Status and development of critical incident stress management services in the United Kingdom National Health Service and other emergency services combined: 1993-1996

Surveys conducted amongst members of the Association of NHSOccupational Physicians indicate few changes in the status anddevelopment of Critical Incident Stress Management Services(CISMS) in the United Kingdom National Health Service between1993 and 1996. Limited CISMS are confirmed by the majority ofrespondents in the two surveys with developments having typicallyoccurred within long-established staff care services such ascounselling. In 1996 NHS provision is typically based on theindependent use of own resources. A 1996 comparison of NHS withpooled returns from Ambulance Services, Fire Brigades and SocialServices Departments indicates few variations in status, provisionand levels of expertise in the delivery of CISMS. Other emergencyservices co-operate to a greater extent with each other thandoes the health care sector. Occupational Health Departmentresponders confirm availability of expertise resources to provideCISMS, but low priority status frustrates delivery of CISMS.Survey results indicate the NHS is at risk of not fulfillingits duty to care for staff after major incidents. The establishmentof regional centres of CISMS excellence with local and nationalresponsibilities is advocated.     

Buying time II: an economic evaluation of a joint NHS/Social Services residential rehabilitation unit for older people on discharge from hospital

The study's aim was to investigate the cost-effectiveness of an NHS/Social Services short-term residential rehabilitation unit (a form of intermediate care) for older people on discharge from community hospital compared with 'usual' community services. An economic evaluation was conducted alongside a prospective controlled trial, which explored the effectiveness of a rehabilitation unit in a practice setting. The aim of the unit was to help individuals regain independence. A matched control group went home from hospital with the health/social care services they would ordinarily receive. The research was conducted in two matched geographical areas in Devon: one with a rehabilitation unit, one without. Participants were recruited from January 1999 to October 2000 in 10 community hospitals and their eligibility determined using the unit's strict inclusion/exclusion criteria, including 55 years or older and likely to benefit from a short-term rehabilitation programme: potential to improve, realistic, achievable goals, motivation to participate. Ninety-four people were recruited to the intervention and 112 to the control group. Details were collated of the NHS and Social Services resources participants used over a 12-month follow-up. The cost of the resource use was compared between those who went to the unit and those who went straight home. Overall, costs were very similar between the two groups. Aggregated mean NHS/Social Services costs for the 12 months of follow-up were pound 8542.28 for the intervention group and pound 8510.68 for the control. However, there was a clear 'seesaw' effect between the NHS and Social Services: the cost of the unit option fell more heavily on Social Services (pound 5011.56, whereas pound 3530.72 to the NHS), the community option more so on the NHS (pound 5146.74, whereas pound 3363.94 to Social Services). This suggests that residential rehabilitation for older people is no more cost-effective over a year after discharge from community hospital than usual community services. The variability in cost burden between the NHS and Social Services has implications for 'who pays' and being sure that agencies share both pain and gain.     

Priorities among recommended clinical preventive services.

BACKGROUND: Many recommended clinical preventive services are delivered at low rates. Decision-makers who wish to improve delivery rates, but face competing demands for finite resources, need information on the relative value of these services. This article describes the results of a systematic assessment of the value of clinical preventive services recommended for average-risk patients by the U.S. Preventive Services Task Force. METHODS: The assessment of services' value for the U.S. population was based on two dimensions: burden of disease prevented by each service and cost effectiveness. Methods were developed for measuring these criteria consistently across different types of services. A companion article describes the methods in greater detail. Each service received 1 to 5 points on each of the two dimensions, for total scores ranging from 2 to 10. Priority opportunities for improving delivery rates were determined by comparing the ranking of services with what is known of current delivery rates nationally. RESULTS: The highest ranked services (scores of 7+) with the lowest delivery rates (< or =50% nationally) are providing tobacco cessation counseling to adults, screening older adults for undetected vision impairments, offering adolescents an anti-tobacco message or advice to quit, counseling adolescents on alcohol and drug abstinence, screening adults for colorectal cancer, screening young women for chlamydial infection, screening adults for problem drinking, and vaccinating older adults against pneumococcal disease. CONCLUSIONS: Decision-makers can use the results to set their own priorities for increasing delivery of clinical preventive services. The methods provide a basis for future priority-setting efforts.     

