Specialist palliative care in the UK: its future and the effects of NHS reforms

This article examines the impact legislative developments in the UK have had, and are likely to have, on health care in general and how specialist palliative care providers may need to adapt to these changes. The focus of adaptation is on communication and multidisciplinary teamwork. A brief review of the previous Conservative government's reforms offers a background to understanding how the current Labour government agendas affecting health and social care have been developed. Ideas are put forward to ensure that specialist palliative care provision is maintained and developed within the current structure of the health service.     

Modernizing UK health services: 'short-sharp-shock' reform, the NHS subsistence economy, and the spectre of health care famine

Modernization is the trend for societies to grow functionally more complex, efficient and productive. Modernization usually occurs by increased specialization of function (e.g. division of labour, such as the proliferation of specialists in medicine), combined with increased organization in order to co-ordinate the numerous specialized functions (e.g. the increased size of hospitals and specialist teams, including the management of these large groups). There have been many attempts to modernize the National Health Service (NHS) over recent decades, but it seems that none have significantly enhanced either the efficiency or output of the health care system. The reason may be that reforms have been applied as a 'drip-drip' of central regulation, with the consequence that health care has become increasingly dominated by the political system. In contrast, a 'short-sharp-shock' of radical and rapid modernization seems to be a more successful strategy for reforming social systems - in-between waves of structural change the system is left to re-orientate towards its client group. An example was the Flexner-initiated reform of US medical education which resulted in the closure of nearly half the medical colleges, an immediate enhancement in quality and efficiency of the system and future growth based on best institutional practices. However, short-sharp-shock reforms would probably initiate an NHS 'health care famine' with acute shortages and a health care crisis, because the NHS constitutes a 'subsistence economy' without any significant surplus of health services. The UK health care system must grow to generate a surplus before it can adequately be modernized. Efficient and rapid growth in health services could most easily be generated by stimulating provision outside the NHS, using mainly staff trained abroad and needs-subsidized 'item-of-service'-type payment schemes. Once there is a surplus of critically vital health services (e.g. acute and emergency provision), then radical modernization should rapidly improve the health service by a cull of low-quality and inefficient health care providers.     

The impact of recent primary care reforms in the UK on interprofessional working in primary care centres

This study comprises the perspectives of professionals in primary care regarding the impact of the changes in its organisation and interprofessional collaboration in the UK. General practitioners (GPs), nurses and practice managers were interviewed in three primary cares located within a 20-mile radius and in the same health authority. Interviews were analysed using the grounded theory approach of Glaser & Strauss (1967) as developed by Strauss & Corbin (1998). The separate ideologies and subcultures of GPs, nurses and managers influenced their perceptions of reforms in primary care. Professional identities and the traditional power structure generated some conflict between the three groups which affected collaboration in implementing the reforms. Based on the findings of the study, it seems probable that it will take a new generation of health professionals to bring about an interprofessional culture in the NHS.     

Pediatric nursing in the United Kingdom.

Child health matters remain low on the government agenda, and present reforms of the NHS are overtly concerned with financial aspects rather than the quality of care. Pediatric nurses must therefore become more assertive and pro-active in their role as advocates for children and their families. However, pediatric nurses are extremely fortunate in the UK because they have (a) a nurse education system that has always recognized that the nursing needs of children are different to those of adults, (b) the opportunity to work with medical and voluntary organizations committed to improving children's health, and (c) a professional organization that is not only large and powerful, but since 1984 has been committed to advancing the art and science of pediatric nursing. It employs a full-time adviser to assist its members and publishes the only pediatric nursing journal. Pediatric nurses have assisted in advancing the art and science of pediatric nursing with caring for children and their families in a holistic fashion, with families supported and participating in their child's care. But there are still many opportunities to improve the quality of health care to children and their families. Quality caring is what children and their families want and deserve, but is not as easy to measure as quantity care. At a time when in so many countries, health service managers concentrate on quantity, pediatric nurses must use every opportunity to shape the health policy of their nation for the benefit of children. We all live in interesting times and it would be interesting to see what we make of them on behalf of children.     

The relationship between health care reform and nurses' interest in union representation: the role of workplace climate.

Market-based reforms are rapidly changing the landscape of the American health care system. Over the last decade, a great deal of attention has been paid to these reforms, particularly the advent and rapid growth of managed care and the vertical and horizontal integration of provider institutions. The ramifications of these changes on both individual and institutional consumers has also been widely considered by scholars and policymakers. Yet, although these market reforms are driving the massive restructuring of work in hospitals and other health care organizations, comparatively little attention has been paid to the impact these changes have on health care employees and the environment in which they work. This article reports the results of an exploratory study examining the relationship between health care market reforms, nurses' perceptions of the climate for patient care in hospital settings, and nurses' interest in union representation. A model is proposed to help explain nurses' support for union representation in the presence of market-based reforms.     

