Post-secondary education for students with intellectual disabilities
in the United States refers to the opportunities and challenges faced
by these students when pursuing higher education. Historically,
individuals with intellectual disabilities
(ID) have faced barriers in accessing post-secondary education,
primarily due to restrictions in federal student aid and academic
prerequisites. However, the enactment of the Higher Education Opportunity Act of 2008
introduced significant changes, allowing students with ID to qualify
for federal student grants and work-study programs. Over the last two
decades, there has been a growth in specialized PSE programs designed
for students with ID, focusing on fostering skills beyond traditional
academic achievements, such as increased independence, self-determination, and employment readiness.
Background
In previous years, students in the United States who have been diagnosed to have intellectual disabilities (ID) cannot have access or have difficulty having access to post-secondary education
(PSE). One significant reason why these students have been marginalized
from continuing their education is their being denied federal student
aid. Many were disqualified due to the lack of having a high school
diploma while others were not able to pass standardized tests which
should indicate if their claim to secure aid is justified. With the legislation of the Higher Education Opportunity Act of 2008, students with ID can now qualify for student grants and work-study programs.
History
Over
the past two decades, PSE programs for students with ID have surged in
the U.S., with financial backing from the Office of Post-secondary
Education starting in 2010.
Although attaining any type of academic degree is not possible
for many students with ID, they do stand to benefit from participating
in PSE programs. The benefits do not necessarily lead to traditional
measures of academic achievement. Instead, students gain increased
independence, self-determination, positive social experiences,
self-advocacy, problem solving, self-monitoring and goal setting and
time management skills.
All of these skills help students be more independent, improve their
psychological well-being and provide them stronger opportunities to find
employment.
In a study conducted by Ross and colleagues,
researchers compared employment and independent living outcomes of 125
graduates from the Taft College Transition to Independent Living (TIL)
program designed for students with intellectual and developmental
disabilities with outcomes from the general population of people with ID
and developmental disabilities. The researchers found that 94% of TIL
graduates lived by themselves, with their spouse or roommates in a home
that they rented or owned compared to only 16% in the general
population. Furthermore, the study found that 95% of graduates continue
to socialize with fellow alumni through home visits, phone calls or
email.
Employment Outcomes
Historically, students with ID have faced poor employment prospects.
For instance, in 2009, only 35% of young adults aged 21–25 with ID were
employed, compared to a 90.2% employment rate among the general
population. That same year, 40.3% of employees with ID earned less the federal minimum wage.
The combination of an increasing number of jobs requiring some type of
education after high school and their history of exclusion from the
higher education system have led to this conclusion. In the past,
employment options for people with ID have been limited to supported employment and sheltered workshops.
Going to college is often connected with getting well paying jobs
and higher employment rates. This premise applies to students with
disabilities including those with ID. Students that attend a PSE program are more likely to find employment than those who only complete high school. Using the American Community Survey (ACS)
researchers compared findings on people with disabilities, with
cognitive disabilities and no disabilities. They found that 43% of
people with cognitive disabilities and some college credit were employed
compared to 31% who had only completed high school.
Additionally, students with ID who attend a PSE program are more likely to earn higher wages. For example, Ross and colleagues (2012)
found that 87% of TIL graduates who were employed earned at least the
minimum wage. In one study, researchers compare the employment outcomes
of alumni from two PSE programs and a control group made up of people
who never attended a program by surveying the participants.
They found that students who attended a PSE program were employed at
higher frequencies in office support at 58%, sales at 17% and teaching
at 17%.
Inclusion in Higher Education
Advocacy groups like the DREAM Partnership and Think College have pioneered the effort to make college accessible and achievable for students with ID. Despite the evident advantages of PSE, only 37% of students with ID pursue higher education after high school.
Once in college, even though students with disabilities participate in
campus events and students life, they tend to feel as lonely as
non-students.)
Still, progress has been made. For example, in K-12 education, students
with disabilities are increasingly getting more integrated into
mainstream classrooms and are succeeding with reasonable supports.
Supports and accommodations
In the U.S., several laws ensure individuals with disabilities receive adequate accommodations in education. Notably, section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act ensure that these students receive required supports.
These supportive accommodations may vary from college to college but
usually include the assistance of a designated note taker, extended time
for tests, taking tests at a designated quiet space, voice recorders
for lectures and assistive technology computer software such as
text-to-speech and speech recognition software. Additionally, peer mentors, coaches, or ambassadors often support students by assisting with assignments and campus activities.[1]
Post-secondary education programs
There
are two main paths for students with ID that are interested in
continuing their education after high school. One path, known as the
inclusive, individual support model,
is to complete entrance examinations, applications and complete degree
requirements with the use of accommodations (Hart, Grigal & Weir,
2015). The second path is to not matriculate but instead enter into PSE
program designed for students with ID. In these programs, students may
take credit or non credit courses, audit courses or take extended study
courses.
The minimum requirements to be admitted into a PSE program are to read
at a third grade minimum and not be considered able to attain a degree
with support.
Currently, there are over 220 PSE programs in the United States.
While wide variation exists among programs, they do share several
features. For example, they do not focus on academic access; the focus
is on independent living skills and employment development.
Programs usually collaborate with outside organizations such as local
school districts, the department of rehabilitation and local non-profit
community organizations. In addition, programs use person centered planning to develop a structure that will help the student meet their goals.
PSE programs can be categorized into three types: the dual
enrollment model, the substantively separate model and the mixed model.
