); translating as fighting patriarchy, as liberating women (and men) from patriarchal gender roles (Munday 110). 'Cultural Turn' means developments in the philosophy of the human sciences around the beginning of the twentieth century. 'Cultural Turn' describes extra-ordinary growth in the significance of work concerned with the nature and forms of language. The readers use cultural texts in ways that cannot be predicted from analysis of the text alone. In this case, "cultural turn" helps to describe and analyses a text in terms of cultural am social influence. Discourse analysis, is the one branch of linguistics that supposedly addresses itself to issues of production and reception that might be useful in a translation-studies purview; but unfortunately the few linguists who have attempted to apply discourse analysis to the study of translation have hobbled themselves methodologically by tying all discursive studies of translation to equivalence (Munday 108). For theorists in these schools it doesn't matter what the translated text looks like; or, well, it does, but not to the theorist, only to the receiving culture (DTS), the client (skopos), or the translator himself or herself (TAP). What matters theoretically is what the translator does, and what complex forces influence that doing (Munday 111). Now perhaps this seems like no great gain: taking all the approaches of the so-called "cultural turn," all the action-oriented theories that have overwhelmed and overthrown the hegemony of linguistics, and lumping them together under a new name-even if that name is rather tendentiously "linguistics." "This is the term used in translation studies for the move towards the analysis of translation from a cultural studies" (Munday 125). Translation is a sensitive pointer of cultural tensions. Translation practice is always grounded in a set of issues in which linguistic forms carry cultural meanings in an implicit form. Understanding the

Policy Development Paper Essay Example for Free

Policy Development Paper Essay In this paper, research will be made on reducing prison population and how policy affects and restores how the system works. In the research of how to reduce prison population will include statistics, facts, and public opinion history information which will support the policies claims. This topic has always been controversial and the following research will indentify the stakeholders and their opinions as they relate to the proposed policies and how politics will have an impact in its implementation of these policies. Finally the author will provide policy recommendation and the justification for these policies. In the last several years, this country has gone through many changes in the criminal justice system and one of the major changes is prison overcrowding and the unwarranted prison costs that come with it. This problem not only affects one area of the nation’s prisons, it is practically a problem in every state of the United States. One major question that policymakers should be addressing is whether is it worth having these expenses just to have low-level drug using criminals in jail that are consuming an estimated 65 billion a year? There have got to be a better way to deal with these types of low-level criminals which do not have any business in the prisons whatsoever. These drug offenders need help with rehabilitation and getting their drug problems handled not throwing them in prisons where they are only going to learn more criminal behaviors from the other violent inmates. Two major factors that contribute to the overcrowding of the prison population are: the technical violations those individuals brake like probation and parole, not showing up to court, and just following simple instructions that the parole or probation officers give the offenders and they break those rules. The second factor is that prisons have their policies and if inmates do not follow them and break them they will be punished and serve more time, another reason is that policies change often and for that reason inmates have their sentences increased all the time. In order to reduce the prison overcrowding and maybe have some hope of sinking the recidivism rates, the criminal justice system needs to make some changes and try different alternatives to prison. With the implementation of community-based programs, reminiscent of drug rehabilitation programs, electronic monitoring and house arrest, there can be better results for individual who are trying to better their lives instead of throwing them to the prison system and having them learn new criminal skills from real violent criminals. To prevent overcrowding in the prison system, there are alternatives that the system can use instead of throwing everyone into prison and having to spend much more money for people that clearly do not belong in the prisons. One way to decrease the prison population is to evaluate the prisoners and really study the individuals who are ready to be rehabilitated and serve time in productive manner and this way the prisons can decrease costs at the same time (Heroux, 2011). There are people in this country that may have very extreme views about prisons, they feel that in a modern society, prisons should not exist and everyone has the right to be free (Heroux, 2011). In ones opinion, views like