Primary health and social care services in the UK: progress towards partnership?

There has been a shift in the theoretical debates around the ways in which organisations deliver the state's objectives of providing health and social care services for its citizens, focusing on issues of welfare governance and the encouragement of partnership working between organisations. This article develops these theories by focusing on developments in primary health and social care policy in the UK, which have undergone a radical change recently. Responsibility for commissioning health care services now falls to primary care groups and trusts (PCG/Ts), run by general practitioners, other primary care practitioners, managers and lay members, and there is some pressure on primary care groups and primary care trusts to engage in partnership working with social services, for example, to cut hospital waiting lists or provide intermediate care services. One policy option is for these organisations to form Care Trusts, integrating the commissioning of health and social care for older people and ending the historical organisational divisions between health and social care in the UK. This paper examines evidence from the first stage of a 3-year longitudinal quantitative and qualitative study of the development of partnership working between PCG/Ts and social services departments in England. It examines whether the evidence suggests that the integration of health and social care is feasible or desirable in older people's services.     

Do health insurers possess monopsony power in the hospital services industry?

This paper uses metropolitan data to test empirically if health insurers possess monopsony or monopoly-busting power on the buyer-side of the hospital services market. According to theory, monopsony power is indicated by a fall in output, whereas, monopoly-busting power is shown by an increase in output when buyer concentration rises. The empirical results provide evidence that greater health insurer buyer concentration is not associated with monopsony power. Instead, some evidence is found to suggest that higher health insurer concentration translates into increased monopoly-busting power. That is, metropolitan hospitals offer increased services when the buyer-side of the hospitals services market is more highly concentrated.     

What determines the size of occupational health services in UK universities?

BACKGROUND: There is wide, largely unexplained, variation in occupational health (OH) provision between UK employers. AIM: To explain the variation in OH provision across the UK university sector. METHODS: Analyses of data from a survey of university OH services and from the Higher Education Statistics Agency. The outcome variable was clinical (doctor + nurse) staffing of the university's OH service. The explanatory variables examined were university size, income, research activity score and presence or absence of academic disciplines categorized by an expert panel as requiring a high level of OH provision. RESULTS: All 117 UK universities were included and 93 (79%) responded; with exclusions and incomplete data, between 80 and 89 were included in analyses. There was wide variation in clinical OH staffing (range 0-8.4 full-time equivalents). Number of university staff explained 34% of the variation in OH staffing. After adjusting for other factors, neither the research activity nor the presence of high-needs disciplines appeared to be factors currently used by employers to determine their investment in OH. CONCLUSIONS: Government or other guidelines for university employers should take organizational size into account. Employers may need guidance on how to provide OH services proportionate to specific occupational hazards or other OH needs.     

A new mode of organizing in health care? Governmentality and managed networks in cancer services in England

We explore the argument that a new mode of health care organizing is emerging which moves beyond the established professional dominance versus New Public Management (NPM) debate. We review Foucault's work on 'governmentality', as applied to health care organizations. We specify two specific Foucauldian themes (the power/knowledge nexus in Evidence Based Medicine (EBM); and the technologies of the clinical managerial self) to analyse organizing in the English cancer services field. We introduce two qualitative case studies of Managed Cancer Networks. We suggest their governance can be fruitfully seen through a 'governmentality' lens. We consider implications for developing Foucauldian analysis of health care organizations.     

Are HIV/AIDS services in Leeds, UK, able to meet the needs of asylum seekers?

BACKGROUND: The Yorkshire and Humberside region of England ranks second only to London for reception of those seeking asylum in the UK. Human immunodeficiency virus (HIV) prevalence amongst asylum seekers is likely to mirror that in the country of origin. In 2001, the city of Leeds received 1100 asylum seekers, including dependents. Many of these were from areas with high seroprevalence of HIV, and HIV-infected asylum seekers require medical and social support. Are the current services for HIV-infected persons in Leeds appropriate and adequate for this new patient group? Provision of sexual health services for this client group needs to be evaluated. OBJECTIVES: To determine whether existing HIV/acquired immunodeficiency syndrome (AIDS) services in Leeds meet the needs of HIV-positive asylum seekers. METHODS: This was a qualitative study using semi-structured interviews. Seven service providers and 14 HIV-positive patients at Leeds Centre for Sexual Health, six of whom were asylum seekers, took part in the study. RESULTS: Asylum seekers and UK residents were equally satisfied with HIV/AIDS services at Leeds Centre for Sexual Health. Other agencies such as the Health Access Team and Terrence Higgins Trust had different strengths that provided valuable support for this client group. Unmet needs of asylum seekers were identified, such as specialist services for torture victims and educational opportunities. In areas of asylum seeker dispersal with increased case loads, this methodology may inform development of client-centred care networks.     