Close to a third of PSE programs in the United States follow the dual
enrollment model.
Programs with this model are funded through the Individuals with
Disabilities Education Act of 2004. The act provides for special
education transition services to students with ID up to the age of 21 to
attend college.
In these programs, students attend high school and college courses
simultaneously. The college courses may be restricted to non-credit,
continuing education or to courses specifically designed for students
with ID.
Programs that follow the substantively separate approach hold
student courses and social activities on campus yet the courses are
restricted to their program. These programs tend to serve larger student populations compared to the mixed programs.
Moreover, students who participate in this type of programs usually
have very little interaction with other students outside of the program.
Mixed model programs attempts to include their students with the rest
of the student body. Students are encouraged to be very active in campus
activities and they take mostly inclusive courses while completing
their program courses which focus on employment building skills.
A comparison of three major U.S. stock indices: the NASDAQ Composite, Dow Jones Industrial Average, and S&P 500 Index. All three have the same height at March 2007. The NASDAQ spiked during the dot-com bubble in the late 1990s, a result of the large number of technology companies on that index.
In finance, a stock index, or stock market index, is an index that measures the performance of a stock market, or of a subset of a stock market. It helps investors compare current stockprice levels with past prices to calculate market performance.
Two of the primary criteria of an index are that it is investable and transparent: The methods of its construction are specified. Investors may be able to invest in a stock market index by buying an index fund, which is structured as either a mutual fund or an exchange-traded fund, and "track" an index. The difference between an index fund's performance and the index, if any, is called tracking error.
Types of indices by coverage
Stock market indices may be classified and segmented by the set of
underlying stocks included in the index, sometimes referred to as the
"coverage". The underlying stocks are typically grouped together based
on their underlying economics or underlying investor demand that the
index is seeking to represent or track. For example, a 'world' or
'global' stock market index—such as the MSCI World or the S&P Global 100—includes stocks from all over the world, and satisfies investor demand for an index for broad global stocks.
Regional indices that make up the MSCI World index, such as the MSCI Emerging Markets
index, include stocks from countries with a similar level of economic
development, which satisfies the investor demand for an index for emerging market
stocks that may share similar economic fundamentals. The coverage of a
stock market index is separate from the weighting method. For example,
the S&P 500
market-cap weighted index covers the 500 largest stocks from the
S&P Total Market Index, but an equally weighted S&P 500 index is
also available with the same coverage.
Global coverage
These indices attempt to represent the performance of the global stock market. For example, the FTSE Global Equity Index Series includes over 16,000 companies.
Regional coverage
These indices represent the performance of the stock market of a
single geographical region. Some examples of these indices are the FTSE
Developed Europe Index, and the FTSE Developed Asia Pacific Index.
Country coverage
These indices represent the performance of the stock market of a
single country—and by proxy, reflects investor sentiment on the state of
its economy. The most frequently quoted market indices are national
indices composed of the stocks of large companies listed on a nation's
largest stock exchanges, such as the S&P 500 Index in the United States, the Nikkei 225 in Japan, the DAX in Germany, the NIFTY 50 in India, and the FTSE 100 in the United Kingdom.
Exchange-based coverage
These indices may be based on the exchange on which the stocks are traded, such as the NASDAQ-100, or groups of exchanges, such as the Euronext 100 or OMX Nordic 40.
Chart of S&P BSE SENSEX Index monthly data from August 2, 1995, to August 2, 2017. The SENSEX represents the top 30 companies by market cap.
National Stock Exchange of India from 2000 to 2020. (Indices NIFTY 50). The NIFTY 50 represents the top 50 companies by market cap.
Stock market indices may be categorized by their index weight
methodology, or the rules on how stocks are allocated in the index,
independent of its stock coverage. For example, the S&P 500 and the
S&P 500 Equal Weight each cover the same group of stocks, but the
S&P 500 is weighted by market capitalization,
while the S&P 500 Equal Weight places equal weight on each
constituent. Some common index weighting methods are listed below. In
practice, many indices will impose constraints, such as concentration
limits, on these rules.
Market-capitalization weighting
This method weights constituent stocks by their market
capitalization (often shortened to "market cap"), i.e. the stock price
multiplied by the number of shares outstanding. Under the capital asset pricing model,
a market-cap weighted market portfolio (which could be approximated by a
market-cap weighted equity index portfolio) is mean-variance efficient,
meaning that it can be expected to produce the highest available return
for a given level of risk. A market-cap weighted index might also be
thought of as a liquidity-weighted index, since the largest-cap stocks
tend to have the highest liquidity and the greatest capacity to handle
investor flows; portfolios with such stocks could have very high
investment capacity.
This method adjusts each company's market-cap index weight by
excluding closely or strategically held shares that are not generally
available to the public market. Such shares may be held by governments,
affiliated companies, founders, and employees. Foreign ownership limits
imposed by government regulation could also be subject to free-float
adjustments. These adjustments inform investors of potential liquidity
issues from these holdings that are not apparent from the raw number of a
stock's shares outstanding. Free-float adjustments are not easy to
calculate, and different index providers have different free-float
adjustment methods, which could sometimes produce different results.
Price weighting
This method weights each constituent stock by its price per share
divided by the sum of all share prices in the index. A price-weighted
index can be thought of as a portfolio with one share of each
constituent stock. However, a stock split for any constituent stock of
the index would cause the weight in the index of the stock that split to
decrease, even in the absence of any meaningful change in the
fundamentals of that stock. This feature makes price-weighted indices
unattractive as benchmarks for passive investment strategies and
portfolio managers. Nonetheless, many price-weighted indices, such as
the Dow Jones Industrial Average and the Nikkei 225, are followed widely as visible indicators of day-to-day market movements.
