Struggle for control: General practitioners in the Swedish health care system

This paper reports on findings on the perspectives of generalpractitioners (GPs) in Sweden since the introduction of theStockholm model. The research design was exploratory with theintention of discovering several perspectives shared by doctors.The subjects were asked to describe their work, how long theyhad been working and to describe whether they were familiarwith the Stockholm model. Questions also focused on professionalautonomy, the use of diagnostic related groups (DRGs), the Isolationof work and the possible impact on patient care. While previousresearch suggests that doctors may be losing autonomy, the experiencein Sweden, in particular, as it relates to GPs, may be different.Most of the doctors interviewed reported that the Stockholmmodel had increased productivity and efficiency, that economicincentives influenced their medical decisions and that medicaltreatment appears more patient focused than before. GPs reportedan enhanced social and economic status within the medical professionsince the introduction of the Stockholm model.     

Correlates of care seeking for infertility treatment in Europe: Implications for health services and research

Study: To compare care seeking and non-care seeking coupleswith infertility in order to describe potential differenceswhich may have consequences for health care planning and research.Design: multicentre surveys of randomly selected women of child-bearingage. Setting: seven centres in five countries: Denmark, Germany(two centres), Italy (two centres), Poland and Spain. Data werecollected from 1991 to 1993 as part of a European concertedaction. Participants: population-based samples of women between25 and 44 years. The samples ranged from 442 women in Polandto 2, 729 women in Italy. The participation rates ranged from54% in Germany to 88% in Poland. Data: data were collected duringface to face interviews by means of highly structured questionnaires.Questions were asked about life style factors, work exposures,pregnancy history, fecundity and care seeking behaviour. Mainoutcome measures: seeking medical advice and help for infertilityamong couples who had tried to become pregnant for more than12 months. Main results: nulliparity was the strongest predictorfor seeking help in all the European centres and more than 50%of the nulliparous women sought help in all the centres. Thefrequency of care seeking among couples with secondary infertilityvaried to a large extent between the different centres. Womenwith a paid job and smokers were less likely to seek help inmost centres (except in Spain and Italy). Conclusion: far fromall those with an infertility problem seek medical advice andhelp, and the correlates of care seeking differ to a large extentbetween different cultural and health care settings. Researchbased upon clinical samples could easily be biased if the topicof research correlates with care seeking behaviour.     

Education not training: the challenge of developing professional autonomy

The aims of this paper are first, to differentiate between education and training, emphasizing the importance of the former in the professional education of occupational therapists; and second, to outline some of the possible threats to professional autonomy. A focus on training may result in a level of education that cannot sustain professional autonomy. However, the establishment of proscribed and detailed, nationally controlled educational standards may also limit a profession. The latter may occur when cost‐containment is a major societal concern, focusing educational standards on training and measurable outcomes of professional practice. Copyright © 2000 Whurr Publishers Ltd.     

Future Scenarios for Public Health in Europe

The public health task is determined by a combination of demography,patterns of ill-health and the availability of policies andinterventions which can make an impact on health outcomes. Thechanging political and administrative environment provides bothopportunities and threats for the public health enterprise inEurope. If we are to optimize our contribution public healthpractitioners must acquire a strategic overview of the issueswhich need to be addressed. There are tools available whichcan help in the process of strategic analysis which come fromthe world of business. Such tools may not seem initially attractiveto those working in the public sector, however, they shouldbe judged by their utility in generating understanding and indicatingappropriate policy directions. The application of some suchtools would seem to indicate a mismatch and a tension betweenthe old and new public health agendas and the institutionalarrangements which support them. This paper is intended to stimulatea debate about the most effective way forward whereby a widerange of energies can achieve the greatest synergy.     