Women's health centers: are the National Centers of Excellence in Women's Health a new model?

This paper describes the characteristics of the clinical centers of the first 12 National Centers of Excellence (CoE) in Women's Health, designated by the U.S. Department of Health and Human Services Office on Women's Health between 1996 and 1997. These centers are compared with 56 hospital-sponsored primary care women's health centers identified in the 1994 National Survey of Women's Health Centers, the only source of nationally representative data on primary care women's health centers. While analysis demonstrates that some organizational and clinical attributes of primary care women's health centers were in evidence before the CoE program was initiated, the CoE centers demonstrate further integration of clinical services with research and medical training in women's health, and the delivery of services to a more diverse population of women.     

Provider arrangements for mental health services in 'The New NHS'

Mental health services in England, in common with many other European countries, have been the subject of sustained government attention during the 1990s. Since the election of the Labour administration in Britain in May 1997, mental health services have been discussed in most Department of Health documents on health and social care policy, and mental health services in England have a new national strategy. At the same time, the local provision of mental health services within NHS Trusts has been undergoing organisational change. This paper sets out the policy context and evidence base for the reorganisation of provider arrangements for mental health services. In addition, the results of a documentary analysis of unpublished reviews of provider arrangements in 10 localities are presented. The review identified three major themes: firstly, the reconfiguration of NHS Trusts is based around Specialist Mental Health Trusts and Community and Mental Health Trusts; secondly, the joint provision of services and/or the integration of services between health and social services is starting to appear and; thirdly, the delegation of responsibility to localities based on Primary Care Group/Social Services boundaries is being discussed. The paper discerns a number of trends and points to the need for further research, in particular into the relationship between organisational arrangements and effective service delivery.     

Entitlement to military healthcare--limitations of the NHS model.

The Defence Medical Services provide to a British population healthcare services that are funded from taxation and are free at the point of delivery. This paper reviews some principles for determining entitlement to healthcare for the population cared for by the Defence Medical Services. The starting point for entitlement uses the principles under which the National Health Service (NHS) was established. These are then extended to acknowledge the limitations of an NHS model when considering occupational health issues and geographical variations in healthcare provision.     

Indicator-based systems of performance management in the National Health Service: a comparison of the perceptions of local- and national-level managers.

Historically, the UK Government has policed the use of National Health Service (NHS) resources through the centralization of control. With the majority of resource-draining decisions being taken by clinicians, however, professional financial accountability is becoming more important within the NHS management structure. Variations in clinical performance can be monitored through the use of performance indicators, although these are not without their problems. The use of league tables of such indicators in the national press is now infamous and there is much anecdotal evidence about the intraorganizational conflict arising from the use of such tables. A questionnaire survey and interview study of clinical directors, clinical service directors and business managers in several Scottish NHS Trusts was undertaken to ascertain the perceptions of local-level managers on the issue of performance indicators. Interviews were also carried out with a number of personnel in the Scottish Office Department of Economics and Information, the Division of Health Gain and the Finance Directorate. This paper explores the differences between the perceptions of the managers at these two levels of the NHS with regards to issues of performance measurement, intraorganizational conflict and corporate vision.     

Benchmarking self-reported practice regarding Scottish Executive guidance on hepatitis C-infected health care workers

BACKGROUND: The 2002 Scottish Executive guidance 'hepatitis C-infected health care workers' advised NHS Scotland occupational health departments regarding screening health care workers (HCW) who perform or who may perform exposure-prone procedures (EPPs) for hepatitis C virus (HCV) infection. In 2004, 2 years following the launch of the guidance, there was anecdotal evidence of challenges to implementation and clinical and ethical concerns regarding the screening process. AIM: To benchmark the implementation of the Executive guidance on hepatitis C-infected HCW in NHS Scotland. METHODS: Lead occupational health practitioners in 15 Scottish NHS Boards completed a questionnaire and provided relevant local policies. RESULTS: All 15 NHS Boards responded: 87% (n = 13) had implemented the guidance with partial implementation in the remaining boards. While 87% required identified and validated samples (IVS), no consistent method was reported for how results from an IVS were recorded. There was also no consensus as to the duration a result was considered valid or consistency in charging for tests required by other employers. Across Scotland, some employee groups were being screened over and above those recommended within the guidance. Overall, there was agreement on the value of a standardized NHS hepatitis C status certificate and the importance of explicit screening criteria and identifying EPP workers. CONCLUSION: The survey confirms the challenges in implementing the guidance on managing HCV-infected HCW within NHS Scotland. These include lack of clarity regarding who, when and how frequently a HCW should be screened and how the results of such tests should be recorded.     

