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These findings suggest that at the local authority level, the "hot spots" index of deprivation may represent the same level of magnitude in predicting the rates of suicide as the number of unemployed or income-deprived people. However, more studies using multilevel modelling are needed to shed more light on the ecological associations between suicide rates and socio-economic and social cohesion status.

Study objective -To produce a priority list for purchasers to use when purchasing elective care in the speciality of orthopaedics so that efficiency in health care purchasing (that is, maximising the benefit per unit of resource available for the resident population) can be achieved. Design -The study used cost utility analysis in the elective speciality of orthopaedics. The diagnostic groups in the study were chosen on the basis of those conditions that constituted the greatest proportion of the orthopaedic waiting list, and consequently the greatest proportion ofactivity within the speciality. Costs were derived by two methods: the extra contractual referral tariff (ECR) and individual patient based costings. Outcome was assessed before surgery and again approximately six months afterwards. The outcome of the procedures was derived in two ways: Rosser and EuroQol indices. Setting -The study took place at Wrightington hospital, a specialist orthopaedic hospital in north west England. Patients -Prospective assessments were obtained from 99 patients for nine orthopaedics procedures. All the patients were individually interviewed on each occasion. Rosser and EuroQol assessments were completed for each patient by the patient and the patient's consultant before and after surgery.Main results -Priority lists presenting cost utility rankings for each of the procedures were derived from the patients' and consultants' assessments. Conclusions -It is feasible to generate priority lists in a systematic way. Purchasers may then use the results from these priority lists to help them maximise the benefits per unit of resource for their resident population. (J7 Epidemiol Community Health 1996;50: 182-189) To function effectively in the market, commissioners of health services (purchasers) must be able to make clear and explicit decisions about the goods and services they purchase in order to achieve the "best" possible health care package for their resident population -that is, to maximise efficiency in purchasing. The "new public health" function in purchasing has a role to play in this process which requires prioritisation between competing services or procedures. To do this purchasers need access to information on a range of outcomes, the quality of these outcomes, and about costs -that is, cost benefit information.The work reported here took place in West Lancashire Health Authority in the north west of England from 1990-92. It develops the application of cost utility analysis to a range of orthopaedic procedures. The published reports on outcome assessment in orthopaedics are clinically dominated and contain very little on the patients' functional and psychological assessment of outcome.`5 The use of health status measurement, and specifically the application of the quality adjusted life year, will extend the purchaser's information set and should facilitate improved decision making.The quality adjusted life year (QALY) measures the quality and the quantity of life. Hence, the QALY is calculated by multiplying...

A lack of effect was found once we move from ward to local authority level. This may happen because of the non-homogeneous nature of the local authorities in terms of their income and employment indices. In this sense, wards are more homogeneous. This means that in examining ecological risk factors, a balance was found between large areas (diluted effects but greater power) and small areas.

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