Resisting blame and managing emotion in general practice: The case of patient suicide

UK Governing bodies are imposing increased forms of regulation on General Practitioners (GPs). This paper explores one example of such governance – the audit of GP practice through Critical Incident Reviews (CIRs) following patient suicide. Drawing on interviews with 16 GPs about their involvement in a CIR of a patient's suicide, we found that the review process initially provoked strong emotions of sadness and guilt as well as fear of blame. Ultimately, however, most GPs felt comforted by the CIRs because their findings confirmed that they were not responsible for the suicide. At the same time, the GPs indicated that such comfort was tenuous due to the broader blame culture and because they foresaw many future audits as part of an inflationary spiral of surveillance and risk management. While the GPs adopted strategies to manage and resist surveillance, the effects of CIRs on patient care may be mixed, with the potential both to improve clinical practice and contribute to adverse outcomes. We argue that CIRs paradoxically contain and create anxieties about suicide among GPs and society more broadly.     

Globalisation des politiques de santé et psychiatrie française : enjeux et impacts

Objective

In recent years, the French psychiatric landscape seems to be shifting towards an approach that focuses on community care. The purpose of this article is to comment on this recent evolution as well as the impact of these changes. It is important to discuss because of the links that our psychiatric institutions have established with organizations entertaining a global view of mental health, such as the World Health Organization.

A multisite audit to assess how women with complex social factors access and engage with maternity services

Objectiveto audit women with socially complex lives’ documented access to and engagement with antenatal care provided by three inner city, UK maternity services in relation to birth and neonatal outcomes, and referral processes.Backgroundwomen living socially complex lives, including young mothers, recently arrived immigrants, non-English speaking, and those experiencing domestic violence, poor mental health, drug and alcohol abuse, and poverty experience high rates of morbidity, mortality and poor birth outcomes. This is associated with late access to and poor engagement with antenatal care.Methoddata was collected from three separate NHS trusts data management systems for a total of 182 women living socially complex lives, between January and December 2015. Data was presented by individual trust and compared to standards derived from NICE guidelines, local trust policy and national statistic using Excel and SPSS Version 22. Tests of correlation were carried out to minimise risks of confounding factors in characteristic differences.Findingsnon-English speaking women were much less likely to have accessed care within the recommended timeframes, with over 70% of the sample not booked for maternity care by 12 weeks gestation. On average 89% primiparous women across all samples had less than the recommended number of antenatal appointments. No sample met the audit criteria in terms of number of antenatal appointments attended. Data held on the perinatal data management systems for a number of outcomes and processes was largely incomplete and appeared unreliable.Conclusionthis data forms a baseline against which to assess the impact of future service developments aimed at improving access and engagement with services for women living with complex social factors. The audit identified issues with the completeness and reliability of data on the perinatal data management system.     

Guidance for the governance of public-private collaborations in vaccine post-marketing settings in Europe

IntroductionThe 2009 influenza pandemic highlighted challenges for vaccine post-marketing monitoring in Europe, particularly the need to have appropriate infrastructures to strengthen public-private collaborations (PPCs) with suitable processes to improve stakeholder interactions and collection and analysis of safety and effectiveness data. The ADVANCE consortium comprises public and private stakeholders who have worked together to build and test new system components for vaccine post-marketing projects, one component being a governance framework for efficient, transparent and trustworthy PPCs.MethodsBased on the results of a landscape analysis and screening of formalised existing governance structures, we identified the elements of a governance framework and developed recommendations to support stakeholders willing and able to implement collaborative projects. These proposals and their implementation were discussed by 70 experts during a workshop to gain from their experience.ResultsWe identified core governance principles and defined five fundamental functions (decision-making, scientific advice, quality control and audit, implementation and management, and financial administration) that can be attributed to individual partner organisations or to a committee with representatives from more than one partner organisation. We propose a generic governance model with options for its adaptation to specific contexts and projects. The advantages and disadvantages of PPCs were also examined. Stakeholders’ concerns (e.g. scientific integrity and public trust) were addressed through recommendations about transparent decision-making rules and conflict of interest management.ConclusionsNo one-size-fits-all solution for PPC governance exists but our recommendations could be used to set-up a tailored-made and fully transparent governance structure supporting collaborative projects in the European vaccine post-marketing environment. To allow the rapid establishment of robust projects, the next steps will involve this guidance being used by real-world collaborations to assess what works and what does not work and what added-value can be obtained from these collaborations.     