Equal weighting
This method gives each constituent stocks weights of 1/n, where n
represents the number of stocks in the index. This method produces the
least-concentrated portfolios. Equal weighting of stocks in an index is
considered a naive strategy because it does not show preference towards
any single stock. Zeng and Luo (2013) notes that broad market equally
weighted indices are factor-indifferent and randomizes factor
mispricing. Equal weight stock indices tend to overweight small-cap
stocks and to underweight large-cap stocks compared to a market-cap
weighted index. These biases usually result in higher volatility and
lower liquidity than market-cap weight indices. For example, the Barron's 400 Index assigns an equal value of 0.25% to each of the 400 stocks included in the index, which together add up to the 100% whole.
Fundamental factor weighting
This method, also known as fundamentally based indexes,
weights constituent stocks based on arbitrarily selected "stock
fundamental factors" rather stock financial market data. Fundamental
factors could include sales, income, dividends, and other factors
analyzed in fundamental analysis.
Similar to fundamental analysis, fundamental weighting assumes that
stock market prices will converge to an intrinsic price implied by
fundamental attributes. Certain fundamental factors are also used in
generic factor weighting indices.
Factor weighting
This method weights constituent stocks based on market risk factors
of stocks as measured in the context of factor models, such as the Fama–French three-factor model.
Such factors commonly include Growth, Value, Size, Yield, Momentum,
Quality, and Volatility. Passive factor investing strategies are
sometimes known as "smart beta" strategies. Investors could use factor
investment strategies or portfolios to complement a market-cap weighted
indexed portfolio by tilting or changing their portfolio exposure to
certain factors.
Volatility weighting
This method weights constituent stocks by the inverse of their
relative price volatility. Price volatility is defined differently by
each index provider, but two common methods are the standard deviation
of the past 252 trading days (approximately one calendar year), and the
weekly standard deviation of price returns for the past 156 weeks
(approximately three calendar years).
Minimum variance weighting
This method weights constituent stocks using a mean-variance
optimization process. In a volatility weighted index, highly volatile
stocks are given less weight in the index, while in a minimum variance
weighting index, highly volatile stocks that are negatively correlated
with the rest of the index can be given relatively larger weights than
they would be given in the volatility weighted index.
Presentation of index returns
Some indices, such as the S&P 500 Index, have multiple versions. These versions can differ based on how the index components are weighted and on how dividends
are accounted. For example, there are three versions of the S&P 500
Index: price return, which only considers the price of the components,
total return, which accounts for dividend reinvestment, and net total
return, which accounts for dividend reinvestment after the deduction of a
withholding tax.
The Wilshire 4500 and Wilshire 5000
indices have five versions each: full capitalization total return, full
capitalization price, float-adjusted total return, float-adjusted
price, and equal weight. The difference between the full capitalization,
float-adjusted, and equal weight versions is in how index components
are weighted.
Criticism of capitalization-weighting
One
argument for capitalization weighting is that investors must, in
aggregate, hold a capitalization-weighted portfolio anyway. This then
gives the average return for all investors; if some investors do worse,
other investors must do better (excluding costs).
Indices and passive investment management
Passive management
is an investing strategy involving investing in index funds, which are
structured as mutual funds or exchange-traded funds that track market
indices.
The SPIVA (S&P Indices vs. Active) annual "U.S. Scorecard", which
measures the performance of indices versus actively managed mutual
funds, finds the vast majority of active management mutual funds underperform their benchmarks, such as the S&P 500 Index, after fees.
Unlike a mutual fund, which is priced daily, an exchange-traded fund is priced continuously and is optionable.
Critics of such initiatives argue that many firms satisfy
mechanical "ethical criteria" (e.g. regarding board composition or
hiring practices) but fail to perform ethically with respect to
shareholders (e.g. Enron).
Indeed, the seeming "seal of approval" of an ethical index may put
investors more at ease, enabling scams. One response to these criticisms
is that trust in the corporate management, index criteria, fund or
index manager, and securities regulator, can never be replaced by
mechanical means, so "market transparency" and "disclosure"
are the only long-term-effective paths to fair markets. From a
financial perspective, it is not obvious whether ethical indices or
ethical funds will out-perform their more conventional counterparts.
Theory might suggest that returns would be lower since the investible
universe is artificially reduced and with it portfolio efficiency. (It
conflicts with the Capital Asset Pricing Model, see above.) On the other
hand, companies with good social performances might be better run, have
more committed workers and customers, and be less likely to suffer
reputation damage from incidents (oil spillages, industrial tribunals,
etc.) and this might result in lower share price volatility,
although such features, at least in theory, will have already been
factored into the market price of the stock. The empirical evidence on
the performance of ethical funds and of ethical firms versus their
mainstream comparators is very mixed for both stock and debt markets.
The National Health Service (NHS) is the umbrella term for the publicly funded healthcare systems of the United Kingdom, comprising the NHS in England, NHS Scotland and NHS Wales. Health and Social Care in Northern Ireland was created separately and is often locally referred to as "the NHS". The original three systems were established in 1948 (NHS Wales/GIG Cymru was founded in 1969) as part of major social reforms following the Second World War.
