In a democracy, what should a healthcare system do? It is a question of relevance to many disciplines. In this thesis, I examine that question, and add something original to the existing debate by drawing on, and synthesizing, thinking from several disciplines, and especially philosophical ethics, economics and systems theory. Paper 6 in this thesis, entitled “In a democracy, what should a healthcare system do?”, tackles the thesis question directly. The central conclusion of that paper, and of this thesis, is that a healthcare system in a democracy should do as much good as possible, although sometimes some overall good should be sacrificed for the sake of fairness, as John Broome has argued. However, what counts as the good of healthcare, and when good should be traded off for fairness, depend on your weltanschauung (or worldview). Political pluralism is normal, and every democracy has institutions and processes for making policy when people disagree because their worldviews differ. Ultimately, elected policymakers are accountable for making decisions. This analysis is complemented by paper 5, entitled “Accountability for reasonableness – as unfair as QALYs?”. It assesses the vulnerability of three theories of resource allocation to injustice. It concludes that Daniels and Sabins’ accountability for reasonableness approach is vulnerable because it does not require evidence of costs and benefits. Maximising quality-adjusted life years can also lead to large-scale injustice because it is concerned only with health gain, and not with fairness. I conclude that a “good and fairness framework”, which is drawn from the writing of John Broome, is the least vulnerable to large-scale injustice. There are four other papers in this thesis. “What has the state got to do with healthcare?” (paper 3) makes the case for an important assumption underpinning this thesis, namely that the question of what a healthcare system should do is a question of public policy. Paper 1, entitled “It’s time for rational rationing” argues that efficiency gains are not inexhaustible, and to continue with its austerity programme, policymakers should assess whether the NHS in England could do more good with the same money by doing different things. I explore how philosophical ethics can contribute to policy, and the importance of context when writing papers about policy, in: “Should policy ethics come in one of two colours: green or white?” (paper 2) and “How can one be both a philosophical ethicist and a democrat?” (paper 4).These latter two papers, and much of the narrative within this thesis, explain how my thinking has developed during the course of my PhD, and why I have looked within and beyond philosophical ethics for an answer to my central research question.

Automated testing is a fast-growing requirement for many IT companies. The idea of testing is to create a better product for both the company and the customer. The goal of this study is to examine different aspects of au- tomated testing and Xray as a test management tool. The literature study considers information from several different scientific reports. It shows that the benefits of automated testing include increased productivity and reliable software but also pitfalls like a high initial cost and a maintenance cost. Research suggests that automated testing is complementary to man- ual testing. Manual testing is more suited for exploratory testing, while automated testing is better for regression testing. Using historical data manual tests can be placed into prioritised clusters. The coverage of each test within a cluster determines its priority, where a test with high cover- age has a high priority. A near-optimal solution for prioritising automated tests is the combination of two well-known strategies, the additional cov- erage strategy and the total coverage strategy. Tests are prioritised based on how much of the code they uniquely cover. Code coverage is mea- sured using statements, methods or complexity. Furthermore, this thesis demonstrates a proof of concept for how the unified algorithm can pri- oritise Xray tests. Xray is evaluated according to the ISO/IEC 25010:2011 standard together with a survey done on Xray practitioners. The evalua- tion for Xray shows that Xray provides the necessary tools and functions to manage a testing suite successfully. However, no official encryption exist for the Jira server, and Xray lacks integrated documentation.

Background: Modern Code Review (MCR) is a process of reviewing code which is a commonly used practice in software development. It is the process of reviewing any new code changes that need to be merged with the existing codebase. As a developer, one receives many code review requests daily that need to be reviewed. When the developer receives the review requests, they are not prioritised. Manuallyprioritising them is a challenging and time-consuming process. Objectives: This thesis aims to address and solve the above issues by developing a machine intelligence-based code review prioritisation tool. The goal is to identify the factors that impact code review prioritisation process with the help of feedback provided by experienced developers and literature; these factors can be used to develop and implement a solution that helps in prioritising the code review requests automatically. The solution developed is later deployed and evaluated through user and reviewer feedback in a real large-scale project. The developed prioritisation tool is named as Pineapple. Methods: A case study has been conducted at Ericsson. The identification of factors that impact the code review prioritisation process was identified through literature review and semi-structured interviews. The feasibility, usability, and usefulness of Pineapple have been evaluated using a static validation method with the help of responses provided by the developers after using the tool. Results: The results indicate that Pineapple can help developers prioritise their code review requests and assist them while performing code reviews. It was found that the majority of people believed Pineapple has the ability to decrease the lead time of the code review process while providing reliable prioritisations. The prioritisations are performed in a production environment with an average time of two seconds. Conclusions: The implementation and validation of Pineapple suggest the possible usefulness of the tool to help developers prioritise their code review requests. The tool helps to decrease the code review lead-time, along with reducing the workload on a developer while reviewing code changes.

