Integrated health and social care in England – Progress and prospects

This paper reviews recent policy initiatives in England to achieve the closer integration of health and social care. This has been a policy goal of successive UK governments for over 40 years but overall progress has been patchy and limited. The coalition government has a new national framework for integrated care and variety of new policy initiatives including the ‘pioneer’ programme, the introduction of a new pooled budget – the ‘Better Care Fund’ – and a new programme of personal commissioning. Further change is likely as the NHS begins to develop new models of care delivery. There are significant tensions between these very different policy levers and styles of implementation. It is too early to assess their combined impact. Expectations that integration will achieve substantial financial savings are not supported by evidence. Local effort alone will be insufficient to overcome the fundamental differences in entitlement, funding and delivery between the NHS and the social care system.With a national election set to take place in May 2015, all political parties are committed to the integration of health and social care but clear evidence about the best means to achieve it is likely to remain as elusive as ever.     

Racism in health and health care in Europe: where does the Netherlands stand?

Racial discrimination is a sensitive and difficult topic. Thelack of systematic evidence of racism in many European countriesleads to an automatic assumption that racism does not play arole in society. Where evidence exists, there is reluctanceto acknowledge the reality of discrimination. Bhopal touched on this sensitive topic and emphasised that ifdiscrimination is left unchecked, the economic, social, scientificand political circumstances that allowed Hitler's policies toflourish could return.1 To most well-meaning     

Does managed health care reduce health care disparities between minorities and Whites?

This paper investigates whether managed care ameliorates or aggravates ethnic and racial health care disparities in Medicare. First, we analyze the choice of type of insurance made by Medicare enrollees to see if minorities are more likely to choose the managed care alternative. Second, we study the differential effect of managed care on disparities using several measures of access, use and cost of services. Both analyses are conducted on two independent data sets, the Medicare Current Beneficiary Survey and the National Health Interview Survey. We conclude that relative to Whites, minorities are at least as well off -- in terms of benefits and costs -- in Medicare managed care as in Medicare traditional indemnity plans.     

Perceptions of postnatal depression and health care needs in a South African sample: the “mental” in maternal health care

Background

Maternal mental health care is a neglected area in low and middle income countries (LAMIC) such as South Africa, where maternal and child health care priorities are focused on reducing maternal and infant mortality and promoting infant physical health. In the context of a paucity of mental health specialists, the aim of this study was to understand the explanatory models of illness held by women with maternal depression with the view to informing the development of an appropriate counselling intervention using a task sharing approach.

Methods

Twenty semi-structured qualitative interviews were conducted with mothers from a poor socio-economic area who were diagnosed with depression at the time of attending a primary health care facility. Follow-up interviews were conducted with 10 participants in their homes.

Results

Dimensions of poverty, particularly food and financial insecurity and insecure accommodation; unwanted pregnancy; and interpersonal conflict, particularly partner rejection, infidelity and general lack of support were reported as the causes of depression. Exacerbating factors included negative thoughts and social isolation. Respondents embraced the notion of task sharing, indicating that counselling provided by general health care providers either individually or in groups could be helpful.

Conclusion

Counselling interventions drawing on techniques from cognitive behavioural therapy and problem solving therapy within a task sharing approach are recommended to build self-efficacy to address their material conditions and relationship problems in poorly resourced primary health care facilities in South Africa.

     

What is 'best practice' in health care? State of the art and perspectives in improving the effectiveness and efficiency of the European health care systems