How health policy shapes healthcare sector productivity? Evidence from Italy and UK

The English (NHS) and the Italian (SSN) healthcare systems share many similar features: basic founding principles, financing, organization, management, and size. Yet the two systems have faced diverging policy objectives since 2000, which may have affected differently healthcare sector productivity in the two countries. In order to understand how different healthcare policies shape the productivity of the systems, we assess, using the same methodology, the productivity growth of the English and Italian healthcare systems over the period from 2004 to 2011. Productivity growth is measured as the rate of change in outputs over the rate of change in inputs. We find that the overall NHS productivity growth index increased by 10% over the whole period, at an average of 1.39% per year, while SSN productivity increased overall by 5%, at an average of 0.73% per year. Our results suggest that different policy objectives are reflected in differential growth rates for the two countries. In England, the NHS focused on increasing activity, reducing waiting times and improving quality. Italy focused more on cost containment and rationalized provision, in the hope that this would reduce unjustified and inappropriate provision of services.     

Can contracted out health facilities improve access,equity, and quality of maternal and newborn health services? Evidence from Pakistan

Background

The case of contracting out government health services to non-governmental organizations (NGOs) has been weak for maternal, newborn, and child health (MNCH) services, with documented gains being mainly in curative services. We present an in-depth assessment of the comparative advantages of contracting out on MNCH access, quality, and equity, using a case study from Pakistan.

Methods

An end-line, cross-sectional assessment was conducted of government facilities contracted out to a large national NGO and government-managed centres serving as controls, in two remote rural districts of Pakistan. Contracting out was specific for augmenting MNCH services but without contractual performance incentives. A household survey, a health facility survey, and focus group discussions with client and spouses were used for assessment.

Results

Contracted out facilities had a significantly higher utilization as compared to control facilities for antenatal care, delivery, postnatal care, emergency obstetric care, and neonatal illness. Contracted facilities had comparatively better quality of MNCH services but not in all aspects. Better household practices were also seen in the district where contracting involved administrative control over outreach programs. Contracting was also faced with certain drawbacks. Facility utilization was inequitably higher amongst more educated and affluent clients. Contracted out catchments had higher out-of-pocket expenses on MNCH services, driven by steeper transport costs and user charges for additional diagnostics. Contracting out did not influence higher MNCH service coverage rates across the catchment. Physical distances, inadequate transport, and low demand for facility-based care in non-emergency settings were key client-reported barriers.

Conclusion

Contracting out MNCH services at government health facilities can improve facility utilization and bring some improvement in  quality of services. However, contracting out of health facilities is insufficient to increase service access across the catchment in remote rural contexts and requires accompanying measures for demand enhancement, transportation access, and targeting of the more disadvantaged clientele.

     

Can contracted out health facilities improve access,equity, and quality of maternal and newborn health services? Evidence from Pakistan

Background

The case of contracting out government health services to non-governmental organizations (NGOs) has been weak for maternal, newborn, and child health (MNCH) services, with documented gains being mainly in curative services. We present an in-depth assessment of the comparative advantages of contracting out on MNCH access, quality, and equity, using a case study from Pakistan.

Methods

An end-line, cross-sectional assessment was conducted of government facilities contracted out to a large national NGO and government-managed centres serving as controls, in two remote rural districts of Pakistan. Contracting out was specific for augmenting MNCH services but without contractual performance incentives. A household survey, a health facility survey, and focus group discussions with client and spouses were used for assessment.

Results

Contracted out facilities had a significantly higher utilization as compared to control facilities for antenatal care, delivery, postnatal care, emergency obstetric care, and neonatal illness. Contracted facilities had comparatively better quality of MNCH services but not in all aspects. Better household practices were also seen in the district where contracting involved administrative control over outreach programs. Contracting was also faced with certain drawbacks. Facility utilization was inequitably higher amongst more educated and affluent clients. Contracted out catchments had higher out-of-pocket expenses on MNCH services, driven by steeper transport costs and user charges for additional diagnostics. Contracting out did not influence higher MNCH service coverage rates across the catchment. Physical distances, inadequate transport, and low demand for facility-based care in non-emergency settings were key client-reported barriers.

Conclusion

Contracting out MNCH services at government health facilities can improve facility utilization and bring some improvement in  quality of services. However, contracting out of health facilities is insufficient to increase service access across the catchment in remote rural contexts and requires accompanying measures for demand enhancement, transportation access, and targeting of the more disadvantaged clientele.

     

Does deregulation in community pharmacy impact accessibility of medicines,quality of pharmacy services and costs? Evidence from nine European countries

Objective

To analyse the impact of deregulation in community pharmacy on accessibility of medicines, quality of pharmacy services and costs.

Methods

We analysed and compared community pharmacy systems in five rather deregulated countries (England, Ireland, the Netherlands, Norway, Sweden) and four rather regulated countries (Austria, Denmark, Finland, Spain). Data were collected by literature review, a questionnaire survey and interviews.

