Learning to recognise what good practice looks like: how general practice trainees develop evaluative judgement

Advances in Health Sciences Education - The nature of healthcare means doctors must continually calibrate the quality of their work within constantly changing standards of practice. As trainees...     

Variation in how mothers, health visitors and general practitioners use the personal child health record

BACKGROUND: In the UK, a national personal child health record (PCHR) with local adaptations is in widespread use. Previous studies report that parents find the PCHR useful and that health visitors use it more than other health professionals. This study was carried out in Nottingham, where the local PCHR is similar to the national PCHR. OBJECTIVES: To explore variation in use of the PCHR made by mothers with differing social characteristics, to compare heath visitors' and general practitioners' (GPs') use of the PCHR, and to compare health visitors' and GPs' perceptions of the PCHR with those of mothers for whose children they provide care. METHODS: Questionnaires to 534 parents registered with 28 general practices and interviews with a health visitor and GP at each practice. A score per mother for perceived usefulness of the PCHR was developed from the questionnaire, and variation in the score was investigated by linear regression adjusted for clustering. RESULTS: Four hundred and one (75%) questionnaires were returned. Three hundred and twenty-five (82%) mothers thought the PCHR was very good or good. Higher scores for usage of the PCHR were significantly associated with teenage and first-time mothers, but no association was found with mother's social class, education or being a single parent. There was no association between variation in the score and practice, health visitor or GP characteristics. Mothers, health visitors and GPs reported that mothers took the PCHR to baby clinic more frequently than when seeing their GP, and that health visitors wrote in the PCHR more frequently than GPs. Eighteen (67%) health visitors and 20 (71%) GPs said they had difficulty recording information in the PCHR. CONCLUSION: The PCHR is used by most mothers and is important for providing health promotion material to all families with young children. It may be particularly useful for first-time and teenage mothers.     

Making abortions safe: a matter of good public health policy and practice

Globally, abortion mortality accounts for at least 13% of all maternal mortality. Unsafe abortion procedures, untrained abortion providers, restrictive abortion laws and high mortality and morbidity from abortion tend to occur together. Preventing mortality and morbidity from abortion in countries where these remain high is a matter of good public health policy and medical practice, and constitutes an important part of safe motherhood initiatives. This article examines the changes in policy and health service provision required to make abortions safe. It is based on a wide-ranging review of published and unpublished sources. In order to be effective, public health measures must take into account the reasons why women have abortions, the kind of abortion services required and at what stages of pregnancy, the types of abortion service providers needed, and training, cost and counselling issues. The transition from unsafe to safe abortions demands the following: changes at national policy level; abortion training for service providers and the provision of services at the appropriate primary level health service delivery points; and ensuring that women access these services instead of those of untrained providers. Public awareness that abortion services are available is a crucial element of this transition, particularly among adolescent and single women, who tend to have less access to reproductive health services generally.     

Poverty in America: how public health practice can make a difference

Health inequities linked to poverty remain entrenched in certain subgroups in the United States, despite public health efforts to the contrary. My experiences in working with the poor in Nepal and Pakistan informed my later approach to addressing health and poverty in the Appalachians of eastern Tennessee. Three aspects of this approach include enhancing community power through participation in local decisionmaking about health, educating students within the actual context of poverty, and increasing local opportunity by employing people from the communities of concern to serve as a means to reach those communities. Empowerment, education, and opportunity can serve as ways to ameliorate poverty and may serve to modulate the persistent underlying conditions that create and sustain poverty.     

Cross-border health activities in the Euregios: good practice for better health

BACKGROUND: Health-related cooperation between neighbouring countries has a long tradition in the European Union, especially in the transfrontier structures well-known under the label of Euregio or Euroregion. OBJECTIVE: Overview and analysis of cross-border health-related activities in the Euregios. METHODS: The EU-funded project "EUREGIO" carried out a systematic inventory analysis of cross-border health projects. It is based on written surveys among 53 Interreg IIIA secretariats, 67 Euregios and 328 project bodies. The responses of 122 health projects were considered. RESULTS: 37 Euregios or similar cross-border structures established health-relevant working groups, working circles, forums or projects. The cross-border health projects cover a wide spectrum of issues, e.g., education and training, patient care, prevention, and disaster control. Target groups were in most cases medical personnel, patients or decision-making bodies. Four official criteria for cooperation (joint project development, implementation, staffing and financing) are met by the great majority of projects. However, the survey shows a lack of information, publication and evaluation. CONCLUSIONS: Cross-border cooperation in health is underrepresented in many regions. The project results point to great potentials which should be further developed both in terms of quantitative and qualitative aspects. Recommendations are given for project actors and stakeholders.     