For the majority of the estimated 70,000 industrial chemical substances available on the European market today there is not enough information to enable a reasonably complete assessment of the risks that they might pose to man and the environment. Any strategy for the generation of additional data for these substances should aim at making testing as efficient as possible taking into account environmental and health protection, time, monetary cost and animal welfare. To achieve this, appropriate priority setting rules are needed. The main criterion currently used for regulatory priority setting for testing of industrial chemicals is production volume; the higher the production volume, the more information is required. This was also the main criterion in the former legislation, preceding REACH (Registration, Evaluation and Authorisation of Chemicals). The aim of this thesis is to evaluate other priority setting criteria and their implications for risk management, in particular classification and labelling. The first paper in this thesis includes a study of the efficiency ratio for some of the tests required for the notification of new substances, i.e. the ratio between the likelihood that the test will lead to a classification, and the monetary cost of performing the test. The efficiency ratio was determined for the standard tests for acute oral toxicity, irritation, sensitisation and subacute toxicity using data from 1409 new chemicals notified in Europe between 1994 and 2004. The results of this investigation suggest that, given limited resources for testing, it is more efficient to perform acute toxicity tests on a larger number of substances rather than to perform additional subacute toxicity studies on the substances already tested for acute toxicity. The second paper included in this thesis, reports the results from a comparative study of the bioaccumulating properties of substances being (a) classified as carcinogenic, mutagenic and/or toxic to reproduction (CMR-substances), or (b) classified as acutely toxic or (c) unclassified. The purpose of this investigation was to evaluate potential consequences of prioritising bioaccumulating chemicals for evaluation and testing, as this is one of the strategies prescribed in REACH. The results of this study suggest that bioaccumulating substances are neither over- nor underrepresented among the CMR-substances. This result lends support to the use of the bioconcentration factor for priority setting. The studies reported in this thesis utilize existing data on classification of substances as an indicator of the outcome of the risk assessment process, relating priority setting methods to the risk management measures that they give rise to. To the best of my knowledge there are still only very few studies published that address the issue of priority setting in chemicals control using this approach, and in my view there is need for more studies of priority setting methods and a further development of priority setting strategies that are science-based. / QC 20101115

Yes / Black, Asian and minority ethnic communities suffer from disproportionately poorer health than the general population. This issue has been recently exemplified by the large numbers of infection rates and deaths caused by covid-19 in BAME populations. Future research has the potential to improve health outcomes for these groups. High quality research priority setting is crucial to effectively consider the needs of the most vulnerable groups of the population. The purpose of this systematic review is to identify existing research priority studies conducted for BAME health and to determine the extent to which they followed good practice principles for research priority setting. Method: Included studies were identified by searching Medline, Cinnahl, PsychINFO, Psychology and Behavioral Sciences Collection, as well as searches in grey literature. Search terms included “research priority setting”, “research prioritisation”, “research agenda”, “Black and minority ethnic”, “ethnic group”. Studies were included if they identified or elicited research priorities for BAME health and if they outlined a process of conducting a research prioritisation exercise. A checklist of Nine Common Themes of Good Practice in research priority setting was used as a methodological framework to evaluate the research priority processes of each study. Results: Out of 1514 citations initially obtained, 17 studies were included in the final synthesis. Topic areas for their research prioritisation exercise included suicide prevention, knee surgery, mental health, preterm birth, and child obesity. Public and patient involvement was included in eleven studies. Methods of research prioritisation included workshops, Delphi techniques, surveys, focus groups and interviews. The quality of empirical evidence was diverse. None of the exercises followed all good practice principles as outlined in the checklist. Areas that were lacking in particular were: the lack of a comprehensive approach to guide the process; limited use of criteria to guide discussion around priorities; unequal or no representation from ethnic minorities, and poor evaluation of their own processes. Conclusions: Research priority setting practices were found to mostly not follow good practice guidelines which aim to ensure rigour in priority setting activities and support the inclusion of BAME communities in establishing the research agenda. Research is unlikely to deliver useful findings that can support relevant research and positive change for BAME communities unless they fulfil areas of good practice such as inclusivity of key stakeholders’ input, planning for implementation of identified priorities, criteria for deciding on priorities, and evaluation of their processes in research priority setting. / This work was supported by the National Institute for Health Research (NIHR) under its Applied Research Collaboration (ARC) Yorkshire and Humber in the form of Ph.D. funding to HI [NIHR200166], the UK Prevention Research Partnership (UKPRP) in the form of funding to JW and RM [MR/S037527/1], the NIHR Clinical Research Network in the form of funding to JW, and the NIHR ARC Yorkshire and Humber in the form of funding to RM.