Results

Following a deregulation, several new pharmacies and dispensaries of Over-the-Counter (OTC) medicines tended to be established, predominantly in urban areas. Unless prevented by regulation, specific stakeholders, e.g. wholesalers, were seen to gain market dominance which limited envisaged competition. There were indications for an increased workload for pharmacists in some deregulated countries. Economic pressure to increase the pharmacy turnover through the sale of OTC medicines and non-pharmaceuticals was observed in deregulated and regulated countries. Prices of OTC medicines were not found to decrease after a deregulation in pharmacy.

Conclusions

Access to pharmacies usually increases after a deregulation but this is likely to favour urban populations with already good accessibility. Policy-makers are recommended to take action to ensure equitable accessibility and sustainable competition in a more deregulated environment. No association between pharmaceutical expenditure and the extent of regulation/deregulation appears to exist.     

Self-treatment and its discussion in medical consultations: how is medical pluralism managed in practice?

Recent policy changes in the UK such as deregulation of prescribed medicines and the introduction of telephone helpline services are intended to promote self-treatment. Drawing on interviews with, and consultations between, 35 patients and 20 general practitioners, we use Kleinman's (Patients and Healers in the context of culture: an exploration of the Borderland between Anthropology, Medicine and Psychiatry, University of California Press Ltd., London) model of the three sectors of health care in order to examine the range of self-treatments people use and the discussion of these treatments in medical consultations. We argue that despite the availability of a range of treatment options and policy changes advocating greater use of self-treatment, patients are inhibited from disclosing prior self-treatment, and disclosure is affected by patients' perceptions of the legitimacy of self-treatment. The findings are in keeping with Cant and Sharma's (A New Medical Pluralism, Alternative Medicines, Doctors, Patients and the State, UCL Press, London) contention that although there has been a pluralisation of "legitimate" providers of health care and a restructuring of expertise, biomedicine itself remains dominant.     

Is the medical brain drain beneficial? Evidence from overseas doctors in the UK

The 'beneficial brain drain' hypothesis suggests that skilled migration can be good for a sending country because the incentives it creates for obtaining training increase that country's net supply of skilled labour. Necessary conditions for this hypothesis to work are that the possibility of migration significantly affects decisions to take medical training and that migrants are not strongly screened by the host country. We conducted a survey among overseas doctors in the UK in 2002, which suggested that neither condition is likely to be fulfilled. Apart from the 'beneficial brain drain' argument, the survey findings also cast light on the backgrounds and motives of migrant doctors, and finds evidence that there could, nonetheless, be other benefits to sending countries via routes like remittances and return migration.     

"Knights" or "knaves"? Public policy, professional power, and reforming maternity services

Recent quality and safety discourse stresses locating "human errors and mistakes" within an institutional framework. I go further to contend that, in spite of well-meaning individual practitioners, aspects of a powerful, self-interested obstetric professional culture pose a major barrier to quality childbirth care. Using my analysis, I contrast the profession's "knightly" self-image with critical scholarship, and it examine evidence given to public inquiries into obstetric misdemeanors and mistakes in Australia, England, and Ireland. Policy incentives to reform maternity care need to go beyond technical auditing measures to foster collaboration, social as well as institutional accountability, and critical self-reflection within the obstetric profession.     

AIDS services in Florida: who's doing what, and who's paying for it?

The rapid growth of AIDS in the 1980s was paralleled by a rapid growth in AIDS Service Organizations (ASOs) throughout the United States. This article examines one state, Florida, and the 52 ASOs to determine each ASOs organizational affiliation, major types of service offered, sources of funding, and geographic dispersion in the state. Based on the results of this examination, several research and policy implications are discussed.     

More aspiration than achievement? Children's complaints and advocacy in health services in Wales

The present paper reports on key results from a government-funded survey of all National Health Service trusts, local health boards and community health councils in Wales, which was conducted in 2004-2005 to identify the characteristics of complaints involving children, and the use of professional advocacy services in these complaints and their role in supporting children in relation to health service matters more generally. Findings from the survey are presented which reveal the marginal take-up of professional advocacy services in health complaints, and the slender resource in professional advocacy for children commissioned by a small number of health bodies. Advocacy support for users of health services typically focuses upon adult-related issues. The needs of children, particularly those who may have special requirements because of disability, being looked after, or having language or cultural needs are not well met according to the present survey. This raises the question of whether recent policy and guidance on advocacy (particularly for children and vulnerable groups) is seen by health bodies as warranting decisive action and dedicated investment, or whether rhetoric and modest change is the more likely outcome in the face of other pressing demands on health budgets.     

The UK Quality and Outcomes Framework pay-for-performance scheme and spirometry: rewarding quality or just quantity? A cross-sectional study in Rotherham, UK

Background  

Accurate spirometry is important in the management of COPD. The UK Quality and Outcomes Framework pay-for-performance scheme for general practitioners includes spirometry related indicators within its COPD domain. It is not known whether high achievement against QOF spirometry indicators is associated with spirometry to BTS standards.