that have no place in this country or any country at all, because it is necessary to have prisons to have control over people that are really aggressive and violent who cannot live freely in our society or else they would cause nothing but chaos in the streets and citizens would not be safe. Society may feel that if policies get tougher with our criminals, the results will be lower crime rates. Unfortunately it does not matter if policies and laws get tougher because not only in this country, but in the whole world, the criminals do not care about laws and policies. Criminals think, act and live a life of crime different than the normal law abiding citizens of this nation, which is why they do not follow the laws and going to prison just comes with the territory f or them. A criminal is well aware that some day they will be behind bars and it does not matter how severe the laws or policies are they will continue to live that life of crime (Marion Oliver, 2006). It is thought to be said that if all criminals were to be locked up, they would not commit any crimes and therefore society would be safer (Heroux, 2011). Statistics show that there is no relationship between mass incarceration and decreased crime rates (Heroux, 2011). Proponents of mass incarceration will lead you to believe that during the 1990s an increase in incarceration resulted in the decrease of crime rate, but this is just a typical case of cherry-picking data to mislead the public. There are three different cases with totally different outcomes that show no evidence that mass incarcerations will decrease the crime rate. In the first case since the 1930s throughout the 1960s, both incarceration and crime rates bounced up and down just a bit, but they stayed at a set level (Heroux, 2011 ). The second case showed that incarceration rates and crime rates shot up simultaneously in the late 1970s to 1980s (Heroux, 2011). The final case showed that incarceration rates sustained its level while crime rates decreased in the 1990s and in the 2000s the incarceration rates continued to increase while crime rates stayed at the same level (Heroux, 2011). So in order to deal with all the prisoners who show potential to have a good rehabilitation in the system, we must provide them with good programs because they are still costing the states billions of dollars every year. First of all the correctional system should be looking closely at those individuals with a low level and first time offenders because they clearly do not belong in the prisons, they belong in programs where they can start paying they dues to society and get them ready to be productive members of society. These individuals have a much higher percentage of not returning to the system because they do not show signs of violent behaviors. Although they have broken the laws, these types of offenders usually have a higher rate of recidivism than ot her individuals who go through the prison system (Heroux, 2011). One major factor why offenders return to prison is because prison will habitually teach individuals to be aggressive and more often than not will make them engage in criminal behavior once they are released to the public sector (Heroux, 2011). On the other hand, alternative sanctions that are more suitable for offenders will eliminate that feeling of trying to commit a crime all the time; it will teach individuals new habits instead of teaching them how to be criminals. Here are different options in which the criminal justice system can adopt to eliminate some of that recidivism rate and decrease it so that the prisons will not be so overcrowded. The first sanction is electronic monitoring, this device had been around for some time now and it works as long the individual does not muddle with it and try to trick it a take it off. Another program in which offenders can be reprogrammed is with community service, probation, parole and restorative justice. Although these sanctions have been designed for individuals who can make a change and have not shown to be violent in prisons, there are prisoners who definitely cannot participate in these types of programs for the reason that they cannot be rehabilitated due to mental issue s and violent behaviors. Of course these programs are not for everyone, just because the programs are available it does not mean that anyone can participate in them. There are steps to be taken by the prison administrators and the courts before allowing an individual to go thru one of these alternative sanctions. One problem that is in the minds of politicians and the states is how much will these programs cost will it be cost effective to send these individuals through these programs to reduce the prison overcrowding. The data shows that alternative sanctions have been proven to be cost effective and they are successful in reducing the criminal behavior and decreasing the prison population (Heroux, 2011). The goal of the criminal justice system is not to eliminate all prisons all together, but to keep them full of individual who really deserve to be there, for instance violent, aggressive and mentally challenged individuals who cannot be walking around in the public because they pose a threat to the society. Another program that is helping many individuals and juveniles especially is the drug treatment programs. As we