Sustainable scaling up of good quality health worker education for tuberculosis control in Indonesia: a case study

Background  

In 2000, an external review mission of the National Tuberculosis Control Programme of Indonesia identified suboptimal results of TB control activities. This led to a prioritization on human resource capacity building representing a major shift in the approach following the recommendations of the external review team.     

The policy context for community development practice in public health: a Canadian case study

The Community Action in Public Health Study explored how public health managers, frontline staff, and community participants interpret, implement and receive policy guidelines urging collaboration with community groups in public health work. In-depth case studies of 6 public health units in Ontario, Canada focussed on 19 community development projects in 3 program areas (107 interviews). In the absence of formal policy guidelines on community development at provincial or local levels, informal policy predominated. Local senior management frequently set the tone, distinguishing health units in which community development was a basic philosophy underlying a broad spectrum of public health practice from those in which it was seen as only one among many possible strategies. Uncertainty and risk associated with informal policy lead many frontline staff to adopt strategies intended to preserve autonomy in community work, including "seeking forgiveness rather than permission" and maintaining relative "invisibility."     

Policy requirements and performance indicators for good practice in workplace health: public health perspectives

The author lists the main objectives, work areas and benefits of good practice in health, environment and social management in enterprises (GP HESME). History of this cross-sectoral and multidisciplinary approach to management of occupational, lifestyle, environmental and social health determinants is outlined. Health policy requirements and performance indicators are provided to facilitate GP HESME implementation at the enterprise and local levels. The role of local authorities and networking of enterprises, representing various sectors is highlighted.     

城乡居民基本医疗保障制度案例研究:试点实践和主要发现

本文以浙江嘉兴和江苏常熟等10个试点县市实施的"新型农村合作医疗与城镇居民基本医疗保险制度衔接"(简称"两制"衔接)为案例,实证分析了试点地区的"两制"衔接工作进展,将"两制"衔接模式总结为部分整合型、完全融合型和合作管理型,并在此基础上提炼出试点地区实施"两制"衔接的主要发现。文章认为,"两制"衔接不仅能有效解决"失地农民"和"辖区内城乡流动人口"医保权利的转移和接续问题,而且是加快我国基本医保制度统一的"良方",另外,"两制"衔接在解决外来人口医保问题、降低医保管理成本,提高管理效率等方面有很大优势,并且由卫生部门监管医疗机构存在明显的技术优势。     

Forensic mental health services as a risk escalator: A case study of ideals and practice

Medium/low secure units occupy a central role in forensic mental health care, bridging high secure and community services. Although outcomes, assessed in terms of readmission and identified reoffending, have been evaluated, little research exploring processes underlying attempted rehabilitation for offenders diagnosed as having mental health problems has been undertaken. The present qualitative study built upon previous research completed in a northern England medium/low secure forensic mental health care institution for adults with learning disabilities (Heyman et al. 2002a,b). It was carried out in a medium/low secure forensic mental health care Unit located in London. In phase one, 43 staff, including general managers, doctors, nurses, psychologists and occupational therapists were interviewed about their philosophy of care, views about risk management for forensic mental health patients and perceptions of the Unit. In phase two, 10 case studies of patients were undertaken. As far as possible, patients were interviewed twice over a period of 11‐20 months, and staff were asked about their progress. Two case conferences were observed. Data were analysed using the metaphorical concept of a rehabilitative risk escalator around three themes carried forward from the previous study: organisational issues; patient active risk management; and multiprofessional collaboration.     

