Medical workforce education and training: A failed decentralisation attempt to reform organisation,financing, and planning in England

The 2010–2015 Conservative and Liberal Democrat coalition government proposed introducing a radical decentralisation reform of the organisation, financing, and planning of medical workforce education and training in England. However, following public deliberation and parliamentary scrutiny of the government's proposals, it had to abandon and alter its original proposals to the extent that they failed to achieve their original decentralisation objectives. This failed decentralisation attempt provides important lessons about the policy process and content of both workforce governance and health system reforms in Europe and beyond. The organisation, financing, and planning of medical workforce education is as an issue of national importance and should remain in the stewardship of the national government. Future reform efforts seeking to enhance the skills of the workforce needed to deliver high-quality care for patients in the 21st century will have a greater chance of succeeding if they are clearly articulated through engagement with stakeholders, and focus on the delivery of undergraduate and postgraduate multi-professional education and training in universities and teaching hospitals.     

Pushing forward to only ever healthy body weight in children and adolescents: the Swiss paradox

The economic future of a country depends largely on the vitality of its new generations: they need to be healthy enough to lead. However, facts and high prevalence of obesity epidemic demonstrate that the individual choice approach towards adequate nutritional behaviour and exercise is not working, and governments around the globe are stepping into halt and hopefully reverse the trend towards a future without childhood overweight. Figuring out how best to proceed is an issue that has been raised also in Switzerland, a country known for its excellent living conditions and healthy environment, and measures are being actively implemented by cantons, addressing healthier lifestyles. However, solving the obesity epidemic requires implementation of a comprehensive program that, beyond cantonal and local endeavours, could use heavier legislative and regulatory authority from the Swiss government to ensure that there are no gaps left in the development, test and propagation of national policies concerning schools curricula, food labelling and prices. Nevertheless, encouraging signs are coming from scientific reports supporting the levelling off of overweight and obesity rates in children and adolescents from around the world, including Switzerland. There is optimism about the future, but also certainty about the critical role that advocacy, by all involved parts, plays to maintain high standards in goals to achieve, and shared responsibility to prevent conflict of interests among governments, industry and consumers.     

Joint commissioning across the primary health care–social care boundary: can it work?

General ideas about joint working have been commonplace in the UK for several decades and those more specifically about joint commissioning have been popular since the quasi-market reforms of the early 1990s. The Labour Government is now placing a heavy premium upon 'partnership working' and expects this to breathe new life into joint commissioning initiatives; especially those involving social care and primary health care. However, despite the relatively lengthy experience of joint commissioning, we still know very little about how it works in practice. This article reviews joint commissioning as a policy concept, describes some recent research findings and pulls out messages for policy and practice. It concludes that although effective joint commissioning is attainable, there can be no 'quick fix' at local level.     

Back to the market: yet more reform of the National Health Service.

Yet more reform of the National Health Service in England has been announced by the Department of Health. In opposition, the Labour Party criticized the creation of an "internal market" for health care by the Conservative government, but five years into the Blair administration, market incentives are to be reinvigorated and the private sector is to be embraced in ways not seen hitherto. New guidance signals the introduction of competitive contracting using cost-per-case currencies, more choice for patients in where they will receive hospital treatment, and the freeing of NHS care providers from the direct political control of ministers. It is intended that the monopolistic features of the NHS in England should give way to greater pluralism, in particular through contracts with privately owned health care organizations. However, there is little evidence to suggest that these policies will be effective, and a number of practical problems may obstruct implementation.     

Anything but 'empowerment'? Smokers,tar and nicotine data and cigarette design

While there are important differences between the public health policies of Conservative governments of the 1980s and 90s and the current British Labour government a significant element of continuity is the emphasis on government facilitating informed choice by consumers as a key public health objective. The article considers such approaches to disclosure of health risks with respect to policy on the regulation of smoking. It argues that regulation, in this area, under the Conservatives has not served to 'empower' consumers and that such regulatory weaknesses appear to be replicated under its successor. Defects in regulation are traced with respect to disclosure of information on tar and nicotine 'yields'; and cigarette design with respect to tip ventilation and the use of additives to increase nicotine delivery. It is argued that lack of disclosure and insufficient controls on the industry have led to consumers being misled concerning the relative risks of different types of cigarette. Equally, it is also likely that such deficiencies have enabled manufacturers to represent some cigarette types as 'safe'. The paper concludes by arguing that, while the weaknesses of the current regulatory regime suggest the need for measures of increased disclosure and control of product design, there is also an unresolved tension as to whether 'empowerment' is an intrinsic goal of policy or a means to the achievement of public health targets.     

The criminal justice (children) (northern ireland) order: A long time coming; was it worth the wait?

