Trends in guardianship usage following the Mental Health Act 1983

The Mental Health Act 1983 substantially modified Guardianship, a previously little used facility for the compulsory care of mentally ill and mentally handicapped people in the community. This paper describes the results of a survey of information based on the annual returns from Local Authorities to the Department of Health and Social Security, and examines the impact of the new legislation upon the use of Guardianship in psychiatric practice. Although the number of Guardianship Orders in force remains relatively small compared to hospital admissions, recent trends indicate a significant increase in its application to people with a mental illness, and a decline in its use for people with a mental handicap. Despite the overall increase in use, the Regional differences of cases in England remain essentially unchanged and reflect the differing attitudes and policies of Local Authorities towards Guardianship Orders.     

Childhood Diagnostic and Handicap registers—Away forward

The information on childhood impairments, disability and handicap at present is far fromsatisfactory. The Steering Group on Health Services Information in its recent report on Community Health Services explicitly identified the need for District Handicap registers. The reorganisation of the National Health Service has also threatened the future of existing registers, as 96 (60%) were kept at the level of the previous Area Health Authorities. This appears to us to be the opportune time to consider seriously standardized District Diagnostic and Handicap registers with possible Regional coordinating registers. We suggest a basic data set with limited diagnoses to be considered by Districts. The recording of disability and handicap needs further development. For a start we suggest a simple four-point disability scale across seven functional components along with a care-orientated three-point handicap scale.     

Community medicine in the restructured NHS

Summary Community medicine is the medical specialty that deals mainly with populations or groups rather than with individual patients. Therefore, in the context of a national system of health care it comprises those doctors who try to measure the needs of the population both sick and well, who plan and administer services to meet those needs and those who are engaged in research and teaching in the field. Within the specialty, the roles of the community physician as specialist, manager and adviser are essentially medical. The reorganization of the structure of the National Health Service in England which was carried out in 1974 has inhibited the full development of the specialty by dispersing and diluting its scarce manpower and skills. The forthcoming simplification of this structure into District Health Authorities and Regional Health Authorities provides an opportunity to remedy these defects by enabling community medicine to make a fully effective contribution in future. In DHAs the principal tasks of Community Medicine will be the promotion of health, preventive medicine and environmental health, planning for care groups, the investigation and evaluation of health needs and services and the provision of relevant information, collaboration with other authorities and organizations and the performance of certain management functions. These tasks are described in some detail earlier in this paper and recommendations are made on the organization, staffing levels and support facilities required for their performance, including links with university departments and community medicine at regional level. Proposals are made to enable community medicine at regional level to link more closely with clinicians, with academic community medicine and with community physicians in DHAs to complement the work of the latter. Taken altogether, the proposals in this paper provide a framework for one integration of service and academic community medicine across the region which will enable community medicine to contribute fully to the tasks which lie before health authorities and the specialty in the future. In many areas the establishment of the new District Health Authorities entails a rearrangement of the ways in which some community physicians will function. The British Medical Association's Central Committee for Community Medicine (CCCM) has already circulated a document outlining the tasks of community physicians employed by District Health Authorities. This has concentrated on the managerial responsibilities, the operational activities and the size and nature of the workforce needed to discharge them. The Faculty has supported the CCCM document. At the same time it has prepared a complementary paper, based upon views received from community physicians in the regions, in which the emphasis is placed more upon the role of community medicine in the restructured service. We reproduce it here in the belief that it will be of particular help to any of the specialty's practitioners who continue to have to expound its raison d'être in a professionally competitive environment.     

Decentralization,health care and policy process in the Punjab,Pakistan in the 1990s

The Province of the Punjab underwent a number of attempts to decentralize the health sector in the 1990s. Among the most important were the decentralization of financial management within the district, the Sheikhupura PHC Pilot Project, the establishment of the District Health Authorities and District Health Management Teams, the creation of semi-autonomous hospitals and the programme of District Health Government (DHG). These usually received donor support and promotion, and emerged from within the provincial Department of Health, and more specifically the Secretariat and the internationally supported Second Family Health Project (FH2). Of particular significance was the DHG change, which involved a decentralization to the district, the appointment of powerful Chief Executives, the formation of District Management Committees and purchaser-provider separation. The paper reviews these proposals, focusing on the need to build on experiences and learning lessons from pilot projects, reform continuity, developing consultation and involvement and policy analysis. The latter indicates the importance of developing more in-depth policy analysis around the role of the central organization, the form of decentralization and the purchaser-provider separation. The paper concludes by underlining the need to ensure that political strategy and in-depth policy are appropriately coordinated in the policy process.     