Worrying times for Medicare

The Federal Government's recent proposed reforms to primary health care and bulk billing have been presented as a measure to strengthen Australia's public health system. While the Federal Government maintains the proposed package will produce a 'fairer' Medicare, many in the industry see the move as the beginning of the end of Australia's universal access to health, based on need rather than capacity to pay.     

Malnutrition needs identifying in the community

A recent survey found that in the UK, more than one in three adults are malnourished on admission to hospital or care homes, and one in five are malnourished on admission to mental health units. The Nutrition Screening Week report supported by the British Association of Parenteral and Enteral Nutrition was conducted to establish the prevalence of malnutrition in the UK. Data was collected from hospitals, care homes and mental health units. Empowering healthcare staff to recognise existing skills they have in this area and ensuring reporting mechanisms are used and followed up may help to tackle malnutrition in individuals.     

Community nursing in systems reform: the London polyclinic experience

Internationally, the polyclinic has been a feature of many health systems. The recent UK policy shift towards enhanced coordination of care closer to home resulted in the development of polyclinics, most notably in London. This article explores the background to the development of polyclinics and draws on the early experience of developments in London to explore what their impact has been, and is likely to be, on community nursing. Emerging findings from an evaluation of four pilot polyclinics suggests that rather than one model, polyclinics evolved in distinctively different ways more appropriately labelled as polysystems. Although policy makers clearly identified community nursing as being one of the key components of integrated, community-based care, the evaluation suggests a focus on high-level organizational restructuring and system change can shift attention from what many would consider core activities such as community health services.     

Reforming primary care in England--again. Plans for improving the quality of care

An extensive programme of health service reform has begun in England. Improvement in the quality of care is a key objective of the reforms, and several initiatives are being introduced in response. These include systems to provide national guidance about appropriate treatment and services, a local system to support quality improvement and arrangements to monitor performance, including a new performance framework, an inspection agency and an annual survey of patients. The local quality improvement system has features of particular interest. These include arrangements for setting objectives for quality improvement, the use of various quality improvement methods tailored to local needs and a new system to provide accountability to both the health service and the public. The introduction of clinical governance and all the other reforms presents primary care practitioners with a major challenge. However, if sufficient time is allowed and adequate resources are made available, the reforms do have the potential to improve health care in England.     

The relevance of the Dutch system of maternity care to the United Kingdom

The Dutch system of maternity care is occasionally held up as an example to be emulated by health care providers in the United Kingdom There are, however, certain differences between maternity care in the two countries which prevent the direct transfer of a system of maternity care from the Netherlands to the UK The countries are different in terms of their geography and social class distribution The organizational frameworks within which maternity care is provided demonstrate important differences The midwives are from a different background, undergo a different preparation and face crucially different working arrangements There are also certain, largely cultural, differences between mothers in the two countries Despite these discrepancies, much may be learned by those involved in maternity care in the UK from their Dutch counterparts and the Dutch system of care     

Reforming primary care in England - again: Plans for improving the quality of care

An extensive programme of health service reform has begun in England. Improvement in the quality of care is a key objective of the reforms, and several initiatives are being introduced in response. These include systems to provide national guidance about appropriate treatment and services, a local system to support quality improvement and arrangements to monitor performance, including a new performance framework, an inspection agency and an annual survey of patients. The local quality improvement system has features of particular interest. These include arrangements for setting objectives for quality improvement, the use of various quality improvement methods tailored to local needs and a new system to provide accountability to both the health service and the public. The introduction of clinical governance and all the other reforms presents primary care practitioners with a major challenge. However, if sufficient time is allowed and adequate resources are made available, the reforms do have the potential to improve health care in England.     

Evaluation of changes in primary health care availability and provision from the patient perspective

This study was designed to investigate changes in primary care following recent NHS reforms. The study was carried out by home interview of random samples of people aged 65 years and over in three district health authorities; 1500 in 1990 and 1500 in 1992, before and after the introduction of the reforms. The response rate was 94% (1413 in 1990 and 1405 in 1992). Few patients (6%) changed their general practitioner (GP) in 1990 or 1992. There was an increase in the provision of written practice information in 1992, but more than 60% of patients could not recall receiving leaflets. More practices included practice nurses and appointments systems and fewer used rotas of local practices or deputizing services for 'out of hours' calls. In 1992 more patients aged 75 years and over saw their GP within the previous year and significantly more were assessed for vision, hearing, continence, foot problems and blood pressure and had their urine tested, but most of these health assessments, except blood pressure (64%), were recalled by few patients. There have been small changes in the provision and use of primary health care by older people since the introduction of the new GP contract.     

A public policy problem. Access to long-term health care

A system providing humanistic health care without catastrophic financial consequences for elderly citizens must be based on principles and practices ensuring equal access to long-term health care. The purpose of this article is to analyze issues of limited access to long-term care (LTC) and recommend policy directions for society, which nurses can use in their understanding of and advocacy for their elderly patients. Issues pertaining to LTC screening methods, financing, and Medicaid reimbursement are analyzed. Recommendations include the development of a comprehensive, integrated LTC system through incremental reforms. Nurses' advocacy for LTC system reform to enhance access and quality of care for older adults is discussed.     