Health risks and the health care professional

Health care professionals are one of a large group of individuals who are exposed to significant risks by virtue of their occupation, such as the police, mountain rescuers, fire-service. The types of risk to which health care professionals are exposed are numerous, many of which remain largely unrecognised by the public and may even be underestimated by the professionals themselves. Examples of these health risks include fatigue, emotional/psychological trauma, physical injury caused by the use of machinery, back injuries, possible even violent physical assault from a patient or hospital visitor. There is also a very significant risk of acquiring an illness in the course of employment, for example, physical damage caused by the prolonged use of toxic substances, and also infectious diseases which are acquired by various routes, such as air-borne infections, needle-stick injuries. Subjective risk evaluation and the notion of risk in health care from the patients' perspective has been widely considered over many years, and in a number of different areas, including medical research, screening procedures, consent to surgery or other medical intervention. In this paper, however, the moral dilemmas which may arise for health care professionals in relation to health risks are highlighted and specific questions are raised. This revised version was published online in July 2006 with corrections to the Cover Date.     

Effects of performance-based reimbursement on the professional autonomy and power of physicians and the quality of care.

The key question addressed in this study is whether performance-based reimbursement in health care affects the professional power and autonomy of physicians, and if so, whether this has any consequences for the quality of care. This cohort study examines the period 1994-98 in 11 Swedish county councils. Four hundred and eighteen physicians were studied in Stockholm County Council, which has a performance-based reimbursement system, and in ten councils without such a system. The results show that professional power and autonomy are considered to be very limited in all councils, and that they have decreased during the period studied. Professional autonomy is, however, more limited in Stockholm. The limitations in Stockholm are more related to financial considerations, whereas the limitations in the other councils are more due to guidelines and lists of recommended drugs. Professional autonomy and power were found to be important determinants for quality of care, and the physicians in Stockholm estimated the quality of care lower than their colleagues in the ten other councils. Thus, our study suggests that the performance-based reimbursement system might fail to reach the desired results due to its negative impact on professional power and autonomy.     

Lessons for health strategies in Europe: The evaluation of a national health strategy in England

Objectives: To determine the impact of the national health strategyfor England, ‘Health of the Nation’ (HOTN) at thelocal level; the mechanisms by which this was achieved; andto provide lessons for the new strategy, ‘Saving lives:our healthier nation’. Design: Case studies. Semi-structuredInterviews with key actors across a range of organisations (n=133),analysis of documents (n=189), and analysis of expenditure forthe period 1991/1992 – 1996/1997. Setting: Eight randomlyselected English health authorities. Main outcome measures:Perceptions and documentary evidence of the impact of HOTN onlocal policy and changes In expenditure. Results: Three modelsof implementation were Identified: strategies based directlyon HOTN; HOTN plus additional elements (‘HOTN plus’);and strategies under another label such as healthy cities orurban regeneration. There was clear commitment to Intersectoralwork and some support for joint appointments of directors ofpublic health by health and local authorities. HOTN was seenas failing to address underlying determinants of health, reducingcredibility with key partners. Views were divided on whetherto adopt a population- or disease-based model. Consistency incentral government policies and communication of the strategywere criticised. HOTN was universally perceived as increasinghealth promotion activities, particularly in the key areas.HOTN received few mentions in corporate contracts and generalpractice reports. Expenditure on health promotion activitiesIncreased slightly then declined, and HOTN appears to have hadonly limited influence on resource allocation. Conclusions:Central government, In England, should enable rather than prescribestrategy implementation. It should ensure appropriate structuresare in place and that national polices are consistent with thestrategy. There is a debate about where the responsibility forhealth strategy should lie, whether with the NHS or local authorities.The new strategy should address different audiences: local government;the NHS; the voluntary sector; the private sector; and the public.One model is the matrix approach of the European Commissionhealth promotion programme. HOTN failed to engage three groups:the public, primary care, and the private sector. This studyhas important implications for the monitoring of the new strategy.It needs to be firmly embedded in the work of those who mustimplement it. It should be incorporated into the NHS performancemanagement framework. The current financial reporting mechanismspreclude monitoring expenditure on a health strategy. Ring-fencingsome resources for the new strategy should be considered, ifonly to give it the high priority it requires. This study, bothin terms of the methods used to evaluate the strategy and thelessons learned, could be used by other European countries developingand evaluating their own health strategies.     