all know, jail and prisons do not always work for many individuals because they have different problems that need to be looked at by specialists, for example drug addiction. Adult and juveniles who were charged with drug offenses, but they were not violent had the chance to participate in these programs to try and rehabilitate themselves and not return to their bad habits and prisons. These alternative programs are there to give hope to many individuals who did not have the same opportunities that others had and with some training they can be successful and be model citi zens. As a condition to these criminals is that if they do not participate and cooperate with the program the only solution is to return them to prison where they can serve their remainder of their sentences. Drug treatment programs usually take from 16 to 24 months of residential drug treatment depending on the severity of the individual’s addiction (The National Reentry Resource Center, 2012). Drug treatment programs have a successful track record in different states of the country. According to the National Reentry Resource Center, participants who were successful in completing the program were 33 percent less likely to return to prison, 45 percent less likely to be convicted (The National Reentry Resource Center, 2012). In conclusion, alternative sanctions exist so that individuals can have a second chance to straighten up their lives and not return to prisons where more damage can actually happen for them. The programs will not be easy to complete, but in the end they will feel proud of themselves and they will be ready to face the world in a different perspective. Studies have been shown that individuals who participated in alternative programs were more than likely to be more successful than individuals who did not participate in them. The programs mentioned above have been used for years and they have been proven to decrease the prison population, but in order to make a difference we as a society need to support these programs because they are very expensive and is the only way we are going to decrease the overcrowding in our prisons. References Dunn, W. N. (2008). Public Policy Analysis: An Introduction (4th ed.). Upper Saddle River, NJ: Prentice Hall. Heroux, P. (2011). Reducing Prison Overcrowding, Improving Justice and Preventing Crime. Retrieved from http://www.huggingtonpost.com/paul-heroux/ways-to-reduce-prison-ove_b_925603.html Marion, N. E., Oliver, W. M. (2006). The Public Policy of Crime and Criminal Justice (Rev ed.). Upper Saddle River, NJ: Prentice Hall. The National Reentry Resource Center. (2012). Justice Center. Retrieved from http://www.nationalreentryresourcecenter.org/what_works/evaluations/washingtons-drug-offender-sentencing-alternatives-dosa

Cardiovascular Disease

Cardiovascular Disease Cardiovascular Disease Introduction This paper utilizes qualitative data drawn from a series of focus group discussions with patients living with coronary heart disease which explored their understanding of and adherence to a prescribed monitoring and medication regime. These findings are drawn upon in order to contextualize, from the patients perspective, the outcomes of the Departments of Healths Coronary Heart Disease National Service Framework strategy. The paper focuses attention on the consequences of this regulatory approach to clinical and risk management for those patients already living with coronary heart disease. Case Study Patient is 59 yrs old and had a myocardial infarction 2 years ago. He is obese, a smoker and poorly motivated. The case exemplifies many of the difficulties that frequently arise in managing cardiovascular disease, and suggests potential avenues for improving outcomes through the application of a disease management programme. The Coronary Heart Disease National Service Framework By the mid 1980s, it had been generally accepted by most clinicians that there was strong evidence to support the existence of a linear relationship between cholesterol levels and cardiac mortality (Shaper et al. 1985, Stamler et al. 1986), and that therefore lowering total cholesterol levels would reduce the risk of individuals developing coronary heart disease. This opened the way to the process of establishing a recommended cholesterol threshold level at which treatment should be instigated (Leitch 1989). Since then, the trend has been towards setting ever-lower threshold targets for treatment for those designated as being at high risk of developing coronary heart disease and for those already living with the disease. In 2000, the Department of Health published its Coronary Heart Disease National Service Framework which set out 12 standards for the prevention, diagnosis and treatment of the disease (Department of Health 2000). The National Service Framework standard Number 3 recommended that GPs identify and develop a register of diagnosed patients and those patients at high risk of developing coronary heart disease. Dietary and lifestyle advice (what the document terms ‘modifiable risk factors) was to be offered to these patients, and their medication reviewed at least every 12 months. It was also recommended that statins be prescribed to anyone with coronary heart disease or having a 30% or greater 10-year risk of a ‘cardiac event, in order to lower their blood