Medical and dental staffing prospects in the NHS in England and Wales 1991

This article offers some background information to help junior doctors, and those who advise them, to make decisions about their future careers. Further information can be obtained from the Regional tables, which the Department of Health circulate to Regional Postgraduate Deans, Health Authorities and clinical tutors. All the information presented here is retrospective. Comparing this with the previous annual articles in this series may help you to assess the likely future prospects in your particular specialty.     

Survey of health promotion organisational arrangements and levels of service for health promotion

This study was promoted by the Executive Committee of the Association of Directors of Public Health when faced with the need to examine the organisation of and quantify health promotion arrangements in the Health Districts of England and Wales, resulting from the concerns of many of the members of the Association. These concerns were based on the views that health promotion is a key purchasing function of the District Health Authorities and must be appropriately and effectively structured and adequately resourced if the requirements of The Health of The Nation are to be fulfilled.There are many aspects to health promotion work and the delivery of health promotion services which will need addressing in the new commissioning environment of the NHS. A need was recognised for up-to-date data about health promotion services to inform a necessary debate about future arrangements, since it appeared that organisational change was being driven by influences unconnected with the possibly most appropriate structure of health promotion departments and which relate to a contemporary view of health promotion. Reducing the size and cutting the cost of commissioning authorities was perceived as one of the most important influences. A postal questionnaire survey to all Health District and Regional Health Authorities in England and Wales was conducted covering questions about the present organisational arrangements and levels of service, and soliciting the opinions of those canvassed. A total of 185 District and Regional Health Authorities, effectively reduced to 171 because of mergers, was sent questionnaires, of which 141 were completed and returned, giving a response rate of 82.5%.Most Health Promotion Units are currently purchaser-only based or split betweenpurchaser and provider bases. The majority of Districts have an establishment for a Director of Health Promotion, who is likely to be based at the purchaser level, Most directors have support staff. The median staff level in this survey is 7 WTEs (whole-time equivalents), and the level for the population served is 2.74/100,000. A little over 50% of respondents felt that health promotion should be a split purchaser and provider function, and there is evidence that this opinion has changed in recent years. This reflects concern expressed in comments made by respondents about the practical problems inherent in the separation of the purchaser and provider elements of health promotion activities, resulting from the ostensible requirements of the purchaser/provider reorientation in the NHS. The survey provides a picture of the present organisational arrangements in health promotion across the country and forms a basis for discussion of future developments. It highlights the problems of integrating all health promotion functions under a single management umbrella, purchaser or provider, and of the perceived importance of ensuring an adequate health promotion structure at the commissioning level.     

Community care: changing the role of hospital social work

Health and social services have been subjected to many changes over the past decade. Legislative reforms in the National Health Service (NHS), the implementation of policies for care in the community, and the transfer of funding for social care have given Local Authorities the lead role in the assessment of need and development of a mixed economy of care. The challenge for the organization and management of health social work is how to adjust to the change, whilst ensuring that increased choices are made available to users. It raises questions as to whether the reforms will provide a real opportunity for innovation or lead to a different form of rationing of services—a ‘top-down’, imposed, technocratic solution to reducing public spending. This paper presents the findings of an exploratory research study which considers the effect of organizational change on the provision of hospital-based social-work services to adults with health and social care needs in four Local Authorities in England. Local Authorities have responded differently; some have integrated care management within a social-work perspective; others have moved towards employing care managers who need not be qualified social workers. Change is proceeding slowly, not surprisingly, for none has been wholeheartedly enthusiastic. This paper examines the limited evidence on how social-work managers and practitioners are meeting the changes imposed upon them. Managers are more optimistic and see the changes as challenging, offering opportunities for acquiring new knowledge and different skills; workers are more pessimistic, fearing that preventive, professional practice will be eroded, disempowering users. Both are in agreement that the process has been stressful and that the practice of social work in hospitals has changed.     

The NHS as an agent of change: creating a smoke-free environment in hospital.