Women's autonomy and husbands' involvement in maternal health care in Nepal

Both increasing women's autonomy and increasing husbands' involvement in maternal health care are promising strategies to enhance maternal health care utilization. However, these two may be at odds with each other insofar as autonomous women may not seek their husband's involvement, and involved husbands may limit women's autonomy. This study assessed the relationship between women's autonomy and husbands' involvement in maternal health care. Field work for this study was carried out during September–November 2011 in the Kailali district of Nepal. In-depth interviews and focus group discussions were used to investigate the extent of husbands' involvement in maternal health care. A survey was carried out among 341 randomly selected women who delivered a live baby within one year prior to the survey. The results show that husbands were involved in giving advice, supporting to reduce the household work burden, and making financial and transportation arrangements for the delivery. After adjustment for other covariates, economic autonomy was associated with lower likelihood of discussion with husband during pregnancy, while domestic decision-making autonomy was associated with both lower likelihood of discussion with husband during pregnancy and the husband's presence at antenatal care (ANC) visits. Movement autonomy was associated with lower likelihood of the husband's presence at ANC visits. Intra-spousal communication was associated with higher likelihood of discussing health with the husband during pregnancy, birth preparedness, and the husbands' presence at the health facility delivery. The magnitude and direction of association varied per autonomy dimension. These findings suggest that programs to improve the women's autonomy and at the same time increase the husband's involvement should be carefully planned. Despite the traditional cultural beliefs that go against the involvement of husbands, Nepalese husbands are increasingly entering into the area of maternal health which was traditionally considered ‘women's business’.     

Building integrated health systems in central and eastern Europe: an analysis of WHO and World Bank views and their relevance to health systems in transition

BACKGROUND: Two questions are addressed. i) What are the views on health and health systems as expressed in the World Development Report 2000/2001 of the WB and the World Health Report 2000 and Health 21 of the World Health Organization, and how compatible are those views? ii) To what extent will compliance of CEEC and NIS with the WHO and WB recommendations result in health systems that produce maximum health for all by adequately addressing the needs of their populations? METHOD: The reports prepared by the World Bank and the World Health Organization were assessed against the theoretical framework of a needs-based public health approach. RESULTS: It is observed that the WHO and WB approaches are currently converging, although there remain differences in their respective focuses. The main merit of the WHO approach is its focus on performance and the systems approach towards health (care). The merit of the WB view is the integrated approach to health, education and poverty. It is argued that CEEC and NIS need to anticipate an ageing population and growing numbers of chronically ill. This calls for integrated health care systems and more integrated funding and payment systems. CONCLUSION: The recommendations provided in the WHR and the WDR with regard to integrated care and integrated financing remain rather abstract. Advisors of CEEC and NIS on health care reform and Western assistance projects should focus more on future needs, in order to avoid building health systems that consistently lag behind the needs of their populations.     

The politics of interprofessional working and the struggle for professional autonomy in nursing

This study of interprofessional work relations in a Canadian mental health team examines how nursing deployed different forms of power in order to alter the mental health division of labour, to gain administrative, organizational and content control over its own work, expand its jurisdictional boundaries by expropriating the work of other professionals, and exclude others from encroaching on its old and newly acquired jurisdictions. This is set against the context of nursing's long-standing professional project to consolidate and expand its professional jurisdiction. Using an ethnographic study of a single interprofessional mental health team in a psychiatric hospital in Canada, the paper attempts to understand the politics and paradoxes involved in realizing nursing's professional project and how the politics of professional autonomy and professional dominance are actually conducted through micro-political struggles. The data demonstrates the effects of the political struggles at the organizational and work process levels, particularly in the forms of collaboration that result. Nurses gained substantial autonomy from medical domination and secured practical dominion over the work of non-medical professionals. New forms of interprofessional collaboration were accomplished through both simultaneous and sequential micro-political struggles with psychiatrists and non-medical professionals, and the formation of political alliances and informal agreements. Nursing solidarity at the elite level and substantial effort by the elite nurses and their committed colleagues to mobilize their less enthused members were fundamental to their success. The nurses deployed political (power) strategies and tactics to organize and reorganize themselves and other professionals on multiple levels (politically, organizationally, ideologically, socially and culturally). This study reveals the complexity and robustness of micro-political dynamics in the constitution of professional and collaborative interprofessional work relations.     