cholesterol levels to less than 5 mmol/l or by 30% (which ever is greater). These recommendations were vigorously promoted when they were incorporated into the new General Medical Services contract that came into operation in 2003. The relative performance of an individual Primary Care Organization in meeting each of these indicators attracts points on a sliding scale that are then converted into payments for individual GPs. In relation to the management of patients with coronary heart disease, higher payments are received if a Primary Care Organization increases the percentage of patients with coronary heart disease who have their total serum cholesterol regularly monitored, and whose last cholesterol reading was less than 5 mmol/l (Department of Health 2004a). The most recent Department of Health progress report on the National Service Framework argues that the massive growth in statin therapy since 2000; ‘. . . is one of the most important markers of progress on the NSF, and was directly saving up to 9,000 lives per year (Department of Health 2005: 19). Statin prescriptions have been rising at the rate of 30% per year since 2000, and in 2004/5  £750 million was spent on statins, equivalent to some 2.5 million people on statin therapy in England (Department of Health 2005). In July 2004, low doses of statins became available over the counter without prescription for the first time, for those at moderate risk. The Public Health Discourse(S) Of Cardiac Risk The application of risk discourses in the field of public health (or more precisely the ascription of health risk to particular behaviours) as conceptualized within those elements of the risk literature most influenced by Foucauldian notions of governmentality, are seen as serving to construct the socially recalcitrant as distinct from the responsible citizen (Foucault 1977, Turner 1987, Lupton 1995). In a similar way, Dean (1999) argues that once risk has been attributed to particular health behaviours, the distinction is then drawn within public health policies between ‘active citizens who are perceived as able to manage their own heath risks, and ‘at-risk social groups who become the object of targeted interventions designed to manage these risks. Two distinct dimensions or approaches to the conceptualization and public health management of cardiac health risks also emerge from an examination of the ‘guiding values and principles which inform the Department of Healths Coronary Heart Disease National Service Framework (Department of Health 2000).While one approach (described below as the ‘epidemiological model of risk) largely conforms to the individualized ‘at-risk discourse, a second discourse (described below as the ‘social model of risk) which is much more concerned with health risk at a social and material level can also be discerned within the National Service Framework. These two distinct and arguably competing discourses of risk point to a complexity in current public health policy that might not be anticipated from a reading of the governmentality literature alone. The first conceptualization of cardiac risk within the Coronary Heart Disease National Service Framework is one that can be termed the ‘social model of health risk. This model essentially reflects a socio-economic understanding of the determinants of population health, and draws attention to the importance of addressing material, social and psychological risk factors in addition to the known biological factors in heart disease. In the National Service Framework, this social model is reflected in the endorsement (albeit at a rhetorical level) of an interventionist role for the state in addressing these wider determinants of the disease: ‘The Governments actions influence the wider determinants of health which include the distribution of wealth and income. A wide range of its policies will have an impact on coronary heart disease including social and legal policies and policies on transport, housing, employment, agriculture and food, environment and crime (Department of Health 2000: Section 1, Para 17). There is also an explicit acknowledgement that these risk factors disproportionately disadvantage particular sections of society, demonstrated in the higher incidence of coronary heart disease among the manual social classes. It is also acknowledged that there is inequity in health service provision; ‘. . . there are unjustifiable variations in quality and access to some coronary heart disease serv ices, with many patients not receiving treatments of ‘proven effectiveness (Department of Health 2000: Section 1, Para 13). This formal acknowledgement of the governments role in addressing the wider social and economic influences on cardiac health risk could to some degree be said to conform to Becks (1992) notion of the ‘risk society; wherein many of the health risks faced by the population are a consequence of unchecked scientific and industrial ‘progress. Beck asserts that in response a greater public awareness or ‘reflexivity of risk has emerged which reflects a shift from ignorance or private fears about the unknown to a widespread knowledge about the world we have created. The question of whether a reflexivity concerning the social and environmental factors associated with cardiac risk can be discerned in a patients own discourses of cardiac