A framework for the classification of information on maintaining or improving effectiveness and efficiency in health care systems is proposed. Activities, disciplines and methods that are available to identify, implement and monitor the available evidence in health care are called 'best practice'. We reviewed the literature in order to (1) establish a definition for 'best practice' in the health sector, (2) develop a framework to classify relevant information, and (3) synthesise the literature on activities, disciplines and methods pertinent to the concept. Health care, public health activities and health policy should be advised by the best available evidence. Currently, the concept can be broken down into three activities (Health Technology Assessment (HTA), Evidence-Based Medicine (EBM), Clinical Practice Guidelines (CPGs)) by which evidence is synthesised either as an evidence base (EBM and most HTA) or in the form of recommendations (CPGs and some HTA) for different decision purposes in health care. These activities gain input mainly through four disciplines: clinical research, clinical epidemiology, health economics and health services research. The different disciplines are related to each other in three 'domains': (a) input, (b) dissemination/implementation and (c) monitoring/outcome. These provide evidence on (a) the (potential) effects of health care interventions and policies; (b) on ways to implement them; and (c) on ways to monitor their actual outcome. None of these separate approaches and activities exclusively forms a successful and all-embracing strategy to ascertain 'best practice'. A collective approach in the management of information is expected to add value to individual efforts. Resources should be devoted to increase quality and quantity of both primary and secondary research as well as the establishment of networks to synthesise, disseminate, implement and monitor 'best practice'.     

Is the United States an outlier in health care and health outcomes? A preliminary analysis

U.S. health care is often seen as an outlier, with high costs and only middling outcomes. This view implies a household production function for health, with both health care and lifestyle serving as inputs. Building on earlier work by Miller and Frech (2004), we make this argument explicit by estimating a production function from augmented OECD data. This allows us to determine whether the U.S. is literally an outlier; which turns on whether the United States is very far off the production surface. We find that the Unites States is somewhat less productive than the average OECD country, but that a substantial part of the observed difference results from poor lifestyle choices, particularly obesity. JEL Classification I12 . I18 Earlier versions of this paper were presented at UCLA on May 29, 2003 and at a Conference on Health and Economic Policy in Munich, Germany on June 27, 2003. Thanks are due to the participants of those sessions for helpful comments, and especially to Tom Rice at UCLA. We also appreciate the excellent research assistance of Andrea Lehman.     

Nutritional guidance during prenatal care in public health services in Ribeirão Preto: discourse and care practice

This study aimed to verify if pregnant women attended in prenatal care services at Basic Health Units in Ribeir?o Preto-SP, Brazil, received nutritional guidance and if this guidance was pertinent to their nutritional status. Ninety-one pregnant women participated. The pregnant women were classified according to their nutritional condition, using a weight, height and pregnancy stage table established by the Brazilian Health Ministry's technical prenatal care manual. We found pregnant women with weight under (13.19%) and exceeding normal levels (37.36%). Independently of their nutritional condition, most of them (60.43%) declared they did not receive nutrition guidance. The mean number of prenatal visits did not influence the nutritional status. The results reveal deficiencies in the contents and quality of nutritional care. This suggests the need for care changes so as to turn discourse into practice.     

Nutrition—an essential component of health and health care.

Nutrition and medicine interface in a variety of ways and combine to serve as a dynamic force in health as well as in disease. A conceptual understanding of this interrelationship is critical to the continued and effective development of clinical nutrition in medical education. The physician may play an important role in critical-care medicine, long-term health care, research, education, and preventive medicine. While there is great potential for the physician to impact on nutrition status in both health and disease, there is clear evidence that greater emphasis needs to be placed on providing adequate nutrition training for every physician.     

Integrated care pathways: pathways to change in health care?

PURPOSE: The purpose of this paper is to demonstrate that, if teams in healthcare focus on the patient using the framework of a care pathway, change can occur without the overt need to "manage" it directly. DESIGN/METHODOLOGY/APPROACH: In this paper the relevant literature is reviewed and it is demonstrated that if this approach is used it also provides a means for addressing difficult professional and organisational issues that are often unresolved in broader projects of organisational change. This is not presented as a panacea or the solution to all change projects, rather the contention here is that it is one means among many that can be used to bring about important changes in practice. FINDINGS: The paper finds that care pathways represent a useful tool, which teams can use to work through the contextual and practical issues involved in changing practice. ORIGINALITY/VALUE: The paper describes the development of integrated care pathways, which can be regarded as a fortunate fusion of managerial and professional concerns.