Problem/Purpose: Process prioritisation is an ill-structured and complex problem that remains a mystery phase in business process management (BPM) research. More explorative approaches are called upon to tackle process management problems, to facilitate process innovation and to design new processes in dynamic environments. This dissertation aims (i) to design and evaluate a Prioritisation and Categorisation Method (PCM) for addressing process prioritisation problems; and (ii) to explore process innovation by disruptive technologies. Research methods: This research follows the design science research (DSR) paradigm. The design exploration and the engaged scholarship approaches are also adapted. The demonstration and evaluation of the Prioritisation and Categorisation Method have been conducted with case studies in large Swedish companies, i.e. Seco Tools and Ericsson. An empirical study of the impacts of disruptive technologies on process innovation was conducted at a large insurance company in Sweden. Results: This research has led to the design and evaluation of the PCM: a new context-aware, effective and holistic method for BPM. In addition, the lessons learnt from the insurance case deepened the understanding of the challenges that are faced by a company when exploring new capabilities (e.g. processes and IT) for future business. Such lessons also emphasise the necessity of configuring PCM based upon business contingencies and industry factors in process prioritisation. Contributions: This dissertation contributes a novel method to explore BPM in a holistic, yet flexible and effective way. The challenges identified in process innovations improve the configuration capabilities of the PCM through a deeper understanding of the dynamic capabilities within organisations (Capability Layer Model-CLM). This research contributes design knowledge to DSR in the forms of the PCM as an invention, and the three design principles for the PCM: design by holistics, design by commitments and design by explorations. The research is evaluated as good BPM and good design science research.

O objetivo deste trabalho é propor uma metodologia para a priorização de obras do sistema de distribuição de média tensão - até 36 kV - voltada ao cumprimento do índice de continuidade DEC e FEC imposto pela ANEEL, visando reduzir a quantidade de conjuntos que estão fora dos limites e que geram multas para a empresa frente ao órgão regulador e aos consumidores. Inicialmente, os diversos tipos de obras têm seu benefício calculado com o uso do Método do Payoff Simplificado, baseado no Método do Payoff COPEL, que consiste na extração somente da parcela relativa a interrupção, no DEC ou FEC, que determinada obra trará ao sistema. De posse deste benefício estimado, as obras foram analisadas de duas maneiras: geral e por conjunto. A análise Geral consiste em observar as obras propostas de maneira independente, preocupando-se com o benefício que elas trarão para a empresa como um todo. Na análise por conjunto, as obras são agrupadas por conjunto ANEEL, e o objetivo é a colocação da maior quantidade de conjuntos dentro dos limites de continuidade impostos pelo órgão regulador. A definição do objetivo apropriado é que irá orientar todo o processo de seleção das obras. Para isso são propostos modelos matemáticos, e para trabalhar com eles, foi utilizada como ferramenta a programação matemática. Foram realizadas simulações divididas em dois grupos: no primeiro, análise geral, a otimização é executada diretamente. Já no segundo, na análise por conjunto, é aplicada a programação multi-nível, mais especificamente, a programação em dois níveis (\"Bilevel Programming Problem\"), utilizando a programação inteira ou por metas (\"goal programming\"). Os resultados das simulações mostraram que o objetivo principal, que é tirar a maior quantidade de conjuntos da transgressão, foi atingido com menor orçamento com o uso da metodologia e dos modelos matemáticos empregados neste trabalho. A metodologia proposta pretende ser uma ferramenta adicional para as concessionárias de distribuição de energia elétrica que normalmente elaboram programas de obras específicos para redução de índices de continuidade ou quando pressionados pelo órgão regulador elaboram programas alternativos que competem pelo mesmo orçamento frente aos programas de obras tradicionais. / The purpose of this paper is to propose a methodology to prioritize planned works in the medium-voltage distribution system - up to 36 kV - aiming to adequate the DEC and FEC continuity index to the limits defined by the Brazilian regulatory agency (ANEEL) through the reduction of the number of sets out of target and consequently the reduction of monetary penalties to the utility imposed by the regulatory agency and consumers. At first every planned work has its benefit calculated by the Simplified Payoff Method which is based on COPEL Payoff Method and which consists in extracting just the interruption event from the DEC or FEC which a given work will bring to the system. Once you have got the estimated benefit, the planned works are analyzed in two different ways - general analysis and set analysis. General analysis consists in