Is digital health care more equitable? The framing of health inequalities within England's digital health policy 2010–2017

Informed by a discourse analysis, this article examines the framing of equity within the UK's digital health policies between 2010 and 2017, focusing on England's development of NHS Digital and its situation within the UK Government's wider digital strategy. Analysis of significant policy documents reveals three interrelated discourses that are engaged within England's digital health policies: equity as a neoliberal imaginary of digital efficiency and empowerment; digital health as a pathway towards democratising health care through data‐sharing, co‐creation and collaboration; and finally, digital health as a route towards extending citizen autonomy through their access to data systems. It advances knowledge of the relationship between digital health policy and health inequalities. Revealing that while inclusion remains a priority area for policymakers, equity is being constituted in ways that reflect broader discourses of neoliberalism, empowerment and the turn to the market for technological solutionism, which may potentially exacerbate health inequalities.     

Self‐care as care left undone? The ethics of the self‐care agenda in contemporary healthcare policy

Self‐care, or self‐management, is presented in healthcare policy as a precursor to patient empowerment and improved patient outcomes. Alternatively, critiques of the self‐care agenda suggest that it represents an over‐reliance on individual autonomy and responsibility, without adequate support, whereby ‘self‐care’ is potentially unachievable and becomes ‘care left undone’. In this sense, self‐care contributes to a blame culture where ill‐health is attributed to personal behaviours or lack thereof. Furthermore, self‐care may represent a covert form of rationing, as the fiscal means to enable effective self‐care and supplement, or replace, self‐care capacities, is not provided. This paper explores these arguments through a contemporary ethical analysis of the self‐care agenda. The terms self‐care and self‐management are used interchangeably throughout whereby self‐management is understood as a point in the wider self‐care continuum.     

Voluntary or compulsory health care reform? The case of primary care organisations in Scotland

Previous studies have suggested that voluntary reform of the delivery of primary care services is more likely to occur in affluent areas. Health system reforms that include voluntary participation of GPs may therefore lead to a two-tier service in terms of access to and utilisation of medical services. New primary care organisations in Scotland (local health care co-operatives) were introduced in 1999. These are groups of general practices and membership was voluntary. The aim of this study is to examine whether the voluntary nature of membership was likely to exacerbate or reduce inequalities in the provision of primary care services. Logistic regression analysis was used to identify differences in population, practice, and GP characteristics between general practices that have joined a co-operative and those that have not. The results indicated that practices located in deprived areas and covering populations with high levels of morbidity were more likely to join a co-operative. High workload decreased the probability of membership. General practices that found it difficult to obtain access to local authority residential care homes were more likely to join a co-operative. The number of fee claims for minor surgery sessions per whole-time equivalent GP increased the probability of membership. There is therefore some evidence indicating that general practices located in areas of high need are more likely to join a co-operative. This suggests that voluntary participation in these new primary care organisations may reduce rather than exacerbate inequalities in the provision of primary care.     

Why do the sick not utilise health care? The case of Zambia

When ill the individual faces the options of seeking health care, using self-medication or doing nothing. In an economic perspective, an individual's propensity to utilise health care is determined by the costs of utilisation and the perceived benefits of health care. The propensity to utilise health care may hence be expected to vary between individuals. In this paper we attempt on the one hand to determine what factors influence sick individuals' propensity to seek health care at a health facility or use self-medication (or do nothing), and on the other hand attempt to determine the factors that influence the magnitude of their expenditures for health care, in particular what other factors than just health status influence utilisation. For the empirical analysis, data, covering 9700 individuals, from the 1998 Living Conditions Monitoring Survey (LCMS) is used. We use a Multinomial Logit selection model to estimate the equation, which allows us to analyse health-care utilisation through two separate processes, the decision to seek care and the magnitude of expenditures incurred. In general, we find that the individuals are influenced by income, insurance, type of illness and access variables such as distance and owning a vehicle.     

The Healthy People 2010 outcomes for the care of children with special health care needs: an effective national policy for meeting mental health care needs?

Objectives To assess the effectiveness of the Maternal and Child Health Bureau’s (MCHB) Six Core Outcomes for children with special health care needs (CSHCN) as indicators in measuring the degree to which mental health care needs are met. Methods This study analyzes data from the 2001 National Survey of Children with Special Health Care Needs for 9,748 CSHCN who needed mental health care. Bivariate and logistic analyses were employed to investigate the impact of the MCHB’s Six Core Outcomes on the probability of having an unmet need for mental health services. Results Of the 2.3 million CSHCN in the U.S. who needed mental health care in 2001, almost one-fifth did not receive all of the mental health services that they needed. Ultimately, eight Outcomes and sub-categories of Outcomes were considered. Sixty-one percent of CSHCN with a need for mental health care had care that fulfills six of the eight considered Outcomes. Logistic analysis indicates that individual fulfillment of each of the Core Outcomes and fulfillment of additional Outcomes have a significant association with reducing the probability of having an unmet mental health care need for CSHCN. Conclusions This study is the first attempt to apply the Six Core Outcomes to meeting the needs for mental health care among CSHCN. Estimates of unmet need for mental health care suggest that efforts can be made to improve access for CSHCN. The initial estimates generated by this study indicate that the MCHB Outcomes are important in meeting children’s mental health needs and are important indicators for informing MCHB policy.     