The founding principles were that services should be comprehensive,
universal and free at the point of delivery—a health service based on
clinical need, not ability to pay. Each service provides a comprehensive range of health services, provided without charge for residents of the United Kingdom apart from dental treatment and optical care. In England, NHS patients have to pay prescription charges; some, such as those aged over 60, or those on certain state benefits, are exempt.
Taken together, the four services in 2015–16 employed around 1.6 million people with a combined budget of £136.7 billion.
In 2024, the total health sector workforce across the United Kingdom
was 1,499,368 making it the seventh largest employer and second largest
non-military public organisation in the world.
When purchasing consumables such as medications, the four
healthcare services have significant market power that influences the
global price, typically keeping prices lower. A small number of products are procured jointly through contracts shared between services. Several other countries directly rely on Britain's assessments for their own decisions on state-financed drug reimbursements.
Following the 1942 Beveridge Report's
recommendation to create "comprehensive health and rehabilitation
services for prevention and cure of disease", cross-party consensus
emerged on introducing a National Health Service of some description. Conservative MP and Health Minister, Henry Willink
later advanced this notion of a National Health Service in 1944 with
his consultative White Paper "A National Health Service" which was
circulated in full and short versions to colleagues, as well as in
newsreel.
When Clement Attlee's Labour Party won the 1945 election he appointed Aneurin Bevan as Health Minister. Bevan then embarked upon what the official historian of the NHS, Charles Webster, called an "audacious campaign" to take charge of the form the NHS finally took. Bevan's National Health Service was proposed in Westminster legislation for England and Wales from 1946 and Scotland from 1947, and the Northern Ireland Parliament's Public Health Services Act 1947.
NHS Wales was split from NHS (England) in 1969 when control was passed to the Secretary of State for Wales.
According to one history of the NHS, "In some respects the war had made
things easier. In anticipation of massive air raid casualties, the
Emergency Medical Service had brought the country's municipal and
voluntary hospitals into one umbrella organisation, showing that a
national hospital service was possible." Webster wrote in 2002 that "the Luftwaffe achieved in months what had defeated politicians and planners for at least two decades."
The NHS was born out of the ideal that healthcare should be
available to all, regardless of wealth. Although being freely accessible
regardless of wealth maintained Henry Willink's
principle of free healthcare for all, Conservative MPs were in favour
of maintaining local administration of the NHS through existing
arrangements with local authorities fearing that an NHS which owned
hospitals on a national scale would lose the personal relationship
between doctor and patient.
Conservative MPs voted in favour of their amendment to Bevan's
Bill to maintain local control and ownership of hospitals and against
Bevan's plan for national ownership of all hospitals. The Labour
government defeated Conservative amendments and went ahead with the NHS
as it remains today; a single large national organisation (with devolved
equivalents) which forced the transfer of ownership of hospitals from
local authorities and charities to the new NHS. Bevan's principle of
ownership with no private sector involvement has since been diluted,
with later Labour governments implementing large scale financing
arrangements with private builders in private finance initiatives and joint ventures.
At its launch by Bevan on 5 July 1948 it had at its heart three
core principles: That it meet the needs of everyone, that it be free at
the point of delivery, and that it be based on clinical need, not
ability to pay.
Three years after the founding of the NHS, Bevan resigned from the Labour government in opposition to the introduction of charges for the provision of dentures, dentists, and glasses; resigning in support was fellow minister and future Prime MinisterHarold Wilson. The following year, Winston Churchill's Conservative government
introduced prescription fees. However, Wilson's government abolished
them in 1965; they were later re-introduced but with exemptions for
those on low income. These charges were the first of many controversies over changes to the NHS throughout its history.
From its earliest days, the cultural history of the NHS
has shown its place in British society reflected and debated in film,
TV, cartoons and literature. The NHS had a prominent slot during the 2012 London Summer Olympics opening ceremony directed by Danny Boyle, being described as "the institution which more than any other unites our nation".
Everyone living in the UK can use the NHS without being asked to pay the full cost of the service, though NHS dentistry and optometry have standard charges in each of the four national health services in the UK. Most patients in England have to pay charges for prescriptions though some patients are exempted.
People who are not ordinarily resident (including British citizens who may have paid National Insurance contributions in the past) may have to pay for services, with some exceptions such as refugees.Patients who do not qualify for free treatment are asked to pay in advance or to sign a written promise to pay for treatment.
There are some other categories of people who are exempt from the
residence requirements such as specific government workers, those in
the armed forces stationed overseas, and those working outside the UK as a missionary for an organisation with its principal place of business in the UK.
Citizens of the EU or European Economic Area (EEA) nations holding a valid European Health Insurance Card (EHIC)
and people from certain other countries with which the UK has
reciprocal arrangements concerning health care can get NHS emergency
treatment without charge. People from the EU without an EHIC, Provisional Replacement Certificate (PRC) or S1 or S2 visa may have to pay.
People applying for a visa or immigration application for more than six months have to pay an immigration health surcharge
when applying for their visa and can then get treatment on the same
basis as a resident. There are some people who do not have to pay,
including health and care workers and their dependents, dependents of
some members of the armed forces, and victims of slavery or domestic violence.
In 2024, the charges were £776 per year for students, their dependents,
those on Youth Mobility Schemes, and those under aged 18, and £1035 for
all other applicants who are not covered by exemptions.
Funding
The NHS is funded by general taxation and National Insurance contributions, plus around 1% of funding from patient charges for some services.