checking up proposed works independently, focusing on the benefit they will bring to the company as a whole. In the set analysis, works are grouped by \"ANEEL sets\" and the main aim is to gather the greatest number of sets into the continuity limits defined by the regulatory agency. The aims definition will lead the whole work selection process. To achieve that mathematical models are proposed and mathematical programming tools are used. Two groups of simulations were done - in the first one which is also called general analysis, optimization is executed directly. The second one called set analysis, is applied the bilevel programming using the integer programming or goal programming. The simulation results showed that the main aim which was to eliminate the greatest number of sets from the transgression was reached with a lower budget using the methodology and mathematical models. The proposed methodology intends to be an additional tool to the electricity distribution companies (utilities). These companies usually plan specific works to reduce the continuity index or when they are pressed by regulatory agencies, they plan alternative programs which compete by the same budget facing traditional work programs.

Australia�s policy on Quality Use of Medicines (QUM) aims to achieve appropriate use of medicines and improved health outcomes. Drug and Therapeutics Committees (DTCs) are educators, policy makers as well as financial gatekeepers in matters relating to medicine use. Increasingly, DTCs are also involved in risk management and clinical governance. As such, DTCs could be considered to be QUM advocates in the institutions in which they function. In a health care arena where there are escalating demands on high standards of clinical practice, quality assessment and improvement is essential in ensuring safe and effective patient care. Given the role DTCs play in safeguarding the interests of the stakeholders of the health care system, research into ways in which DTC performance could be enhanced is required. Although indicators specific to DTCs exist, the literature does not seem to provide straightforward answers to the question of what is currently being done in terms of quality assessment and quality improvement of DTCs. In the absence of such data, an opportunity for research is clearly identified. The first aim of this research project was to gain insight into the current activities undertaken by, and challenges facing Australian DTCs. Following this, the second aim was to explore ways in which DTC performance could be augmented. In addressing the first aim of this project, a national survey of Australian DTCs was conducted. These findings reinforce the evidence in the literature about the roles, structure and stakeholder expectations of DTCs. Our research also documents DTCs� quality improvement initiatives and barriers to DTC activities. It appears that there is little support available to Australian DTCs. Further, a case study was undertaken in order to gain an understanding of the depth and detail of DTC operations. An audit of a DTC in an Australian hospital was conducted. This study revealed that DTC decisions are being implemented in an ad hoc manner. In fact, there were no strategies (or action) planned to implement the majority of their decisions. This could have an impact on DTC performance. In view of this finding, qualitative methods were used to explore stakeholder opinions regarding the implementation of DTC decisions and policies. Stakeholders believed that strategies used to implement DTC policies should be targeted (to the audience as well as the type of decision/policy being implemented), timely, and delivered at the point of care. Face-to-face strategies were perceived to be more effective than printed materials, particularly when an influence on clinical practice was desired. Stakeholders also felt that the lack of resources was a significant barrier to DTC performance augmentation. This probably contributed to a lack of follow-up (or review) of implemented policies. According to stakeholders, other barriers to policy implementation include a lack of ownership of policies, low DTC profile, and an over-reliance on pharmacy to implement DTC decisions. Stakeholders felt one of the ways in which DTC performance could be improved was to prioritise DTC decisions for implementation. In pursuit of a method to prioritise DTC decisions, a survey was conducted. Stakeholders identified patient safety, cost, and the practice of evidence-based medicine as domains of important DTC decisions. The results also suggest that stakeholders recognise the need for the prioritisation of DTC decisions for implementation. Stakeholders implied that higher priority would be assigned to DTC decisions considered to be important. In a follow-up survey, stakeholders (including doctors, nurses, pharmacists, and DTC members) seemed to have agreement of the primary domains of DTC decisions. Higher levels of importance and higher priority were assigned to decisions involving the primary domains of patient safety and cost. However, level of importance and priority assignment were not consistently correlated. The work presented in this thesis suggests that there are ways to improve DTC performance. Although conducted primarily on hospital-based DTCs, it is anticipated that the lessons learnt could be applied to state-based, or even, Area Health-based DTCs. In conclusion, this research found that there was a range of views regarding �importance� and prioritisation for implementation. Social, organisational, as well as environmental factors may contribute to this. Future research should examine other possible factors contributing to the importance and priority of DTC decisions, so that DTC policy could be appropriately implemented into practice.