Who contracts for primary care?

The implications of the 1997 NHS (Primary Care) Act have been largely overlooked in the rush to establish Primary Care Groups. Allowing health authorities to develop local contracts for primary care has far-reaching implications and is an important departure from the national system of negotiation that has characterized general practice to date. This paper describes a content analysis of a sample of Personal Medical Services (PMS) pilot contracts. In the first year little attention has been given to achieving cost savings or greater efficiency and few contracts promote clinical guidelines. The difficulties of specifying services sensitive to local health needs are highlighted and the national Statement of Fees and Allowances (the 'Red Book') may not be swiftly supplanted. However, the pilots have introduced innovations such as salaried general practitioners, nurse-led services and NHS trust-managed care. The development of local contracts provides a valuable learning experience for general practitioners and health authorities in advance of the establishment of Primary Care Trusts.     

Broadening the Evidence Base for Evidence-Based Guidelines: A Research Agenda Based on the Work of the U.S. Preventive Services Task Force

Evidence-based evaluations of clinical preventive services help define priorities for research in prevention as part of primary health care. In this article, we draw on our experiences with the U.S. Preventive Services Task Force (USPSTF) to outline some major areas where research is needed to define the appropriate use of specific screening tests, counseling interventions, immunizations, and chemoprophylaxis. Areas of particular importance included research to: (1) Identify effective and practical primary care interventions for modifying personal health practices of patients, especially around issues such as diet, exercise, alcohol and drug use, and risky sexual behavior; (2) Clarify the optimal periodicity for certain screening tests and counseling interventions; (3) Identify practical ways to allow patients to share decision-making about preventive care, especially for services of possible but uncertain benefit; (4) Examine the most sensitive and efficient ways to identify high-risk groups who may need different services than the average population; and (5) Expand the use of decision-analysis and cost-effectiveness analysis to help identify optimal use of clinical preventive services. Given the difficulty of large, prospective trials, we discuss the use of alternative research designs to fill in critical gaps in the evidence for the effectiveness of specific services. Finally, we note several issues of increasing importance that may need to be addressed by future work of the USPSTF: what are the most reliable and effective ways to (1) measure and (2) improve the delivery and quality of preventive care provided in the primary care setting.     

Attitudes of General Practitioners to Occupational Health Services

To assess the attitude of General Practitioners towards OccupationalHealth Services in the NHS and industry, a questionnaire wassent to 63 GPs with a response rate of 83 per cent. The majority of GPs felt that Occupational Health Departmentsacted in the best interests of their patients; but felt thatoccupational physicians sometimes meddle in primary care. The views of GPs on the acceptability of occupational healthinvolvement in health screening, education and specific vaccinationswas varied, with enthusiasm for health education and very limitedscreening, but little enthusiasm for vaccinations. The overall view of occupational health was positive, but specificareas of communication and overlap of function need to be exploredin more depth. The new GP contract places specific requirementson GPs to undertake health screening and to reach targets forvaccination and cervical cytology. If the quality of the interfacebetween occupational health services and primary care can beimproved, both specialties would benefit. Requests for reprints should be addressed to: Dr G. Parker, Lyndene, Sunnyside Close, Fairfield, Lancaster LA1 5NH, UK     

Primary medical care in the United kingdom

Since 1948 health care in the United Kingdom (UK) has been centrally funded through the National Health Service (NHS). The NHS provides both primary and specialist health care which is largely free at the point of delivery. Family practitioners are responsible for registered populations of patients and typically work in groups of 4-6 self-employed physicians. They hire nurses and a range of other ancillary staff, and act as gatekeepers to specialist care. Recent reforms include a wide range of national quality improvement initiatives and a pay for performance scheme that accounts for around 25% of family practitioners' income. These reforms have been associated with some major improvements in quality, including improved chronic disease management and reduced waiting times for specialist care. The four countries of the UK differ in some important aspects of health care organization: proposed reforms in England would move towards a more market-driven system, with family practitioners acting as payers for specialist care and controlling 70% of the NHS budget. The other countries (Scotland, Wales and Northern Ireland) focus more on trying to create area-based integrated systems of care.     