In 2022/3, £181.7 billion was spent by the Department of Health
and Social Care on services in England. More than 94% of spend was on
salaries and medicines.
In 2024/5, the NHS in Wales budgeted £11.74 billion for health and social care, which was 49% of its budget.
£19.5 billion was budgeted for health and social care in Scotland for 2024/5.
£7.3 billion was budgeted for health in Northern Ireland in 2024/5.
Staffing
The NHS is the largest employer in Europe, with one in every 25 adults in England working for the NHS. As of February 2023, NHS England employed 1.4 million staff.
Nursing staff accounted for the largest cohort at more than 330,000
employees, followed by clinical support staff at 290,000, scientific and
technical staff at 163,000 and doctors at 133,000.
The funding of the NHS is usually an election issue, and fell under scrutiny during the Covid-19 pandemic.
In July 2022, The Telegraph reported that think tank Civitas
found that health spending was costing about £10,000 per household in
the UK. They said that this was the third highest share of GDP of any
nation in Europe and claimed that the UK "has one of the most costly
health systems – and some of the worst outcomes". The findings were made
before the government increased health spending significantly, with a
1.25% increase in National Insurance,
in April 2022. Civitas said that "runaway" health spending in the UK
had increased by more than any country despite the drop in national
income due to the COVID pandemic.
The Labour Government elected in 2024 stated that their policy was that the "NHS is broken". They announced an immediate stocktake of current pressures led by Labour peer Lord Ara Darzi. This was to be followed by development of a new "10 year plan" for the NHS to replace the NHS Long Term Plan published in 2019.
The potential rise of the cost of social care has been signaled by research. Professor Helen Stokes-Lampard of the Royal College of GPs said:
"It's a great testament to medical research, and the NHS, that we are
living longer – but we need to ensure that our patients are living
longer with a good quality of life. For this to happen we need a
properly funded, properly staffed health and social care sector with
general practice, hospitals and social care all working together – and
all communicating well with each other, in the best interests of
delivering safe care to all our patients."
Employment and waiting lists
EU workers joining and leaving the NHS in England, annual variation in absolute numbers (2012–2017)
Joiner
Leaver
In June 2018, the Royal College of Physicians
calculated that medical training places need to be increased from 7,500
to 15,000 by 2030 to take account of part-time working among other
factors. At that time there were 47,800 consultants working in the UK of
which 15,700 were physicians. About 20% of consultants work less than
full-time.
On 6 June 2022, The Guardian said that a survey of more than 20,000 frontline staff by the nursing trade union and professional body, the Royal College of Nursing, found that only a quarter of shifts had the planned number of registered nurses on duty.
The NHS will potentially have a shortage of general practitioners. From 2015 to 2022, the number of GPs fell by 1,622 and some of those continuing to work have changed to work part-time.
In 2023, a report revealed that NHS staff had faced over
incidents of 20,000 sexual misconduct from patients from 2017 to 2022
across 212 NHS Trusts.
In June 2023, the delayed NHS Long Term Workforce Plan was
announced, to train doctors and nurses and create new roles within the
health service.
The Welsh and UK governments announced a partnership on 23
September 2024 to reduce NHS waiting lists in England and Wales during
the Labour Party Conference in Liverpool. This collaboration aimed to
share best practices and tackle common challenges. Previously, Eluned Morgan
rejected a Conservative proposal for treating Welsh patients in
England. The Welsh Conservatives welcomed the new partnership as
overdue, while Plaid Cymru criticized it as insufficient for addressing deeper issues within the Welsh NHS.
One in four patients throughout the UK wait over three months to see
an NHS mental health professional, with 6% waiting at least a year. The National Audit Office
found mental health provisions for children and young people will not
meet growing demand, despite promises of increased funding. Currently
one-quarter of young people needing mental health services can get NHS
help.The Department of Health and Social Care hopes to raise the ratio to 35%. Efforts to improve mental health provisions could reveal previously unmet demand.
NHS England is expanding mental health services. The mental health charity, Mind,
said that the £2.3bn a year was important and that the "longer-term
strategy was developed in consultation with people with mental health
problems to ensure their views are reflected."
Inclusion
In 2024, some NHS hospitals required radiographers
to ask all male patients aged 12 to 55 if they were pregnant for
inclusivity purposes. This received a lot of coverage in the media.
Performance of the NHS is generally assessed separately at the level
of England, Wales, Scotland and Northern Ireland. Since 2004 the Commonwealth Fund
has produced surveys, "Mirror, Mirror on the Wall", comparing the
performance of health systems in 11 wealthy countries in which the UK
generally ranks highly. In the 2021 survey the NHS dropped from first
overall to fourth as it had fallen in key areas, including 'access to
care and equity.' The Euro Health Consumer Index attempted to rank the NHS against other European health systems from 2014 to 2018. The right-leaning think tank Civitas
produced an International Health Care Outcomes Index in 2022 ranking
the performance of the UK health care system against 18 similar, wealthy
countries since 2000. It excluded the impact of the COVID-19 pandemic
as data stopped in 2019. The UK was near the bottom of most tables
except households who faced catastrophic health spending.
A comparative analysis of health care systems in 2010, by The Commonwealth Fund, a left-leaning US health charity, put the NHS second in a study of seven rich countries.
The report put the United Kingdom health systems above those of
Germany, Canada and the United States; the NHS was deemed the most
efficient among those health systems studied.