Australia�s policy on Quality Use of Medicines (QUM) aims to achieve appropriate use of medicines and improved health outcomes. Drug and Therapeutics Committees (DTCs) are educators, policy makers as well as financial gatekeepers in matters relating to medicine use. Increasingly, DTCs are also involved in risk management and clinical governance. As such, DTCs could be considered to be QUM advocates in the institutions in which they function. In a health care arena where there are escalating demands on high standards of clinical practice, quality assessment and improvement is essential in ensuring safe and effective patient care. Given the role DTCs play in safeguarding the interests of the stakeholders of the health care system, research into ways in which DTC performance could be enhanced is required. Although indicators specific to DTCs exist, the literature does not seem to provide straightforward answers to the question of what is currently being done in terms of quality assessment and quality improvement of DTCs. In the absence of such data, an opportunity for research is clearly identified. The first aim of this research project was to gain insight into the current activities undertaken by, and challenges facing Australian DTCs. Following this, the second aim was to explore ways in which DTC performance could be augmented. In addressing the first aim of this project, a national survey of Australian DTCs was conducted. These findings reinforce the evidence in the literature about the roles, structure and stakeholder expectations of DTCs. Our research also documents DTCs� quality improvement initiatives and barriers to DTC activities. It appears that there is little support available to Australian DTCs. Further, a case study was undertaken in order to gain an understanding of the depth and detail of DTC operations. An audit of a DTC in an Australian hospital was conducted. This study revealed that DTC decisions are being implemented in an ad hoc manner. In fact, there were no strategies (or action) planned to implement the majority of their decisions. This could have an impact on DTC performance. In view of this finding, qualitative methods were used to explore stakeholder opinions regarding the implementation of DTC decisions and policies. Stakeholders believed that strategies used to implement DTC policies should be targeted (to the audience as well as the type of decision/policy being implemented), timely, and delivered at the point of care. Face-to-face strategies were perceived to be more effective than printed materials, particularly when an influence on clinical practice was desired. Stakeholders also felt that the lack of resources was a significant barrier to DTC performance augmentation. This probably contributed to a lack of follow-up (or review) of implemented policies. According to stakeholders, other barriers to policy implementation include a lack of ownership of policies, low DTC profile, and an over-reliance on pharmacy to implement DTC decisions. Stakeholders felt one of the ways in which DTC performance could be improved was to prioritise DTC decisions for implementation. In pursuit of a method to prioritise DTC decisions, a survey was conducted. Stakeholders identified patient safety, cost, and the practice of evidence-based medicine as domains of important DTC decisions. The results also suggest that stakeholders recognise the need for the prioritisation of DTC decisions for implementation. Stakeholders implied that higher priority would be assigned to DTC decisions considered to be important. In a follow-up survey, stakeholders (including doctors, nurses, pharmacists, and DTC members) seemed to have agreement of the primary domains of DTC decisions. Higher levels of importance and higher priority were assigned to decisions involving the primary domains of patient safety and cost. However, level of importance and priority assignment were not consistently correlated. The work presented in this thesis suggests that there are ways to improve DTC performance. Although conducted primarily on hospital-based DTCs, it is anticipated that the lessons learnt could be applied to state-based, or even, Area Health-based DTCs. In conclusion, this research found that there was a range of views regarding �importance� and prioritisation for implementation. Social, organisational, as well as environmental factors may contribute to this. Future research should examine other possible factors contributing to the importance and priority of DTC decisions, so that DTC policy could be appropriately implemented into practice.