In 1985 a Health Circular (HC(85)22)1 asked all District Health Authorities (DHAs) to draw up written policies which would establish non-smoking as normal practice on health service premises and for health service staff. Two years later, a survey of all 191 English Health Authorities assessed progress. Results of the survey indicate a high degree of compliance with the primary goal of each DHA. However, few DHAs gave a policy which contained explicit guidelines on implementation and monitoring procedures. This might have had considerable impact on commitment to smoke-free provision in hospitals.     

Leadership: The Winnipeg Community and Long Term Care Authority

The Winnipeg Community and Long Term Care Authority (WCA) was established in 1998 under the Regional Health Authorities Act of the Province of Manitoba. The WCA's role is to provide for the successful integration of Winnipeg's community-based healthcare delivery services through its three main portfolios: Community Care and Public Health, Home Care and Mental Health, and Long Term Care and Specialized Services. The WCA is dedicated to building a quality health future for Winnipeg. Various initiatives undertaken in the pursuit of quality are described.     

Development of a new tool for the early identification of communication‐support needs in people living with dementia: An Australian face‐validation study

Language and communication difficulties are common in dementia but limited tools are available for a timely assessment of those individuals who experience these difficulties. The Communication‐Support Needs Assessment Tool in Dementia (CoSNAT‐D) was developed to assist in (a) the early identification of communication difficulties among people with dementia in the community context; and (b) determining the level of their communication support needs to guide appropriate service access. The CoSNAT‐D was developed based on a literature review. The face validity was tested with end‐users (people with dementia and support persons of people with dementia) regarding relevance, wording, syntax, appropriateness and comprehensiveness of the items of the tool. Data were collected using semi‐structured phone interviews. Seven people with dementia and 15 carers participated in the study. Feedback regarding items' appropriateness was largely positive and minor changes were made to improve comprehensiveness. A new item was added to the original item pool. The interviews highlighted the importance of including people with dementia in the assessment processes and person‐centered approaches in this context. The CoSNAT‐D presents a first step for the early identification of individual support needs of people living with dementia and communication difficulties who live in the community. Items of the CoSNAT‐D have been determined face‐valid by end‐users. The face‐validated version of the tool is currently undergoing further testing to determine additional relevant psychometric properties.     

Contracts and supply assurance in the UK health care market

We present a formal model of the relationship between a health care purchaser and a provider drawing on the recent experience of explicit contracting in the UK health sector. Specifically we model the contractual relationships emerging between District Health Authorities, who are presently the dominant health care purchasers, and the providers of hospital care. The comparative static analysis implies that the transaction cost of using non-local hospitals, the expected patient demand, the extent of excess capacity in local hospitals, and the proportion of that excess capacity expected to be lost to competitive purchasers, are all important determinants of the choice of contract.     

Location-allocation models,social science and health service planning: An example from North East England

This paper reports on a project carried out by the author to assess strategies for hospital location in the Durham Health District, England. This project was set up in the context of a dispute on hospital strategy between the relevant Regional and Area Health Authorities and so the development of the dispute is outlined. This is followed by a summary of the work carried out in which some reservations about the techniques employed are put forward. The subsequent debates between the Regional and Area Health Authorities are also discussed. The paper concludes by raising more general issues concerning the role of the state and the use of knowledge in planning.     

"I don't believe in needles": qualitative aspects of a study into the uptake of infant immunisation in two English health authorities

This paper presents qualitative data to emerge from a largely quantitative case-control study of the uptake of infant immunisation in two District Health Authorities in the North West of England. It was hypothesised that problems arising from transport and time-space constraints would distinguish the parents of those children who had missed appointments from those who had attended. However, most of these difficulties were experienced equally by both groups and so could not solely account for different immunisation behaviour. Rather, the groups could be distinguished further by their differing attitudes towards, and knowledge of, infant immunisation based on a wide range of personal experiences. The paper argues that it is a mistake to label parental decision-making as 'irrational' when one takes into account the interaction between personal experience, differing levels of advice and the impact of constraints, notably gender role constraints, as they affect women with young children.     