Regulating human genetics: The changing politics of biotechnology governance in the European Union

Human genetics poses new political issues for the governance systems of the EU and, in so doing, graphically illustrates the regulatory problematic of innovative health technologies (IHTs). Civil society, industry and the scientific community are registering new, and conflicting, political demands on the governance policy community of the EU. At the same time, the traditional reliance of that community on technocratic networks as the mainstay of policy formation and implementation is no longer a sufficient mechanism for maintaining the legitimacy of the process. New policy networks imbued with different value systems are rapidly making inroads into the previously impermeable policy community of EU governance. Recognising the limitations of the existing means for securing agreement to regulatory change, the institutions of the EU are adapting their stance, or stances, and seeking new methods of engagement both with the expanding numbers of NGOs in the human genetics arena and the public at large. To an extent, there is institutional competition between the departments of the European Commission, the Council of Ministers and, most particularly, the European Parliament for pole position in the business of policy agenda setting. Fuelled by the regulatory difficulties already experienced in biotechnology by GM foods and GM crops, that competition is rapidly causing a sea-change in the political culture of governance policy making at EU level.     

The post‐2015 landscape: vested interests,corporate social responsibility and public health advocacy

This paper explores the tensions between UN calls for private sector engagement in the post‐2015 landscape and public health opposition to those ‘harm industries’ that are ‘corporate vectors of disease’ for the mounting global non‐communicable disease burden. The UN's support for public‐private partnership has provided industries with ‘vested interests’ in the propagation of unhealthy behaviours with new opportunities for the strategic alignment of their corporate social responsibility (CSR) endeavours with the post‐2015 sustainable development agenda. This has galvanised public health advocates to place pressure on the World Health Organisation to formalise their ambiguous stance towards private sector involvement in public policy formation and the resultant ‘conflicts of interest’. This paper critically examines the ‘gathering storm’ between this ‘anti‐corporate movement’ and the alcohol industry in the increasingly politicised domain of CSR. Drawing on the example of SABMiller's Tavern Intervention Program, the paper argues that CSR represents a profound threat to the sanctity and moral authority of the public health worldview. Questions therefore need to be asked about whether the public health‐led path of industry non‐association will necessarily result in health improvements or just a further retrenchment of the ideological faultlines explored in the paper.     

Measuring the quality of care in small countries: the empirical analysis of 30-day mortality following acute myocardial infarction and ischaemic stroke in Latvia

The evaluation of quality of care is a complex task that, over the last decades, has been performed using the Donabedian model as its main conceptual framework. Small countries are an ideal setting in which to make innovative, empirical evaluations of the quality of care. In this research, we discussed the challenges and opportunities of assessing hospital performance in Latvia, a small country in the Baltic region of Northern Europe. The study outcomes were 30-day acute myocardial infarction mortality and 30-day ischaemic stroke mortality. We described how indicator specifications, risk-adjustment, data reliability assessment and graphical representations were tailored to the geographic and institutional context of Latvia. By looking at the impact of structural characteristics on hospital performance, we found that cath labs and large caseloads were significantly associated with lower mortality. This approach allows decision-makers at different governance levels to design and implement actions aimed at improving the quality of care. At the health system level, it may help policy-makers adopt proper strategies to tackle poor outcomes; at the hospital level, it may help managers intervene on structural determinants of performance. Because small countries face some relevant issues that have implications for health care, these analyses might be relevant also for larger countries to improve the design of their health-care services     

公立医院建立健全现代医院管理制度的实践与思考

建立健全现代医院管理制度是深化公立医院改革、推进医院治理体系和治理能力现代化的客观要求。本文阐述了某公立医院按照现代医院管理制度建设的要求,以完善治理体系、加强精准管控、再造服务流程及增强品牌实力为重点,提升医院经济运营效率及品牌影响力,以期对其他医院完善现代医院管理制度提供有益借鉴。     

Governance commitment to reduce maternal mortality. A political determinant beyond the wealth of the countries

Some countries reached, in 2015, the Millennium Development Goal of reducing maternal mortality to 96 or less maternal deaths per 100,000 live births. Others, however, did not. This paper analyses the strength of the association between maternal mortality and each of the six components of Governance—a political determinant scarcely explored in the literature—in 174 countries. It was found that the greater the governance, the lower maternal mortality, independently of a country's wealth. We used all six indicators of the World Bank's Worldwide Governance Indicators Project in 2015: government effectiveness, regulatory quality, rule of law, control of corruption, voice and accountability, and political stability and absence of violence. Findings were encouraging as maternal mortality in low-income countries with higher government effectiveness and regulatory quality was similar to that of medium-income countries with lower government effectiveness and regulatory quality. To achieve the post-2015 sustainable development goal on preventable maternal mortality—which persists despite economic development—all governance dimensions are essential and represent interdependent cornerstones.