The importance of age in allocating health care resources: does intervention‐type matter?

BACKGROUND: Recent proposals to reform cost-effectiveness analysis (CEA) by weighting health benefits [(Quality-adjusted life-years) QALYs] by recipients' age are based on studies examining age-related preferences in life-saving contexts. We investigated whether the perceived importance of age in resource allocation decisions differs among intervention-types. METHODS: 160 individuals were recruited from a cafeteria of a university medical centre and asked to choose between hypothetical health care programmes. Scenario A described two programmes treating life-threatening conditions and Scenario B two programmes providing palliative care. Programmes were identical except in average patient age (35 versus 65). Respondents also directly rated the importance of age for allocating resources for six types of interventions. RESULTS: Responses for the life-saving scenario favoured younger age groups while those for the palliative care scenario showed no age preference. The difference between scenarios was statistically significant. When directly rating the importance of age in allocating treatment resources, people placed greatest importance on age in treating infertility and life-saving, and least importance in treating depression. DISCUSSION: The importance people place on age as a resource allocation criterion depends on the clinical context. As QALYs serve as a common measure of health benefits for all intervention types, age weighting of QALYs is premature.     

How do supply‐side factors influence informal payments for healthcare? The case of HIV patients in Cameroon

Direct out‐of‐pocket payments for healthcare continue to be a major source of health financing in low‐income and middle‐income countries. Some of these direct payments take the form of informal charges paid by patients to access the needed healthcare services. Remarkably, however, little is known about the extent to which these payments are exercised and their determinants in the context of Sub‐Saharan Africa. This study attempts therefore to shed light on the role of supply‐side factors in the occurrence of informal payments while accounting for the demand‐side factors. The study relies on data taken from a nationally representative survey conducted among people living with HIV/AIDS in Cameroon. A multilevel mixed‐effect logistic model is employed to identify the factors associated with the incidence of informal payments. Results reveal that circa 3.05% of the surveyed patients incurred informal payments for the consultations made on the day of the survey. The amount paid informally represents up to four times the official tariff. Factors related to the following: (i) human resource management of the health facilities (e.g., task shifting); (ii) health professionals' perceptions vis‐à‐vis the remunerations of HIV care provision; and (iii) reception of patients (e.g., waiting time) significantly influence the probability of incurring informal payments. Also of note, the type of healthcare facilities is found to play a role: informal payments appear to be significantly lower in private non‐profit facilities compared with those belonging to public sector. Our findings allude to some policy recommendations that can help reduce the incidence of informal payments. Copyright © 2014 John Wiley & Sons, Ltd.     

Performance‐based contracting in home‐care work in The Netherlands: professionalism under pressure?

Our aim was to improve the understanding of the relationships between performance‐based contracting, management supportiveness and professionalism in home care. Using path analysis, this article explores the relationships between home‐care workers' perceptions of management support, implementation of performance‐based contracting (i.e. use of strict time registration rules and cost‐efficiency measures) and autonomy and intrinsic job satisfaction. We hypothesised that: use of strict time registration rules and cost‐efficiency measures relates to lower levels of autonomy and intrinsic job satisfaction (H1); there is an indirect relationship between use of strict time registration rules and use of cost‐efficiency measures and intrinsic job satisfaction via autonomy (H2); higher levels of management support relate to the use of looser time registration rules and less use of cost‐efficiency measures (H3); and higher levels of management support relate to higher levels of autonomy and intrinsic job satisfaction (H4). We used data from a cross‐sectional survey conducted in 2010 of a sample of Dutch home‐care workers (N = 156, response rate = 34%). Overall, our study suggests that the consequences of performance‐based contracting for professionalism are ambiguous. More specifically, using strict time registration rules is related to lower levels of autonomy, whereas using cost‐efficiency measures does not seem to affect autonomy (H1). Performance‐based contracting has no consequences for the level of fulfilment home‐care workers find in their job, as neither of the two contracting dimensions measured was directly or indirectly related to intrinsic job satisfaction (H1, H2). The role of managers must be taken into account when studying performance‐based contracting, because perceived higher management support is related to managers' less frequent use of both strict time registration rules and of cost‐efficiency measures (H3). The insight we gained into the importance of supportive managers for both autonomy and job satisfaction (H4) can help home‐care organisations improve the attractiveness of home‐care work.     