risk is something that will be explored in the discussion below. The second risk discourse emergent within the National Service Framework (Department of Health 2000) is one which reflects a predominantly epidemiological understanding of health risk. In this model, the relative risk of an individual developing heart disease is based upon a calculation of the mean values associated with certain ‘lifestyle behaviours such as smoking, diet and exercise that are drawn from aggregated population data for heart disease incidence. This is a statistical approach that all too often perceives such calculated health risk factors as being realities or causative agents in their own right, often with little acknowledgement of the social and material context of these health behaviours. Nevertheless, it is on the basis of this epidemiological model of health risk that the Department of Health has confidently set national guidelines that now require General Values and principles underlying the CHD National Service Framework Nine stated values underlying development of national policies for CHD Provision of quality services irrespective of gender, disability, ethnicity or age. Ready availability of consistent, accurate and relevant information for the public. Consideration of health impact in regard to social and legal policies and policies on transport, housing, employment, agriculture and food, environment and crime. Public health programmes led by health and local authorities to ensure targets for CHD are met. Reduction in health inequalities. Resources will be targeted at those in greatest need and with the greatest potential to benefit. Evidence-based. CHD policies are to be based on the best available evidence. Integrated approach for the prevention and treatment of CHD in health policy, health promotion, primary care, community care and hospital care. Maintenance of ethics and standards of professional practice. Recognition of the importance of voluntary organizations and carers at home in addressing CHD. Four stated principles underpinning the CHD NSF . Reducing the burden of CHD is not just the responsibility of the NHS. It requires action right across society . The quality of care depends on: ready access to appropriate services ii. the calibre of the interaction between individual patients and individual clinicians iii. the quality of the organization and environment in which care takes place. . Excellence requires that important, simple things are done right all the time. . Delivering care in a more structured and systematic way will substantially improve the quality of care and reduce undesirable variations in its provision. Practitioners to identify and monitor ‘high risk patients and to prescribe the recommended drug treatment regime. It can be argued that this regulatory or ‘managerialist approach to clinical decision-making constitutes a challenge to the discretion that has been traditionally enjoyed by general practitioners in relation to the clinical management of patients. This second ‘official discourse of health risk could be seen as indicative of the regulatory and surveillance forms of governmentality identified within Foucauldian social theory. From this perspective, those social groups whose health behaviour or lifestyle are seen to fall outside the acceptable bounds of self-management then become constructed as ‘at-risk. These are social groups who are seen to, ‘deliberately expose themselves to health risks rather than rationally avoiding them, and therefore require greater surveillance and regulation (Lupton 1995: 76); once identified these groups and individuals then become subject to various health promotion or ‘health improvement initiatives. Implicit in such forms of governmentality as applied within health policy interventions designed to manage risk are a set of assumptions about the nature of human action predicated on the notion of the ‘rational actor model. Jaeger, Renn, Rosa and Webler (2001) have argued such models of rationality operate at three levels of abstraction. In its most general form, it presupposes that humans are capable of acting in a strategic fashion by linking decisions with actions. That is, human beings are goal-orientated who have options available from which they are able to select a course of action appropriate to meeting these goals. The second level of abstraction which the authors term the ‘rational actor paradigm, and which is the level at which rationality is probably understood by policy-makers, contains the following assumptions: all actions are individual choices; individuals can distinguish between ends and means to achieve these ends; individuals are motivated to pursue t heir own self-chosen goals when making decisions about courses of action/behaviour; individuals will always choose a course of action that has maximum personal utility, that is it will lead to personal satisfaction; individuals possess the knowledge about the potential consequences of their actions when they make decisions. Finally, that rational actor theory is not only a normative theory of how people should make decisions about in this case health behaviour, but is also a descriptive model of how people select options and justify their actions (Jaeger et al. 2001: 33). Many of these rational actor assumptions underpin and inform the