The Report of the Children and Young Persons Review Group (the Black Report) was published in 1979. It was commissioned in 1976 by the then Labour government. Over 20 years later the new Labour government will pass the Criminal Justice (Children) (NI) Order through an order in council. Between these two events a radical and reforming Conservative government has changed the political and economic landscape. The new legislation has been a long time coming. Harold MacMillan is said to have remarked, when faced with a major policy decision “die best thing to do is do nothing and do it for as long as possible.” Given the constant changes in the criminal justice system the government has imposed in England and Wales without any tangible benefits, this might not have been a bad plan. However, is the legislation based upon outmoded 70's thinking or is it relevant to today's problems and solutions?     

Thinness and obesity: a model of food consumption, health concerns, and social pressure

The increasing concern of the policy maker about eating behaviour has focused on the spread of obesity and on the evidence of people dieting despite being underweight. As the latter behaviour is often attributed to the social pressure to be thin, some governments have already taken actions to ban ultra-thin ideals and models. This paper proposes a theoretical framework to assess whether increasing the ideal body weight is socially desirable, both from a welfare and a health point of view. We first show that being underweight and being overweight are possible outcomes of a rational eating model. Then, assuming that people are heterogeneous in their healthy weights but exposed to the same ideal body weight, we show that increasing the thin ideal weight can be welfare improving, but may exacerbate the obesity epidemic.     

Analysing the 'new' British National Health Service

The British National Health Service (NHS) has seen a proliferation of confusing and sometimes conflicting labels in recent years. It has been claimed that during the Conservative Government's period of office the 'classic' NHS was 'restructured' and then turned into the 'new' NHS. The New Labour Government of 1997 has claimed that it will deliver a 'new' NHS. If all these claims are correct, it should be possible to identify four distinct periods, with three clear 'breaks of slope' with significant changes in important indices on moving from one label to another. This paper attempts to look behind these labels by critically examining what has changed in the NHS since 1979. In simple terms, what has been 'restructured'? What is new about the 'new' NHS? Why are these changes important? It is concluded that while the NHS has certainly undergone significant changes in the past 20 years or so, the appearance of a 'new' NHS may be premature as in many areas it is possible to see the marks of continuity as well as change, and policy impact is characterised by greater incrementalism than policy rhetoric.     

Understanding the sociocultural roots of childhood obesity: food practices among Latino families of Bushwick, Brooklyn

Despite prevention efforts, childhood obesity has reached epidemic proportions in the United States. This ethnographic study seeks to enhance understandings of the sociocultural dimensions of childhood obesity and inform prevention efforts. Using participant observation, interviews, and life histories, this research probes the sociocultural roots of childhood obesity by exploring the food practices and everyday lives of Latino families in Bushwick, Brooklyn, a low-income neighborhood in New York City. Mired in persistent poverty, Latino families burdened by teetering resources provide for their children using coping strategies in which everyday food practices play an important part. These practices illuminate cultural ideas about good parenting, well-being, and conceptions of the body. We argue that these practices, embedded in the neighborhood food environment, drive food choice and related activities of families, often leading to overweight and obesity in their children. They form the sociocultural roots of childhood obesity, and their implications are critically important for how public health professionals approach the relationship of food, nutrition, and obesity.     

The impact of market-like arrangements on specialist services: a case study.

This article considers how specialist hospital services in the UK fared under Conservative health policy, with its emphasis on market-like arrangements, and what looks likely under the New Labour era, where new shibboleths (cooperation, quality, etc.) supposedly are in place. There appeared inherent in the Conservative health policy threats to specialist services from local competition, and purchaser agendas for local health needs of equity and prioritization. Moreover, small providers grappled with costs and the bureaucracy engendered by market-like arrangements and with their inability to make economies of scale. From the policy rhetoric since the New Labour election victory of May 1997, one might expect such specialist services to be 'coming in from the cold', but the reality seems quite different. In particular, this paper will outline the policy context for specialist providers for the period in the 1990s when the Conservative government undertook to reform the NHS. We also, through the Unit that is the subject of the case study, examine the actual effects of those reforms on this specialist service. Finally, we reflect further upon the resonances for specialist services in the New Labour era that can be gleaned from the case study.     

Is Obesity Policy in England Fit for Purpose? Analysis of Government Strategies and Policies, 1992–2020

Policy Points

• This analysis finds that government obesity policies in England have largely been proposed in a way that does not readily lead to implementation; that governments rarely commission evaluations of previous government strategies or learn from policy failures; that governments have tended to adopt less interventionist policy approaches; and that policies largely make high demands on individual agency, meaning they rely on individuals to make behavior changes rather than shaping external influences and are thus less likely to be effective or equitable.
• These findings may help explain why after 30 years of proposed government obesity policies, obesity prevalence and health inequities still have not been successfully reduced.
• If policymakers address the issues identified in this analysis, population obesity could be tackled more successfully, which has added urgency given the COVID‐19 pandemic.