Convergence versus social embeddedness: Debating the future direction of health care systems

The question of whether health care systems in developed countriesare coming to resemble each other more is attracting increasingattention. A number of recent papers have argued that the currentcrop of health reforms is creating convergence in health systemsstructure and organization. This paper suggests a 3-part frameworkwith which to analyse competing claims about convergence versuswhat can be termed social embeddedness (as reflected in divergencebetween different health systems). The available evidence onsocial, political/health policy and technical/mechanical categoriesis reviewed. The paper concludes that both convergence and divergencecan be seen in subsectors of developed countries' health systems.It might be useful to consider the convergence/divergence mixbetween countries in order to reflect better the current situationas well as to retain a broader range of options for nationalpolicy makers.     

Heatwaves and public health in Europe

Public health measures need to be implemented to prevent heat-related illness and mortality in the community and in institutions that care for elderly or vulnerable people. Heat health warning systems (HHWS) link public health actions to meteorological forecasts of dangerous weather. Such systems are being implemented in Europe in the absence of strong evidence of the effectiveness of specific measures in reducing heatwave mortality or morbidity. Passive dissemination of heat avoidance advice is likely to be ineffective given the current knowledge of high-risk groups. HHWS should be linked to the active identification and care of high-risk individuals. The systems require clear lines of responsibility for the multiple agencies involved (including the weather service, and the local health and social care agencies). Other health interventions are necessary in relation to improved housing, and the care of the elderly at home and vulnerable people in institutions. European countries need to learn from each other how to prepare for and effectively cope with heatwaves in the future. Including evaluation criteria in the design of heatwave early warning systems will help ensure effective and efficient system operation.     

Social reproduction of physical activity: Implications for health promotion in young people

Using a health promotion perspective, nationwide surveys onhealth behaviours and life-styles were carried out in 11 countriesin 1985–1986. The surveys were part of the study 'HealthBehaviour in School-aged Children (HBSC), a World Health Organizationcross-national survey'. The analyses of these survey data from13 and 15 year olds in Austria, Norway and Wales indicated thathigh levels of participation in physical activity by adolescentsare associated with the physical activity levels of their parentsand best friends, finding it easy to make new friends and likingschool. Intervention aimed at increasing the number of adolescentswho adopt and maintain participation in leisure-time physicalactivities is likely to be more successful if a greater numberof strategies in several different settings are applied. Thefindings are explained as being a result of the social reproductionprocess and it is suggested that awareness about how this processaffects the development of health behaviour and life-stylesis vital in establishing realistic goals when planning and evaluatingyouth health promotion efforts.     

Setting priorities for health in Europe: Are we speaking the same language?

Background: In response to its increasing responsibilities inpublic health, the European Commission is undertaking an exerciseto consult on priorities at a European level. The European PublicHealth Association has participated in this exercise. In thefirst stage of this process, national public health associationswere asked to identify a series of priorities, taking into accountspecified criteria relating to European added value. This paperdescribes the lessons learned from that process. Methods: Astandard questionnaire was developed and distributed by nationalsocieties to at least 30 public health professionals in eachof the European Union member states. The responses were broughttogether by national representatives and discussed at a meetingwhich led to the production of an agreed list of ten priorities.Results: The composition and organisation of the national societiesvaries considerably. Consequently the approaches taken in eachcountry varied widely. In general, the responses suggested thatthere was little debate at national level on the European dimensionto public health. Important concepts were frequently interpreteddifferently, reflecting how issues are seen in each country.Conclusions: With greater European integration, it will be increasinglyimportant for the public health community to be heard at a Europeanlevel. To do so, it must speak with a unified voice.     