A 2018 study by the King's Fund, Health Foundation, Nuffield Trust, and the Institute for Fiscal Studies
to mark the NHS 70th anniversary concluded that the main weakness of
the NHS was healthcare outcomes. Mortality for cancer, heart attacks and
stroke, was higher than average among comparable countries. The NHS was
doing well at protecting people from heavy financial costs when ill.
Waiting times were about the same, and the management of longterm
illness was better than in other comparable countries. Efficiency was
good, with low administrative costs and high use of cheaper generic
medicines. Twenty-nine hospital trusts and boards out of 157 had not met any waiting-time target in the year 2017–2018.
The Office for National Statistics reported in January 2019 that
productivity in the English NHS had been growing at 3%, considerably
faster than across the rest of the UK economy.
In 2019, The Times, commenting on a study in the British Medical Journal,
reported that "Britain spent the least on health, £3,000 per person,
compared with an average of £4,400, and had the highest number of deaths
that might have been prevented with prompt treatment". The BMJ study compared "the healthcare systems of other developed countries in spending, staff numbers and avoidable deaths".
Over 130,000 deaths since 2012 in the UK could have been prevented if progress in public health policy had not stopped due to austerity, analysis by the Institute for Public Policy Research found. Dean Hochlaf of the IPPR said: "We have seen progress in reducing preventable disease flatline since 2012."".
The key NHS performance indicators (18 weeks (RTT), 4 hours (A&E)
and cancer (2 week wait) have not been achieved since February 2016,
July 2015 and December 2015 respectively.
Overall satisfaction with the NHS in 2021 fell, more sharply in
Scotland than in England, 17 points to 36% – the lowest level since 1997
according to the British Social Attitudes Survey. Dissatisfaction with hospital and GP waiting times were the biggest cause of the fall.
The NHS Confederation
polled 182 health leaders and 9 in 10 warned that inadequate capital
funding harmed their "ability to meet safety requirements for patients"
in health settings including hospitals, ambulance, community and mental
health services and GP practices.
Public perception of the NHS
In
2016 it was reported that there appeared to be support for higher
taxation to pay for extra spending on the NHS as an opinion poll in 2016
showed that 70% of people were willing to pay an extra penny in the
pound in income tax if the money were ringfenced and guaranteed for the
NHS. Two thirds of respondents to a King's Fund poll, reported in September 2017, favoured increased taxation to help finance the NHS.
A YouGov poll reported in May 2018 showed that 74% of the UK public believed there were too few nurses.
The trade union, Unite, said in March 2019 that the NHS had been under pressure as a result of economic austerity.
A 2018 public survey reported that public satisfaction with the NHS had fallen from 70% in 2010 to 53% in 2018.
The NHS is consistently ranked as the institution that makes people
proudest to be British, beating the royal family, Armed Forces and the
BBC. One 2019 survey ranked nurses and doctors – not necessarily NHS staff – amongst the most trustworthy professions in the UK.
In November 2022 a survey by Ipsos and the Health Foundation
found just a third of respondents agreed the NHS gave a good service
nationally, and 82% thought the NHS needed more funding. 62% expected
care standards to fall during the following 12 months. Sorting out
pressure and workload on staff and increasing staff numbers were the
chief priorities the poll found. Improving A&E waiting times and
routine services were also concerns.
Just 10% of UK respondents felt their government had the correct plans
for the NHS. The Health Foundation stated in spite of these concerns,
the public is committed to the founding principles of the NHS and 90% of
respondents believe the NHS should be free, 89% believe NHS should
provide a comprehensive service for everyone, and 84% believe the NHS
should be funded mainly through taxation.
In 2020, the NHS issued medical advice in combating COVID-19 and
partnered with tech companies to create computer dashboards to help
combat the nation's coronavirus pandemic. During the pandemic, the NHS also established integrated COVID into its 1-1-1 service line as well. Following his discharge from the St. Thomas' Hospital in London on 13 April 2020 after being diagnosed with COVID-19, British Prime Minister Boris Johnson described NHS medical care as "astonishing" and said that the "NHS saved my life. No question." In this time, the NHS underwent major re-organisation to prepare for the COVID-19 pandemic.
On 5 July 2021, Queen Elizabeth II awarded the NHS the George Cross. The George Cross, the highest award for gallantry available to civilians and is slightly lower in stature to the Victoria Cross,
is bestowed for acts of the greatest heroism or most conspicuous
courage. In a handwritten note the Queen said the award was being made
to all NHS staff past and present for their "courage, compassion and
dedication" throughout the pandemic.
Hospital beds
In 2015, the UK had 2.6 hospital beds per 1,000 people. In September 2017, the King's Fund
documented the number of NHS hospital beds in England as 142,000,
describing this as less than 50% of the number 30 years previously. In 2019 one tenth of the beds in the UK were occupied by a patient who was alcohol-dependent.
NHS music releases
The NHS have released various charity singles including:
Relative species abundance is a component of biodiversity and is a measure of how common or rare a species is relative to other species in a defined location or community.
Relative abundance is the percent composition of an organism of a
particular kind relative to the total number of organisms in the area. Relative species abundances tend to conform to specific patterns that are among the best-known and most-studied patterns in macroecology. Different populations in a community exist in relative proportions; this idea is known as relative abundance.
Introduction
Relative species abundance
Figure 1.
Relative species abundance of beetles sampled from the river Thames
showing the universal "hollow curve". (derived from data presented in
Magurran (2004) and collected by C.B. Williams (1964))
Relative species abundance and species richness describe key elements of biodiversity.