Coronary Heart Disease National Service Framework. Such assumptions manifest themselves in a seemingly unproblematic approach to the promotion of ‘risky health behaviour change which plays down the influence of culture, habitus and the material basis of group socialization. This uncritical rationality also threatens the sustainability of the National Service Framework strategy in other ways. The social psychological and sociological literature see the notion of ‘trust as constituted through two dimensions, the deliberative or rational and the affective or non-rational. As Peter Taylor-Gooby (2006) has pointed out in his work on the problematic of public policy reform, the rational deliberative processes associated with the achievement of greater efficiency in the provision of public services have unwittingly served to undermine the non-rational processes that contribute to the building of trust in public institutions and in public sector professionals. In this context, the National Service Framework will need to build trust both in terms of the presentation of the biomedical evidence for the effectiveness of statins and other cardiac drug interventions, as well as the more affective elements associated with the belief that the national targets are designed with the best interests of patients in mind rather than being driven by financial considerations alone. Significantly, given its centrality to a ‘disease management strategy, neither the Coronary Heart Disease National Service Framework (Department of Health 2000) nor the NHS Improvement Plan (Department of Health 2004b) which sets out the governments priorities Coronary heart disease and the management of risk 363 for primary and secondary healthcare up to 2008, attempts to define the use of the term ‘risk, and by extension ‘higher risk. Nevertheless, the conception of risk that shapes the practical interventions proposed within both these strategy documents is clearly the epidemiological one that is described above. In the past, such public health interventions have been largely concerned with bringing about health behaviour change, however now the strategy would appear to be less focused on encouraging greater responsibility for the ‘self management of cardiac risk and more on ensuring compliance with clinical management regimes of monitoring and drug treatme nt. Optimising Care Through Disease Management In the last 15 years, there have been dramatic advances in the pharmacotherapy of heart disease, most notably the introduction of angiotensin converting enzyme (ACE) inhibitors. (Jaeger et al. 2001: 33) Unfortunately, numerous studies have suggested that ACE inhibitors are substantially underutilised in heart disease patients. Moreover, there are a multitude of factors which may confound heart disease management heart disease virtually never occurs in isolation, and comorbidities such as hypertension, diabetes, coronary artery disease, chronic pulmonary or renal disease and arthritis occur frequently. The presence of these comorbid conditions may interfere with heart disease management in several ways. In PATIENTs case, pre-existing renal insufficiency may have contributed to her intolerance to ACE inhibitors. In addition, her use of NSAIDs could promote salt and water retention and antagonise the antihypertensive effects of her other medications. (Jaeger et al. 2001: 33) Multiple comorbidities may also result in polypharmacy, which, in turn, may compromise compliance and lead to undesirable drug interactions. Adherence to dietary sodium restriction is often problematic (as in patients case), particularly in older individuals who are either not responsible for preparing their own meals, or who rely heavily on canned goods and prepared foods. Depression, anxiety and social isolation are common in patients with heart disease, and each may interfere with adherence to the heart disease regimen or with the patients willingness to seek prompt medical attention when symptoms recur. Similarly, the high cost of medications may limit access to therapy in patients with restricted incomes. Physical limitations, such as neuromuscular disorders (e.g. stroke or Parkinsonism), arthritis and sensory deficits (e.g. impaired visual acuity), may compromise the patients ability to understand and comply with treatment. Finally, cognitive dysfunction, which is not uncommon in elderly heart disease patients, may further confound heart disease management. Impact on Clinical Outcomes Despite the widely publicised effects of ACE inhibitors, b-blockers, angiotensin receptor blockers and other vasodilators on the clinical course of heart disease, morbidity and mortality rates in patients with established heart disease remains very high. heart disease is the leading cause for repetitive hospitalizations in adults, and in 1997 Krumholz et al. reported that 44% of older heart disease patients were rehospitalised at least once within 6 months of an initial heart disease admission. Remarkably, this rate was no better than that reported in several prior studies dating back to 1985. (Krumholz et al. 1998) From the disease management perspective, it is important to recognise that the majority of heart disease readmissions are related to poor compliance and other psychosocial or behavioural factors, rather than to progressive heart disease