'We didn't know it would get that bad': South Asian experiences of dementia and the service response

The aim of the present paper was to examine some views and experiences of dementia among older South Asian people, as well as their families and carers, and to explore central issues of service support. Data were collected in Scotland through interviews with 11 professionals working with South Asian people with dementia, and four case studies of South Asian people with a diagnosis of dementia, as well as their families and carers. The case studies demonstrated overwhelmingly negative experiences of dementia, with poor quality of life, desperate needs for support, lack of access to appropriate services, little knowledge of dementia, and isolation from community and family life. The interviews with professionals described a strong demand for services, a need to develop awareness and knowledge about dementia in South Asian communities, and a need to promote more culturally sensitive, individually responsive services. Similarities between South Asian people and the non-South Asian population include stress on carers, increasing isolation, problematic diagnostic practices, lack of knowledge and demand for service support. Differences include limited use of non-National Health Service (NHS) support, dealing with later stages of dementia at home, particularly negative views about residential care, culturally based attitudinal differences and use of the term 'dementia' in English as neutral rather than stigmatising. The present authors suggest that there is little knowledge and experience of dementia in South Asian communities, as well as restricted access to appropriate services, despite the efforts of voluntary sector and NHS special projects. There is demand for services, especially at home. Services need to develop individual responsiveness for effective working in a diverse society.     

Child and Adolescent Mental Health Services and the Strategic Context: The Bigger Picture

This paper gives an overview of the current strategies to deliver Child and Adolescent Mental Health Services (CAMHS) across Scotland, England, Wales and Northern Ireland. Traditionally, services for children and adolescents have tended to be almost an afterthought to adult provision and have long been neglected and under-resourced. There is evidence, however, that this situation is changing, with CAMHS receiving an increasing profile in all regions. Each region has developed their own strategy for the organisation, planning and delivery of a comprehensive mental health service for children and adolescents. This paper examines the common themes of each strategy and their individual differences, and highlights some of the challenges they all face in providing a high-quality, comprehensive CAMHS in the United Kingdom.     

The 2019 introduction of the new National Healthcare System in Cyprus

In 2019, Cyprus launched its new National Healthcare System (NHS) as one of the major structural reforms required by the bail-out agreement with the International Monetary Fund, the European Commission and the European Central Bank (known as the Troika) which averted Cyprus bankruptcy in 2011. This paper presents the key features of the new NHS: A National Health Insurance Fund operated by the Health Insurance Organisation pays for services provided by a mix of public and private providers. A prerequisite for the establishment of this new quasi-market was the transfer of public hospitals from the Ministry of Health to the new State Health Services Organisation, thus establishing a purchaser-provider and regulator split. The first implementation phase started in June 2019 and introduced coverage of outpatient healthcare services for the entire population, providing access – with relatively small user charges – to family physicians, outpatient specialists, pharmaceuticals and laboratories. The second implementation phase began in June 2020 with the inclusion of hospital care, followed by the inclusion of specialty pharmaceuticals in September and was completed in December 2020. The reform is a vital achievement as it is a major step towards the goal of universal health coverage, reducing the excessive reliance on out-of-pocket payment and glaring inequities in access to care.     

Designing and implementing E-health Applications in the UK's National Health Service

Telemedicine/e-health applications have the potential to play an important role in Britain's National Health Service (NHS), including the NHS in Scotland. The Scottish Telemedicine Action Forum (STAF) was established by the Scottish Executive Department of Health in 1999 to take a range of applications, targeted on national priorities, into routine service. In the process it has provided insights into how advanced information and communication technologies (ICTs) can be moved from the research stage into routine service. In this article four of the projects are described and analysed focusing on the key issues that have emerged as critical for carrying projects successfully through to implementation in service as follows: 1. A multisite videoconferencing network linking 15 minor injury units to the main accident and emergency (A&E) centre. 2. A single-site neonatal intensive care "cotside" laptop system to assist communication between parents and clinical staff. 3. A single-site outpatient chronic disease management system. 4. A multisite software audit tool to support the care of cleft lip and palate patients from birth onward.     