The blocked bed: Definition of a problem

The ‘blocked bed’ is a term familiar to doctors and hospital administrators, but has no conventional definition. Estimates of the prevalence of bed blockage vary and are largely subjective. A survey of Area and Regional Health Authorities in the U.K. was used to collect information on the nature and extent of bed blockage. The definitions offered focus on the match between patient characteristics and services provided, and refer in the main to elderly patients in acute hospital beds. It is argued that the emergence of blockage as a problem is related to a dominant model of acute care in hospitals, which does not accurately reflect the situation of elderly patients of their needs for treatment.     

Supporting people with learning difficulties in self-advocacy groups and models of disability

This paper addresses the support offered by 'advisors' to people with learning difficulties in self-advocacy groups. Previous literature has failed to account for the multifaceted nature of self-advocacy support. This failure has resulted in simplistic and unfair attacks on professional (staff) supporters; a lack of conceptualizations of 'support' which are grounded in the empowering discourse of the social model of disability; and ignored the self-determination of self-advocates with learning difficulties themselves. I will present vignettes of support ('interventions') offered by advisors that I observed, which were empowering and disempowering, drawing on an ethnographic study of four self-advocacy groups. These interventions can be best understood as either reflecting a social model or an individual model of disability. Three pairs of intervention are presented reflecting the social-individual dichotomy. With reference to disability theory it is argued that those acts which reflect a social model offer a more authentic means of promoting the self-advocacy skills of people with learning difficulties. Finally, the intra-support networks of self-advocates are exemplified, suggesting that any support offered by professionals or advisors needs to be sensitive to the interventions of people with learning difficulties themselves. This paper concludes by offering practical pointers to policy-makers, service providers and others working with people with learning difficulties.     

Community hospitals in Oxfordshire: their effect on the use of specialist inpatient services.

About one-third of the general practices in the Oxfordshire Health District have access to beds in community hospitals as well as district general hospitals. Hospital Activity Analysis data were used to calculate the average number of hospital beds occupied daily by patients registered with each general practice in the district. Practices with and without access to community hospitals were compared to determine whether such access was associated with a reduction in the use of beds in general medical, geriatric, and other specialties, and an increase in overall utilisation rates. The rate of use of general medical and geriatric beds in district general hospitals by practice populations with access to community hospitals was about half that of populations without such access. Utilisation rates overall, combining the use of beds in both district general hospitals and community hospitals, were a little higher in populations with access to both community hospitals and district general hospitals than in those with access to district general hospitals only.     

Consultants' views of a district's services.

A postal questionnaire survey of consultants in the Bath Health District was conducted to establish a means for individual consultants to express their views about the provision of health services in the district, so that by working together a new relationship between the District Health Authority (DHA) as purchaser and the clinicians as providers of services could commence. A response rate of 84 per cent was achieved. The survey sought views on clinical and management issues to be used in the development of service agreements (contracts) and views on topics identified by general practitioners (GPs) as areas in need of improvement. Detail is given of results relating to out-patient services, issues of communication and the continuing role of community hospitals. Most consultants sanctioned the appropriateness of referrals by GPs to out-patient services but they identified some out-patient referrals as inappropriate. This justifies a further review of the out-patient services to be purchased by the DHA. Consultants were in agreement that there was scope for review of out-patient follow-ups. They agreed with GPs that discharge summaries could be provided within 24 hours of patient discharge to improve communication with GPs and that consultants should be available by pager to be contacted by GPs, but disagreed with GPs about the feasibility of giving patients on waiting lists a firm admission date at the time of going on the waiting lists. The majority of consultants were in favour of continuing support for community hospitals. They identified overall social value of community hospitals and greater clinical value of out-patient services than in-patient services in community hospitals.(ABSTRACT TRUNCATED AT 250 WORDS)     

Section 47 and its use with mentally disordered people

This paper reports a survey of implementations of Section 47 of the National Assistance Act (1948) in four Regional Health Authorities between 1983 and 1986. The majority of those compulsorily removed from their homes under the Section were elderly people in poor physical health suffering from a major psychiatric disorder. The initial mortality was very high, and 41 per cent of the sample died within three months of removal. There is no mechanism for appeal or review for people removed under Section 47. The Mental Health Act (1983), which does have these safeguards, could have been used in many of these instances, but was not because of misunderstandings about its scope and poor liaison between geriatric and psychiatric services. It is recommended that the Mental Health Act should be used where it is appropriate and that Section 47 should be reformed to provide an equivalent protection of civil liberties.