or an acute cardiac event (e.g. myocardial infarction). Thus, Ghali et al. reported in 1988 that 64% of heart disease exacerbationswere attributable to noncompliance with diet, medications or both and that 26% were related to environmental or social factors. Similarly, in 1990 Vinson et al. (Vinson, 1995) found that over half of all readmissions were directly attributable to problems with compliance, lack of social support, or process-of care issues, and these authors concluded that up to 50% of all readmissions were potentially preventable. More recently, Krumholz et al, reported that lack of emotional support among older heart disease patients was a strong independent predictor of adverse outcomes, including death and hospitalization Rationale and Objectives The above considerations provide the rationale for a ‘systems approach to heart disease management. The objectives of this approach are as follows: To optimise the pharmacotherapy of heart disease in accordance with current consensus guidelines. (Vinson, 1990) To maximize compliance with prescribed medications and dietary restrictions. To identify and respond to any psychological, social or financial barriers that might interfere with compliance with the prescribed treatment regimen. To provide an appropriate level of follow-up through telephone contacts, home visits and outpatient clinic visits. To enhance functional capacity by providing an individualized programme of exercise and cardiac rehabilitation. To enhance self-efficacy by helping the patient and family understand that heart disease can be controlled, largely through the patients and familys efforts. To reduce the frequency of acute heart disease exacerbations and hospitalizations. To reduce the overall cost of care. The Disease Management Team Although the composition of a disease management team may vary both from centre to centre and from patient to patient, a suggested list of team members are given below: nurse coordinator or case manager dietitian social services representative clinical pharmacist physical therapist/occupational therapist exercise/rehabilitation specialist  · home health specialist patient and family primary care physician cardiologist/other consultants. Each team member provides their own unique expertise and/or perspective, and these are then woven into an integrated package tailored to meet each individual patients needs, expectations, and circumstances. Importantly, not all patients will require the services of all team members, and it is therefore essential to identify a team leader. In most cases, this will be the nurse coordinator or case manager, who, in addition to being the patients primary contact person and educator, is also responsible for coordinating the efforts of other team members, including the selective activation of appropriate consultations on an individualized basis. In addition to the team itself, several other components are essential for effective disease management. First, the patient and family should be provided with comprehensive information about heart disease, including common etiologies, symptoms and signs, standard diagnostic tests, medications, diet, activity, prognosis and the role of the patient and family in ensuring that heart disease remains under control. This information should be provided in a readily understandable patient-friendly format and several patient-oriented heart disease brochures are now commercially available. In addition to these materials, the patient should be given a scale (if not already owned) and a chart to record daily weights, an accurate and detailed list of medications supplemented by medication aids if needed (e.g. a pill box), and specific information about when to contact the nurse, physician, or other team member in the event that questions or new symptoms arise. In this regard, the importance of establishing an effective one-on-one nurse-to-patient relationship cannot be overemphasized, as this interaction will often be critical to the early diagnosis and effective outpatient treatment of heart disease exacerbations. Patient Perspective While the above studies indicate a beneficial effect on costs, hospital readmissions, etc., they do not address concerns related to the patients perspective on this interdisciplinary care. What issues are important to the patient, and what the advantages are to the patient of participating in an heart disease disease management programme? In recent years, it has become increasingly evident that it is insufficient to merely provide high quality medical services. In a competitive market, it is essential that the patient is also satisfied with the medical encounter, both in terms of the process of care as well as the clinical outcomes. Healthcare is an industry, and like all industries, customer satisfaction is critically important. However, unlike most industries, which deal with a tangible product, the healthcare industry deals with a multifaceted service, the myriad qualities of which are difficult to quantify. As a result, the assessment of patient satisfaction is often complex, and the development of a valid and universally accepted instrument for measuring patient satisfaction has been elusive. Despite these problems, several patient satisfaction questionnaires have been developed, (Garg, 1995) and these have been