A methodological note on combining health and social care expenditures into a single statistic for policy-making purposes

Current national expenditure series in the health sector focus predominantly on spending for medical services. However, as the percentage of elderly individuals grows, national policy makers will increasingly require an expenditure series which includes combined expenditure for social care as well as medical expenditures. In one country, Sweden, national policy makers have begun to relate policy decisions to a 12.0% (1996) figure for combined health and social care expenditures. Calculating such a combined figure presents a number of methodological issues, such as which social care services to include and how to reflect donated care from relatives and friends. An international comparison of this new health and social care figure would enable national decision makers to judge better the efficiency and effectiveness of current policy.     

A European risk model for hepatitis among health care workers

Hepatitis B (HBV) is the most important occupational hazardfacing workers in the hearth care and related environments.It is a serious, but underestimated, occupational hazard amongsuch personnel, who are at a 2 to 10 times greater risk of infectionthan the general population. In the light of recent changesin legislation concerning hepatitis B, we have designed a riskmodel for health care workers (HCW) in Western Europe to estimatethe number of cases of HBV infection in this group. An annualattack rate was derived, based on data from the literature andfrom hearth registers. The number of HCW exposed to HBV infectionwas calculated from official registers, taking into accountthe prevalence and incidence of HBV infection and vaccinationcoverage. Even with the present vaccination coverage of 40%among traditional HCW and 25% among allied HCW, we estimatethat 16,500 cases of HBV infection occur in these groups annually(i.e. over 40 per day). Approximately 5,800 workers will developacute symptoms and 990 will become carriers, of whom 240 willdie due to liver cirrhosis and/or primary hepatocellular cancer.If no further vaccinations are made, the number of infectionswill rise to approximately 24,000 each per year. An increasein vaccination coverage would greatly decrease these numbers.The amendments to the Biological Agents at Work EC Directive(EC90/679/EEC) were formally adopted on 12 October 1993. SinceApril 1994, a specific code of practice on vaccination shouldhave been in place in the national legislation of each memberstate. This represents an important step in achieving consensuson a preventive policy In Western Europe. It is equally importantthat the legislation obliges employers to identify and vacdnate(free of charge) those workers at risk of infection from hepatitisB.     

A four-step health promotion approach for changing dietary patterns in Europe

Nutrition policies to prevent nutrition-related diseases alreadyexist in many countries. Not many countries have been successfulin implementing their dietary recommendations, mainly becauseof the individual focus of nutrition education policies. Expertshave been telling people what foods are good for them but havefailed to build a supportive environment which would enablepeople to exercise a healthy choice. This article identifiesfour steps to a new approach for nutrition promotion. It isbased on the idea that a multi-disciplinary approach and promotionalactivities linked to existing social networks on an individuallevel close to daily life will be more effective than traditionalnutrition education. As an example in this field the SUPER-project,a community based five-country nutrition promotion project isdescribed. This project, based on the four steps described inthe article, is being carried out in five different experimentalsituations to produce a working model for this approach.     

Epidemic of health care reforms

An epidemic of health care reforms is spreading through the world. The basic reason behind the epidemic is the concept of these reforms. Namely, at the time in which Modernity (the main context of mechanicism) has worn out its potentials, they are based on the principles of mechanistic paradigm. Epidemic could fade away if health care reformers would abandon their role of engeneers and turn to catalist role. In that role they could work on reforms which would rely on priciples of evolution. The first result of this reform orientation would be creation of the germ of pluralistic health care systems.