ContextIn England, the majority of adults, and more than a quarter of children aged 2 to 15 years live with obesity or excess weight. From 1992 to 2020, even though the government published 14 obesity strategies in England, the prevalence of obesity has not been reduced. We aimed to determine whether such government strategies and policies have been fit for purpose regarding their strategic focus, nature, basis in theory and evidence, and implementation viability.MethodWe undertook a mixed‐methods study, involving a document review and analysis of government strategies either wholly or partially dedicated to tackling obesity in England. We developed a theory‐based analytical framework, using content analysis and applied thematic analysis (ATA) to code all policies. Our interpretation drew on quantitative findings and thematic analysis.FindingsWe identified and analyzed 14 government strategies published from 1992 to 2020 containing 689 wide‐ranging policies. Policies were largely proposed in a way that would be unlikely to lead to implementation; the majority were not interventionist and made high demands on individual agency, meaning that they relied on individuals to make behavior changes rather than shaping external influences, and are thus less likely to be effective or to reduce health inequalities.ConclusionsThe government obesity strategies’ failure to reduce the prevalence of obesity in England for almost 30 years may be due to weaknesses in the policies’ design, leading to a lack of effectiveness, but they may also be due to failures of implementation and evaluation. These failures appear to have led to insufficient or no policy learning and governments proposing similar or identical policies repeatedly over many years. Governments should learn from their earlier policy failures. They should prioritize policies that make minimal demands on individuals and have the potential for population‐wide reach so as to maximize their potential for equitable impacts. Policies should be proposed in ways that readily lead to implementation and evaluation.     

Ambiguous expectations for intersectoral action for health: a document analysis of the Danish case

Ideas about intersectoral action and policy-making for health (ISA) are prominent among public health professionals. They are often presented as effective ways to address root causes of poor health and health inequality, and as such the best way to promote population health. The implementation of such ideas has proven difficult though. In this paper we argue that neo-institutional theory can help us conceptualize implementation challenges by pointing to implicit expectations and contradictions associated with the ISA idea itself. With Denmark as empirical case, we conducted a document analysis of recommendations for municipal ISA. The analysis shows how the recommendations provide a very abstract conceptualization of ISA that does not give much practical guidance for action. We show how ISA is discursively constructed with buzzword qualities as the natural way to organize health promotion, by being presented as a means to produce better quality services, more cost-effective operations and ensure the future of the welfare state, while at the same time hardly changing much at all. By applying the lens of institutional logics we show how ISA, although being vaguely defined, offer ambiguous normative and symbolic repertoires for action. We discuss the implementation challenges associated with this advocacy rhetoric and suggest that the domination of the corporation logic may appear to reduce the political character of ISA and potentially conflict with the ideals of health as a matter of social justice and human rights.     

Negotiating the care‐giving role: family members’ experience during critical exacerbation of COPD in Norway

Healthcare policies often state that complex conditions are to be treated outside hospital in various forms of public–private partnership. Chronic obstructive pulmonary disease (COPD) is a progressive illness that includes episodes of serious acute exacerbations characterised by extreme breathlessness. There is limited knowledge about COPD exacerbations from the perspective of family caregivers and implications of the changing boundary between hospital care and care at home. In this paper, we explore how caregivers negotiate their role as caregivers with patients and healthcare professionals during acute exacerbations. We conducted 10 qualitative interviews with family caregivers of COPD patients in 2011, all were spouses over the age of 60. The participants were recruited through the patient pool of ambulatory pulmonary services of two hospitals in Oslo, Norway. Data were interpreted using thematic analysis. The caregivers described a lack of understanding and support from health professionals in some situations. They shouldered considerable responsibility, but were not always acknowledged as competent carers by professionals. Caregivers had to balance their involvement. They noted that they could lose the professionals’ co‐operation if their involvement was perceived as interfering or preventing the professionals from exercising their expertise. However, by not sharing their personalised knowledge about the patients, they risked that the professionals would not understand the severity of the exacerbation, which could undermine their own ability to maintain a sense of safety and control. The negotiations caregivers participated in and the uncertainty they experienced shed new light on the complexity of their role, and the discrepancy between practice and ideals in healthcare policy regarding collaboration of care. It is crucial to develop further knowledge about structural, interactional and communicational facilitators and barriers for reaching shared understandings and facilitating mutual trust in these demanding situations.     