Meeting patient expectations: healthcare professionals and service re-engineering.

A central theme underpinning the reform of healthcare systems in western economies since the 1980s has been the emphasis on reorienting service provision around the patient. Healthcare organizations have been forced to re-appraise the design of the service delivery process, specifically the service encounter, to take account of these changing patient expectations. This reorientation of healthcare services around the patient has fundamental implications for healthcare professionals, specifically challenging the dominance of service professionals in the design and delivery of health services. Utilizing a qualitative methodological framework, this paper explores the responses of healthcare professionals to service redesign initiatives implemented in acute NHS hospitals in Scotland and considers the implications of such professional responses for the development of patient-focused service delivery. Within this, it specifically examines evolving professional perspectives on the place of a service user focus in a publicly funded healthcare system, professional attitudes towards private sector managerial practices, and the dynamics of changing professional behaviour.     

The organisation and functioning of Veterinary Services: results of a 2005 survey of Member Countries of the World Organisation for Animal Health

A questionnaire was sent to the 167 Member Countries of the World Organisation for Animal Health (OIE) in 2004 and 2005. The organisation and functioning of national Veterinary Services were analysed based on the responses from 85 of these countries. Leaving aside variations between countries, Veterinary Services are very involved in animal health and food safety controls at farm level (including animal feed), and during primary and secondary processing, whether alone or in conjunction with other services. At the lower end of the chain, namely distribution and the food service industry, responsibilities tend to be more widely shared. Veterinary Services have a central responsibility in international trade in animals and animal products. The main weaknesses in the chain of controls concern the logistical and financial resources of Veterinary Services, and insufficient involvement of livestock producers and even of field veterinarians. The many recent reforms are tending to provide a more consistent, integrated approach to animal health and food safety controls 'from the stable to the table'.     

Charging for NHSPlus: an inferential study based on the internal provision of occupational health services within the National Health Service

BACKGROUND: 'NHSPlus' was conceived as a national agency that would provide occupational health services to organizations, for a fee, without imposing any financial burden on the taxpayer. This self-funding requirement brings into focus the resource implications for such a service and the determination of the charges to be made to external clients. AIM: The existing provision of occupational health services to >100000 National Health Service (NHS) staff by 13 NHS occupational health services of various sizes was analysed, with the objective of determining an appropriate charge-out rate to third parties. METHOD: Two focus groups were questioned on their work external to the NHS. Data collected on the allocation of doctors and nurses to occupational health services in relation to the number of NHS clients serviced were used to investigate the nature of the resourcing relationship using regression analysis. RESULTS: The relationship was found to be stable enough to provide a good estimate of staff requirements (the key resource requirement). Combining this with costing information allowed inferences to be drawn concerning the economic cost and hence the break-even rate of charge for the service. This was then compared with the employer charge rates in the NHSPlus published case studies. CONCLUSIONS: The results suggest that the per capita charges to external clients are lower than the per capita cost of internal occupational health provision within the NHS, raising questions about the viability of the service.     

A difference-in-differences analysis of the effect of free dental check-ups in Scotland

The Scottish Government introduced free NHS dental check-ups in April 2006 as a way of encouraging utilisation and improving the oral health of residents. We use data from the British Household Panel Survey (BHPS), a nationally representative data of 117761 individual respondents in the United Kingdom covering the period between 2001 and 2008 to evaluate the impact of this policy on utilisation of NHS dental check-ups in Scotland, using a difference-in-difference approach. Results show that there was a 3–4 percent increase in NHS dental check-up in Scotland, compared to the rest of the UK. Results suggest that a removal of financial barrier to dental check-ups does indeed lead to a modest increase in utilisation, and may have wider implications for the delivery of dental care in Scotland.