Relative species abundance refers to how common or rare a species is
relative to other species in a given location or community.
Usually relative species abundances are described for a single trophic level. Because such species occupy the same trophic level they will potentially or actually compete for similar resources. For example, relative species abundances might describe all terrestrial birds in a forest community or all planktoniccopepods in a particular marine environment.
Relative species abundances follow very similar patterns over a
wide range of ecological communities. When plotted as a histogram of the
number of species represented by 1, 2, 3, ..., n individuals
usually fit a hollow curve, such that most species are rare,
(represented by a single individual in a community sample) and
relatively few species are abundant (represented by a large number of
individuals in a community sample)(Figure 1). This pattern has been long-recognized and can be broadly summarized with the statement that "most species are rare". For example, Charles Darwin noted in 1859 in The Origin of Species that "... rarity is the attribute of vast numbers of species in all classes...."
Species abundance patterns can be best visualized in the form of
relative abundance distribution plots. The consistency of relative
species abundance patterns suggests that some common macroecological
"rule" or process determines the distribution of individuals among
species within a trophic level.
Distribution plots
Figure 2. Preston plot of beetles sampled from the river Thames showing a strong right-skew.Figure 3. Whittaker plot of beetles sampled from the river Thames showing a slight "s"-shape.
Relative species abundance distributions are usually graphed as frequency histograms ("Preston plots"; Figure 2) or rank-abundance diagrams ("Whittaker Plots"; Figure 3).
Frequency histogram (Preston plot):
x-axis: logarithm of abundance bins (historically log2 as a rough approximation to the natural logarithm)
y-axis: number of species at given abundance
Rank-abundance diagram (Whittaker plot):
x-axis: species list, ranked in order of descending abundance (i.e. from common to rare)
y-axis: logarithm of % relative abundance
When plotted in these ways, relative species abundances from wildly
different data sets show similar patterns: frequency histograms tend to
be right-skewed (e.g. Figure 2) and rank-abundance diagrams tend to
conform to the curves illustrated in Figure 4.
Understanding relative species abundance patterns
Researchers
attempting to understand relative species abundance patterns usually
approach them in a descriptive or mechanistic way. Using a descriptive
approach biologists attempt to fit a mathematical model to real data
sets and infer the underlying biological principles at work from the
model parameters. By contrast, mechanistic approaches create a
mathematical model based on biological principles and then test how well
these models fit real data sets.
Descriptive approaches
Geometric series (Motomura 1932)
Figure 4.
Generic Rank-abundance diagram of three common mathematical models used
to fit species abundance distributions: Motomura's geometric series,
Fisher's logseries, and Preston's log-normal series (modified from
Magurran 1988)Figure 5.
Plant succession in abandoned fields within Brookhaven National
Laboratory, NY. Species abundances conform to the geometric series
during early succession but approach lognormal as the community ages.
(modified from Whittaker 1972)
I. Motomura developed the geometric series model based on benthic community data in a lake. Within the geometric series each species' level of abundance is a sequential, constant proportion (k) of the total number of individuals in the community. Thus if k
is 0.5, the most common species would represent half of individuals in
the community (50%), the second most common species would represent half
of the remaining half (25%), the third, half of the remaining quarter
(12.5%) and so forth.
Although Motomura originally developed the model as a statistical
(descriptive) means to plot observed abundances, the "discovery" of his
paper by Western researchers in 1965 led to the model being used as a niche apportionment model – the "niche-preemption model". In a mechanistic model k represents the proportion of the resource base acquired by a given species.
The geometric series rank-abundance diagram is linear with a slope of –k, and reflects a rapid decrease in species abundances by rank (Figure 4).
The geometric series does not explicitly assume that species colonize
an area sequentially, however, the model fits the concept of niche
preemption, where species sequentially colonize a region and the first
species to arrive receives the majority of resources. The geometric series model fits observed species abundances in highly uneven communities with low diversity.
This is expected to occur in terrestrial plant communities (as these
assemblages often show strong dominance) as well as communities at early
successional stages and those in harsh or isolated environments (Figure
5).
Logseries (Fisher et al 1943)
where:
S = the number of species in the sampled community
N = the number of individuals sampled
= a constant derived from the sample data set
The logseries was developed by Ronald Fisher to fit two different abundance data sets: British moth species (collected by Carrington Williams) and Malaya butterflies (collected by Alexander Steven Corbet). The logic behind the derivation of the logseries is varied
however Fisher proposed that sampled species abundances would follow a
negative binomial from which the zero abundance class (species too rare
to be sampled) was eliminated. He also assumed that the total number of species in a community was infinite. Together, this produced the logseries distribution (Figure 4). The logseries predicts the number of species at different levels of abundance (n individuals) with the formula:
where:
S = the number of species with an abundance of n
x = a positive constant (0 < x < 1) which is derived from the sample data set and generally approaches 1 in value
The number of species with 1, 2, 3, ..., n individuals are therefore:
Fisher’s constants
The constants α and x can be estimated through iteration from a given species data set using the values S and N. Fisher's dimensionlessα
is often used as a measure of biodiversity, and indeed has recently
been found to represent the fundamental biodiversity parameter θ from neutral theory (see below).
Log normal (Preston 1948)
Figure 6.