O objetivo deste trabalho é propor uma metodologia para a priorização de obras do sistema de distribuição de média tensão - até 36 kV - voltada ao cumprimento do índice de continuidade DEC e FEC imposto pela ANEEL, visando reduzir a quantidade de conjuntos que estão fora dos limites e que geram multas para a empresa frente ao órgão regulador e aos consumidores. Inicialmente, os diversos tipos de obras têm seu benefício calculado com o uso do Método do Payoff Simplificado, baseado no Método do Payoff COPEL, que consiste na extração somente da parcela relativa a interrupção, no DEC ou FEC, que determinada obra trará ao sistema. De posse deste benefício estimado, as obras foram analisadas de duas maneiras: geral e por conjunto. A análise Geral consiste em observar as obras propostas de maneira independente, preocupando-se com o benefício que elas trarão para a empresa como um todo. Na análise por conjunto, as obras são agrupadas por conjunto ANEEL, e o objetivo é a colocação da maior quantidade de conjuntos dentro dos limites de continuidade impostos pelo órgão regulador. A definição do objetivo apropriado é que irá orientar todo o processo de seleção das obras. Para isso são propostos modelos matemáticos, e para trabalhar com eles, foi utilizada como ferramenta a programação matemática. Foram realizadas simulações divididas em dois grupos: no primeiro, análise geral, a otimização é executada diretamente. Já no segundo, na análise por conjunto, é aplicada a programação multi-nível, mais especificamente, a programação em dois níveis (\"Bilevel Programming Problem\"), utilizando a programação inteira ou por metas (\"goal programming\"). Os resultados das simulações mostraram que o objetivo principal, que é tirar a maior quantidade de conjuntos da transgressão, foi atingido com menor orçamento com o uso da metodologia e dos modelos matemáticos empregados neste trabalho. A metodologia proposta pretende ser uma ferramenta adicional para as concessionárias de distribuição de energia elétrica que normalmente elaboram programas de obras específicos para redução de índices de continuidade ou quando pressionados pelo órgão regulador elaboram programas alternativos que competem pelo mesmo orçamento frente aos programas de obras tradicionais. / The purpose of this paper is to propose a methodology to prioritize planned works in the medium-voltage distribution system - up to 36 kV - aiming to adequate the DEC and FEC continuity index to the limits defined by the Brazilian regulatory agency (ANEEL) through the reduction of the number of sets out of target and consequently the reduction of monetary penalties to the utility imposed by the regulatory agency and consumers. At first every planned work has its benefit calculated by the Simplified Payoff Method which is based on COPEL Payoff Method and which consists in extracting just the interruption event from the DEC or FEC which a given work will bring to the system. Once you have got the estimated benefit, the planned works are analyzed in two different ways - general analysis and set analysis. General analysis consists in checking up proposed works independently, focusing on the benefit they will bring to the company as a whole. In the set analysis, works are grouped by \"ANEEL sets\" and the main aim is to gather the greatest number of sets into the continuity limits defined by the regulatory agency. The aims definition will lead the whole work selection process. To achieve that mathematical models are proposed and mathematical programming tools are used. Two groups of simulations were done - in the first one which is also called general analysis, optimization is executed directly. The second one called set analysis, is applied the bilevel programming using the integer programming or goal programming. The simulation results showed that the main aim which was to eliminate the greatest number of sets from the transgression was reached with a lower budget using the methodology and mathematical models. The proposed methodology intends to be an additional tool to the electricity distribution companies (utilities). These companies usually plan specific works to reduce the continuity index or when they are pressed by regulatory agencies, they plan alternative programs which compete by the same budget facing traditional work programs.