The relationships between housing quality and occupant health in Uganda

The Government of Uganda created in 2010 a strategic plan to invest in public health as part of its broader national development goals. The health plan recognizes housing and urbanization as a determinant of health, but has not yet formulated policy to address the relationship. This study can help guide health policy development as it relates to housing. It estimates relationships between housing quality and occupant health using “count outcome” regression models. An economic model of optimal household labor allocation in poor countries provides the foundation for the regression modeling. The data used to estimate the regressions are a stratified random sample of 7096 households surveyed in the 2005–06 Uganda National Household Survey. They provide, among other things, detailed information on physical housing attributes as well as the health status of its occupants. Consistent with the economic model and other empirical work, the results show that exposure to burning of biomass for cooking has the largest adverse health effect. Different definitions of illness yield results consistent with expectations, and a separate specification test suggests that the findings are reasonably robust.     

Medical profiling: narratives of privilege, prejudice, and HIV stigma

In this article, the author uses selected narrative analysis methods to deconstruct stories presented in separate interviews by a married couple who believe that their HIV-infected adult daughter has been victimized by medical profiling. In their accounts, they construct their belief that their daughter's gender, race, education, appearance, and socioeconomic status contributed to her not receiving an accurate diagnosis despite repeated medical examinations. Their similar accounts paint a picture of parents frantically seeking a diagnosis as symptoms worsen without explanation. They perceive that their daughter, not fitting the profiling ideas about who is at risk for HIV, missed her chance for early intervention. The author examines in detail how these parents separately tell similar stories, probably representing the explanation they have jointly constructed to explain what they see as a failure of medicine.     

重庆市农村未婚年轻成人父母对给未婚青年提供生殖健康服务的态度调查

目的：通过向未婚年轻成人的父母了解未婚年轻成人未得到生殖健康需求服务的成因，以确定给未婚年轻成人提供生殖健康服务的最佳途径和可行方法。方法：采用小组访谈法，对重庆市农村地区18-24岁有婚前性行为年轻成人的父母分别访谈，讨论的内容包括父母对未婚年轻成人婚前性行为的态度，父母对婚前性行为和人工流产影响未婚年轻成人健康的认识，父母对给未婚年轻成人提供教育和服务的态度等。结果：农村父母也给子女提一些忠告，但对子女因婚前性行为导致未婚先孕，普遍采取事后补救等被动措施表现出极大忧虑。父母赞成向子女提供有针对性的相关教育和服务，希望政府和社会机构给予重视，结论：农村未婚年轻成人婚前性行为和人工流产的普遍，与其自身文化水平和科学知识不足，家庭观念落后，如父母，教师和社会相关人员生殖健康知识水平不高及社会未重视有关，建议成立青少年生殖健康促进中心，制订相应的媒体法规及将青少年生殖健康教育和生殖健康服务纳入计划生育服务范畴，将有利于保障青少年生殖健康的需求。     

The present state and future prospects of occupational health in Bangladesh

Bangladesh is a relatively young and developing country. At the present time, like in most developing countries, a clear demarcation between occupational health care and general medical care is difficult to be recognized in Bangladesh. Occupational health is a fairly new field, as the country is undergoing industrialization and occupational health activities are operated by several ministries, such as Labour, Health, Industry and Transport. Legal foundations of the occupational health-care system based on British India and Pakistani era, were adopted and amended by the Government of Bangladesh after the liberation of the country in 1971. Most of the Labour laws have been rectified by the Government of Bangladesh according to the ILO Conventions. Reconsideration of the occupational health service system avoiding duplication for the 'occupational health' component in several ministries might be helpful to achieve the successful provision of an occupational health service in the developing Bangladesh.     

A review of health governance: Definitions,dimensions and tools to govern

Background

The premise that good governance will ultimately lead to better health outcomes has been central to the proliferation of work in this area over the past decade.

Objective

To consolidate and align literature on governance by presenting an overview of efforts to define, describe and operationalize the health governance function.

Methods

A targeted review of governance literature.

Results

(1) A variety of terms have been assigned to precede health governance definitions. These terms commonly describe governance ideals (e.g. good, democratic) or characteristics of the organization of actors in governance arrangements (e.g. hierarchical, networked). (2) Dimensions of governance are defined from different perspectives and in varied combinations, capturing values, sub-functions and/or outcomes of governance. (3) Tools used to govern remain to be cataloged, however, measures can be aligned according to dimensions of governance or their ability to create specific relationships between actors.

Discussion

Resolving the conceptual confusion around health governance requires recognition for the differences in the premise and approaches taken to defining governance, as well as specifying core dimensions and aligning applicable tools.

Conclusion

Despite a growing literature base, a concerted effort is needed for a more accessible understanding of health governance that is both practical at present and actionable for policy-makers.