An example of Preston's veil. Fish species abundances sampled using
repeated trawling over a one-month (blue bars), two month (gold bars)
and one-year period (yellow). One year of sampling indicates that the
fish community is log-normally distributed. (derived from Magurran 2004)
Using several data sets (including breeding bird surveys from New
York and Pennsylvania and moth collections from Maine, Alberta and
Saskatchewan) Frank W. Preston (1948) argued that species abundances (when binned logarithmically in a Preston plot) follow a normal (Gaussian) distribution, partly as a result of the central limit theorem (Figure 4). This means that the abundance distribution is lognormal.
According to his argument, the right-skew observed in species abundance
frequency histograms (including those described by Fisher et al. (1943)) was, in fact, a sampling artifact. Given that species toward the left side of the x-axis
are increasingly rare, they may be missed in a random species sample.
As the sample size increases however, the likelihood of collecting rare
species in a way that accurately represents their abundance also
increases, and more of the normal distribution becomes visible. The point at which rare species cease to be sampled has been termed Preston's veil line. As the sample size increases Preston's veil is pushed farther to the left and more of the normal curve becomes visible. Williams' moth data, originally used by Fisher to develop the
logseries distribution, became increasingly lognormal as more years of
sampling were completed.
Calculating theoretical species richness
Preston's
theory has an application: if a community is truly lognormal yet
under-sampled, the lognormal distribution can be used to estimate the
true species richness of a community. Assuming the shape of the total
distribution can be confidently predicted from the collected data, the
normal curve can be fit via statistical software or by completing the Gaussian formula:
where:
n0 is the number of species in the modal bin (the peak of the curve)
n is the number of species in bins R distant from the modal bin
a is a constant derived from the data
It is then possible to predict how many species are in the community by calculating the total area under the curve (N):
The number of species missing from the data set (the missing area to the left of the veil line) is simply N minus the number of species sampled.
Preston did this for two lepidopteran data sets, predicting that, even
after 22 years of collection, only 72% and 88% of the species present
had been sampled.
Yule model (Nee 2003)
The Yule model is based on a much earlier, Galton–Watson model which was used to describe the distribution of species among genera.
The Yule model assumes random branching of species trees, with each
species (branch tip) having the equivalent probability of giving rise to
new species or becoming extinct. As the number of species within a
genus, within a clade, has a similar distribution to the number of
individuals within a species, within a community (i.e. the "hollow
curve"), Sean Nee (2003) used the model to describe relative species
abundances. In many ways this model is similar to niche apportionment models,
however, Nee intentionally did not propose a biological mechanism for
the model behavior, arguing that any distribution can be produced by a
variety of mechanisms.
Mechanistic approaches: niche apportionment
Note: This section provides a general summary of niche apportionment theory, more information can be found under niche apportionment models.
Most mechanistic approaches to species abundance distributions
use niche-space, i.e. available resources, as the mechanism driving
abundances. If species in the same trophic level
consume the same resources (such as nutrients or sunlight in plant
communities, prey in carnivore communities, nesting locations or food in
bird communities) and these resources are limited, how the resource
"pie" is divided among species determines how many individuals of each
species can exist in the community. Species with access to abundant
resources will have higher carrying capacities than those with little
access. Mutsunori Tokeshi later elaborated niche apportionment theory to include niche filling in unexploited resource space.
Thus, a species may survive in the community by carving out a portion
of another species' niche (slicing up the pie into smaller pieces) or by
moving into a vacant niche (essentially making the pie larger, for
example, by being the first to arrive in a newly available location or
through the development of a novel trait that allows access previously
unavailable resources). Numerous niche apportionment models have been developed. Each make different assumptions about how species carve up niche-space.
The Unified Neutral Theory of Biodiversity and Biogeography (UNTB) is
a special form of mechanistic model that takes an entirely different
approach to community composition than the niche apportionment models.
Instead of species populations reaching equilibrium within a community,
the UNTB model is dynamic, allowing for continuing changes in relative
species abundances through drift.
A community in the UNTB model can be best visualized as a grid
with a certain number of spaces, each occupied with individuals of
different species. The model is zero-sum
as there are a limited number of spaces that can be occupied: an
increase in the number of individuals of one species in the grid must
result in corresponding decrease in the number of individuals of other
species in the grid. The model then uses birth, death, immigration,
extinction and speciation to modify community composition over time.
Hubbell's theta
The UNTB model produces a dimensionless "fundamental biodiversity" number, θ, which is derived using the formula:
θ = 2Jmv
where:
Jm is the size of the metacommunity (the outside source of immigrants to the local community)
v is the speciation rate in the model
Relative species abundances in the UNTB model follow a zero-sum multinomial distribution. The shape of this distribution is a function of the immigration rate, the size of the sampled community (grid), and θ. When the value of θ is small, the relative species abundance distribution is similar to the geometric series (high dominance). As θ
gets larger, the distribution becomes increasingly s-shaped
(log-normal) and, as it approaches infinity, the curve becomes flat (the
community has infinite diversity and species abundances of one).
Finally, when θ = 0 the community described consists of only one species (extreme dominance).
Fisher's alpha and Hubbell's theta – an interesting convergence
An unexpected result of the UNTB is that at very large sample sizes, predicted relative species abundance curves describe the metacommunity and become identical to Fisher's logseries. At this point θ also becomes identical to Fisher's for the equivalent distribution and Fisher's constant x
is equal to the ratio of birthrate : deathrate. Thus, the UNTB
unintentionally offers a mechanistic explanation of the logseries 50
years after Fisher first developed his descriptive model.
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