A Cross-Cultural Tool To Identify Continuing Education Needs

Cost-controlled health reforms have created the need for training nurses to provide evidence-based care in new contexts. Planning for nurses' continuing education must thus target the appropriate personnel and simultaneously consider local healthcare needs and training requirements. To plan such educational programmes, a training needs analysis instrument was developed in the UK and used to compare the training needs of nurses in Australia, the USA and the UK. Below, the findings of this survey.     

The organisation of death and dying in today's society

BACKGROUND: This literature review explores service provision for dying people in the wider context of changes in the modern hospice movement, recent government reforms and, in particular, the role of nursing in influencing and improving service delivery. These government reforms are reviewed in the context of the care of the dying. The article then examines the place of death in modern society, and health professionals' views. The concept of the 'good death' is also explored and the satisfaction of patients, carers and health professionals discussed in relation to terminal care in the community. CONCLUSION: Nursing makes a valuable contribution to the care of dying patients and nurses must take the opportunities presented to them by forthcoming healthcare changes to become proactive in representing those they care for.     

Israeli nurses' knowledge of health care reforms

Israeli nurses’ knowledge of health care reforms Objectives. This study examines health care reforms’ implementation processes from the perspective of nurses’ knowledge regarding the reforms. The research has been carried out in the Israeli context, where health care reforms were initiated in 1995. Three specific research questions were formulated: (a) What is the level of nurses’ knowledge regarding the recommendations of the Netanyahu committee? (b) What is the level of nurses’ knowledge concerning the basic principals of the National Insurance Law? and (c) Are there knowledge differences relating to employment setting (hospital, community, and educational settings), nurses’ roles (managerial vs. staff nurses), years of experience, and level and type of education? Method. The stratified nonproportional random sample consisted of a total of 468 nurses. Of these nurses, 206 were employed in community settings (136 in curative care, and 70 in preventive care), 137 were employed in hospital settings, and 125 worked in schools and departments of nursing. Research tools, developed for the purpose of this study, included the nurses’ knowledge questionnaire comprised of five subscales, and the knowledge relevancy questionnaire. Results. Overall, data demonstrated a low to moderate level of knowledge on all knowledge scales. Knowledge level on the criteria questions was particularly low. Contrary to the low level of knowledge, nurses regarded health care reforms’ knowledge as highly relevant to their work life. Curative setting, an extensive work experience, managerial position, and non‐nursing academic degree were all positively related to higher levels of reforms’ knowledge. Conclusion. These findings should encourage both policy makers and managers in various health care organizations to develop programs for informing health care providers on central aspects of health care reforms considered most relevant to the practice setting.     

The community psychiatric nurse in primary care: an economic analysis

Community psychiatric nurses (CPNs) in the United Kingdom are increasingly working in primary health care settings with less serious mental health problems This paper describes an economic evaluation of their work using a randomized controlled trial in which 231 patients were assigned to continuing general practitioner care or one of two conditions of CPN intervention This is only the third systematic economic analysis of community mental health nursing in the UK and the first carried out by mental health nurses Various costs to patients, their families and the health care system were determined Results showed that patients receiving CPN intervention experienced less absence from work and that this resulted in a net benefit However, the cost per quality adjusted life year for intervening with this group of patients was probably several times more than for intervening with the seriously mentally ill Therefore, if one considers both the clinical and economic results of the study, taken together with the recent results of the review of mental health nursing, there seems little justification for CPNs continuing to work in this area     

Inter-group conflict in health care: UK students' experiences of bullying and the need for organisational solutions

This paper addresses bullying of United Kingdom (UK) nursing students whilst on work placement as a specific issue of inter-group difficulty that currently affects nurses and students working in the UK National Health Service. The authors begin by discussing the concept of bullying and sharing the types of bullying reported in two recent studies involving UK nursing students. Both studies illustrate the effects that negative workplace experiences can have on new entrants to the profession. After reviewing various individual solutions which have been recommended for reducing bullying, they suggest that the most effective solution is for health care organisations offering placement training to become much more proactive in creating a culture that will not tolerate bullying behaviour by staff at any level. The literature suggests bullying is a phenomenon affecting workplaces in many countries. Thus the issues described in this article, and the solutions offered have relevance to a variety of health care settings.     

Adolescent cancer--the need to evaluate current service provision in the UK.

This article suggests that service provision for adolescents with cancer requires further attention by health service researchers. Evidence of the care needs of this patient group remains scarce, particularly in terms of evaluations of the available care settings in the UK. The authors discuss the challenges facing the adolescent cancer patient population, and discuss the findings from a recent ethnographic evaluation of one of the first specialist UK units dedicated to the care of adolescents with cancer. The implications for further evaluative research, education and staff-related concerns are explored in the light of the findings.