Is government action out‐of‐step with public opinion on tobacco control? Results of a New South Wales population survey

Objective: To assess community attitudes towards smoking bans, tobacco availability, promotion and product regulation, tobacco industry donations to political parties, and government spending on tobacco control activities. To compare public preferences on these issues with policies of the NSW and Commonwealth governments. Method: Anonymous, computer assisted telephone interviews of adults from randomly selected households in the NSW Electronic White Pages conducted in 2004. All subjects completed a core question set and subsequently, one of three sub‐sets. Results: Overall 49.1% of eligible subjects consented. Data from two sub‐samples containing 1,191 and 1,158 subjects are reported. Majority support existed for smoking bans in all six settings assessed: children's playgrounds (89%), sports stadia (77%), licensed premises (72%), outdoor dining (69%), beaches (55%) and motor vehicles carrying children (55%). Respondents nominated vastly higher tobacco control budgets than current levels of government expenditure. On a scale assessing support for tobacco control (maximum score = 13), the mean scores of both non‐smokers (10.4) and smokers (8.0) were high. Of seven variables tested, only two: living with a smoker and personal smoking status were independent predictors of having a high pro‐tobacco control score. Conclusion: There is strong community support for additional government regulation mandating smoke‐free provision and other counter tobacco measures. Implications: Continued advocacy campaigns are required to align government tobacco control agenda more closely with public preferences.     

Does informal care impact utilisation of home‐based formal care services among end‐of‐life patients? A decade of evidence from Ontario,Canada

Understanding how informal care impacts formal care utilisation for home‐based end‐of‐life patients is an important policy‐ and practice‐relevant question. This paper aims to assess the relationship between informal and formal home care among home‐based end‐of‐life patients and how this relationship has changed over the last decade and over the end‐of‐life trajectory. We focus on informal care provided by family members or friends, and three types of home‐based formal care services: care by personal support workers, physician visits, and nurse visits. Using survey data collected in a home‐based end‐of‐life care programme in Ontario, Canada from 2005 to 2016, we build a two‐part utilisation model analysing both the propensity to use each type of formal care and the amount of formal care received by patients. The results suggest that informal care is a substitute for care by personal support workers, but a complement to physician visits and nurse visits. In the case of nurse visits, an increased complementary effect is observed in more recent years. For home‐based physician and nurse visits, the complementary effect grows with patient's proximity to death. These results highlight the complexity of the relationship between informal and formal care among home‐based end‐of‐life patients. Decision‐makers need to take into account the relationship between informal care and different types of formal services when introducing future policies.     

The risk of users’ choice: exploring the case of direct payments in German social care

In this article, we explore the risks associated with direct payments to users enabling them to purchase social care. These payments are intended to enable people with disabilities to make choices and increase their autonomy. However, there is little evidence in the existing literature about the risks involved in direct payments as seen by service users. In this paper, we draw on data from a qualitative study of direct payments for people with disabilities in a federal state of Germany. We interviewed 37 individuals involved in direct payment schemes including individuals receiving payments, care assistants, members of organisations providing care and the administrative officers of the local authorities between December 2011 and January 2014. In this article, we use a governmentality perspective to explore how individuals who received the payments saw and sought to manage the risks associated with the scheme. We found that while users reported that direct payments reduced the risk associated with being directly dependent on the care providers and hence increased their desired self-determination, they identified new risks linked to their liability for the transferred money, problems associated with their liquidity and cash flow, challenges presented by budget cuts, and sanctions resulting from violation of norms of ‘appropriate use’ and the difficulties of negotiating with the funders. To manage these perceived risks users indicated that they had subjected themselves to a new way of active self-control and self-management, normalising their behaviour. We note that risk to service users has been neglected in policy design and should be acknowledged more explicitly.     

The myth of agency and patient choice in health care? The case of drug treatments to prevent coronary disease

Patient choice is at the heart of health-care reform programmes in the UK and in many other countries. The success of patient choice initiatives is dependent on a well-functioning agency relationship in health care. We interviewed 197 patients from 13 general practices in the West Midlands, UK, both before and after coronary screening. Our study suggests that, for patients presenting for coronary risk screening in primary care, the agency relationship is not working well--patients' expressed preferences relating to decisions to commence drug treatments were largely over-ridden in the clinical consultation. Therefore, if choice is to be a real driver of change in health care it needs to encompass patient empowerment and be based on a more collaborative approach to decision making between patients and professionals.