helpful in defining those issues which are important to patients, and in identifying specific concerns that patients often have with respect to current approaches to healthcare delivery. (Garg, 1995) Factors which have been consistently shown to play a pivotal role in determining patient satisfaction include: communication, involvement in decision- making, respect for the individual, access to care and the quality of care provided. (Philbin, 1996) Not surprisingly, problems in each of these areas are frequently cited as factors which diminish patient satisfaction. Several components of the heart disease disease management system will be of direct assistance in answering patients questions and helping her cope with this new and frightening diagnosis. In particular, the nurse case manager will establish an effective rapport with the patient and her family, and provide an ongoing source of information and emotional support. The patient education brochure and other printed materials will help answer many of Patients questions and assist in relieving some of her anxieties. The nurse, clinical pharmacist and physician (s) can provide detailed information and teaching about the medications used to treat heart disease, and the dietitian can directly address the dietary questions and provide an individualized diet that takes Patients current dietary practices and food preferences into account. The social service representative can assist patient with any financial concerns she may have, make provisions to ensure an adequate social support network, and serve as an additional source of emotional support. The physical therapist or exercise specialist can help in providing recommendations about activities and in the development of an exercise or rehabilitation programme. The nurse case manager, social service representative, home care specialist, and physician will provide assistance to patient in making the transition from the hospital back to the home environment, and they also will ensure a high level of follow-up care. Perhaps most importantly, the comprehensive care provided by the disease management team will reassure patient that she truly is being cared for, and that all of her needs and concerns are being met. Invariably, this will lead to a high level of patient satisfaction. In addition, in the case of patient there is good reason to believe that implementation of a disease management programme at the time of her initial hospitalization may have eliminated the need for a second hospitalization. (Young, 1995) To the extent that patient might have to pay for some of the costs of readmission (e.g. deductible or copayment), the disease management programme would also save her money, a benefit which is universally viewed in a favorable light. And finally, based on compelling data from recent clinical trials, optimizing Patients medication regimen should translate not only into an improved quality of life, but also into increased survival. Conclusion In summary, heart disease management systems provide a win-win-win situation. They are a ‘win for the providers, because they improve clinical outcomes and quality of life. They are a ‘win for the payors, because effective disease management programmes decrease health care expenditures. And they are clearly a ‘win for the patients, who reap multiple benefits, including improved quality of life and well-being, enhanced self-efficacy due to a greater sense of health control, improved exercise tolerance and functionality, increased survival (as a result of more optimal utilisation of heart disease medications), and, in some cases, reduced out-of-pocket expenditures. References Department of Health (2000) National Service Framework for Coronary Heart Disease (London: DoH). Department of Health (2004a) GMS Statement of Financial Entitlements (SFE) 2004/5 (London: DH). Department of Health (2004b) The NHS Improvement Plan: Putting People at the Heart of Public Services Cm 6268 (London: The Stationary Office). Department of Health (2005) The Coronary Heart Disease National Service Framework: Leading the Way-Progress Report 2005 (London: DH Publications). Foucault, M. (1977) Discipline and Punish: The Birth of the Prison (London: Allen Lane). Garg R, Yusuf S, for the Collaborative Group on ACE Inhibitor Trials. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. JAMA 1995; 273: 1450-6 Ghali JK, Cooper R, Ford E. Trends in hospitalization rates for heart failure in the United States, 1973-1986. Evidence for increasing population prevalence. Arch Intern Med 1990; 150: 769-73 Jaeger, C., Renn, O., Rosa, E. and Webler, T. (2001) Risk, Uncertainty, and Rational Action (London: James James/Earthscan). Krumholz HM, Butler J, Miller J, et al. Prognostic importance of emotional support for elderly patients hospitalized with heart failure. Circulation 1998; 97: 958-64 Leitch, D. (1989) Who should have their cholesterol concentration measured? What experts in the United Kingdom suggest. British Medical Journal, 298(6688), 1615 1616. Lupton, D. (1995) The Imperative of Health: Public Health and the Regulated Body (London: Sage). Philbin EF, Andreou C, Rocco TA, et al. Patterns of angiotensin-converting enzyme inhibitor use in congestive heart failure in two community hospitals. Am J Cardiol 1996; 77: 832-8 Redfern, J., MacKevitt, C. and