Measuring socioeconomic inequality in health, health care and health financing by means of rank-dependent indices: a recipe for good practice

The tools to be used and other choices to be made when measuring socioeconomic inequalities with rank-dependent inequality indices have recently been debated in this journal. This paper adds to this debate by stressing the importance of the measurement scale, by providing formal proofs of several issues in the debate, and by lifting the curtain on the confusing debate between adherents of absolute versus relative health differences. We end this paper with a ‘matrix’ that provides guidelines on the usefulness of several rank-dependent inequality indices under varying circumstances.     

Barriers to effective practice for health visitors working with asylum seekers and refugees

The objective of this study was to determine the barriers to effective practice that health visitors experience when working with refugees and asylum seekers. This was a qualitative study based on the analysis of in-depth interviews with a purposive sample of 14 health visitors describing their experiences working with refugees and asylum seekers. These were analysed using the Framework process, a thematic matrix-based analytical method. The findings identified that the barriers to effectiveness for health visitors when working with refugees and asylum seekers were underpinned by ineffective use of services and stretched resources. The results imply that commissioners of services need to have an understanding of these barriers to commission effectively.     

Primary health care in practice: a study in Mozambique

This study investigates the delivery of all aspects of Primary Health Care (PHC) in a case study of one urban health centre in Maputo, Mozambique. Within the context of overall social and economic change, Mozambique has given priority to primary health care as the driving force in its newly developed National Health Service. The urban and rural health centres are intended to be the principal vehicles for PHC delivery, and in this study one of Maputo's recently opened health centres was investigated by observing all clinic sessions, interviewing all health centre workers and collecting data from health centre records. It was found that a dichotomy exists between the tasks ascribed to the health centre in the PHC framework, and the feasibility of their execution given existing personnel and material resources. This derives in part from lack of involvement of PHC practitioners in the organisation and planning of PHC, plus resource allocation which remains in favour of secondary and tertiary rather than primary care. Prevention is accorded priority in PHC theory, yet investigation showed that the major demand on the health centre is for curative care. The quality of both curative and preventive care was evaluated and the need for training in specialist diagnostic skills, and a more socially-based understanding of the determinants of health status and risk emerged, respectively for the groups of workers in the two sectors. The level of contact between the curative and preventive sectors was investigated as was the integration of the health centre into the health service as a whole. The problems arising in these areas must be viewed in the context of the very recent development of a National Health Service in a country where, previously, curative care was available only in urban areas and virtually no preventive programmes existed. This study shows that significant steps are being taken to develop a comprehensive PHC programme in Maputo. More important still will be the extension of this level of care provision to the country as a whole.     

Perceptions of good medical practice in the NHS: a survey of senior health professionals.

OBJECTIVES: To categorize senior health professionals' experience with poor medical practice in hospitals and in general practice, to describe perceptions which senior NHS staff have of good medical practice, and to describe how problems of poor medical practice are currently managed. DESIGN: A postal questionnaire survey. The questionnaire sought perceptions of good medical practice, asked participants to characterise deviations from good practice, and to describe experience with managing poor performance at the time of the introduction of the General Medical Council (GMC) performance procedures. SETTING: A range of NHS settings in the UK: hospital trusts, health authorities/boards, local medical committees, community health councils. SUBJECTS: Senior health professionals involved in the management of medical professional performance. MAIN MEASURES: Perceptions of what constitutes good medical practice. RESULTS: Most respondents considered that persistent problems related to clinical practice (diagnosis, management, and outcome and prescribing) would require local management and, possibly, referral to the GMC performance procedures. Informal mechanisms, including informal discussion, education, training, and work shifting, were the most usual means of handling a doctor whose performance was poor. Many took a less serious view of deficiencies in performance on manner and attitude and communication, although consultation skills rather than technical skills comprised the greatest number of complaints about doctors. CONCLUSIONS: Senior NHS professionals seem reluctant to consider persistently poor consultation skills in the same critical light as they do persistently poor technical practice. These attitudes may need to change with the implementation of clinical governance and updated guidance from the GMC on what constitutes good medical practice.     

Theory and practice – a case study of coordination and ownership in the Bangladesh health SWAp

Background  

In the past decade the sector-wide approach (SWAp) model has been promoted by donors and adopted by governments in several countries. The purpose of this study is to look at how partners involved in the health SWAp in Bangladesh define ownership and coordination, in their daily work and to analyse the possible implications of these definitions.