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.     

Practice variation in the Dutch long‐term care and the role of supply‐sensitive care: Is access to the Dutch long‐term care equitable?

Universal access and generous coverage are important goals of the Dutch long‐term care (LTC) system. It is a legal requirement that everyone eligible for LTC should be able to receive it. Institutional care (IC) made up for 90% of Dutch LTC spending. To investigate whether access to IC is as equitable as the Dutch government aspires, we explored practice variation in entitlements to IC across Dutch regions. We used a unique dataset that included all individual applications for Dutch LTC in January 2010–December 2013 (N = 3,373,358). This dataset enabled an accurate identification of the need for care. We examined the local variation in the probability of being granted long‐term IC and in the intensity of the care granted given that individuals have applied for LTC. We also investigated whether the variation observed was related to differences in the local availability of care facilities. Although our analyses indicated the presence of some practice variation, its magnitude was very small by national and international standards (up to 3%). Only a minor part of the practice variation could be accounted for by local supply differences in care facilities. Overall, we conclude that, unlike many other developed countries, the Dutch system ensured equitable access to long‐term IC.     

Have out‐of‐pocket health care payments risen under free health care policy? The case of Sri Lanka

Compared to its neighbors, Sri Lanka performs well in terms of health. Health care is provided for free in the public sector, yet households' out‐of‐pocket health expenditures are steadily increasing. We explore whether this increase can be explained by supply shortages and insufficient public health care financing or whether it is rather the result of an income‐induced demand for supplementary and higher quality services from the private sector. We focus on total health care expenditures and health care expenditures for specific services such as expenses on private outpatient treatments and expenses on laboratory and other diagnostic services. Overall, we find little indication that limited supply of public health care per se pushes patients into the private sector. Yet income is identified as one key driver of rising health care expenditures, ie, as households get richer, they spend an increasing amount on private services suggesting a dissatisfaction with the quality offered by the public sector. Hence, quality improvements in the public sector seem to be necessary to ensure sustainability of the public health care sector. If the rich and the middle class increasingly opt out of public health care, the willingness to pay taxes to finance the free health care policy will certainly shrink.     

Income‐rich and wealth‐poor? The impact of measures of socio‐economic status in the analysis of the distribution of long‐term care use among older people

This article aims to investigate the impact of using 2 measures of socio‐economic status on the analysis of how informal care and home care use are distributed among older people living in the community. Using data from the Survey of Health, Ageing and Retirement in Europe for 14 European countries, we estimate differences in corrected concentration indices for use of informal care and home care, using equivalised household net income and equivalised net worth (as a proxy for wealth). We also calculate horizontal inequity indices using both measures of socio‐economic status and accounting for differences in need. The findings show that using wealth as a ranking variable results, as a rule, in a less pro‐poor inequality of use for both informal and home care. Once differences in need are controlled for (horizontal inequity), wealth still results in a less pro‐poor distribution for informal care, in comparison with income, whereas the opposite is observed for home care. Possible explanations for these differences and research and policy implications are discussed.     

How do hospital‐specialty characteristics influence health system responsiveness? An empirical evaluation of in‐patient care in the Italian region of Emilia‐Romagna

Studies of health system responsiveness mostly focus on the demand side by investigating the association between sociodemographic characteristics of patients and their reported level of responsiveness. However, little is known about the influence of supply‐side factors. This paper addresses that research gap by analysing the role of hospital‐specialty characteristics in explaining variations in patients' evaluation of responsiveness from a sample of about 38,700 in‐patients treated in public hospitals within the Italian Region of Emilia‐Romagna. The analysis is carried out by adopting a 2‐step procedure. First, we use patients' self‐reported data to derive 5 measures of responsiveness at the hospital‐specialty level. By estimating a generalised ordered probit model, we are able to correct for variations in individual reporting behaviour due to the health status of patients and their experience of being in pain. Second, we run cross‐sectional regressions to investigate the association between patients' responsiveness and potential supply‐side drivers, including waiting times, staff workload, the level of spending on non‐clinical facilities, the level of spending on staff education and training, and the proportion of staff expenditure between nursing and administrative staff. Results suggest that responsiveness is to some extent influenced by the supply‐side drivers considered.     

Home care or long‐term care? Setting the balance of care in urban and rural Northwestern Ontario,Canada

The objective of the study was to determine the extent to which community care packages could be provided at a lower cost than facility-based long-term care (LTC) for 864 individuals on the LTC waiting list in urban and rural parts of Northwestern Ontario, Canada. A sequential mixed methods design was used entailing a retrospective chart review, the formation of case vignettes, the creation of community care packages with an 'expert panel' of care managers, the costing of care packages and the calculation of potential diversion rates from LTC. Data collection took place in Northwestern Ontario between the months of March and June 2008. Eight per cent of individuals in the urban area and 50% of individuals from the rural areas could potentially be safely diverted to the community and provided with a community care package at a cost lower than facility-based LTC. There is potential for home and community care to substitute for more costly long-term care, but doing so requires building capacity in this sector, particularly in rural areas, which are currently underserviced. Reconfiguring the 'balance of care' may lead to long-term cost efficiencies for an ageing population.     

Is inequity undermining Australia's ‘universal’ health care system? Socio‐economic inequalities in the use of specialist medical and non‐medical ambulatory health care

Objectives: To quantify need-adjusted socio-economic inequalities in medical and non-medical ambulatory health care in Australia and to examine the effects of specific interventions, namely concession cards and private health insurance (PHI), on equity.
Methods: We used data from a 2004 survey of 10,905 Australian women aged 53 to 58 years. We modelled the association between socio-economic status and health service use — GPs, specialists, hospital doctors, allied and alternative health practitioners, and dentists — adjusting for health status and other confounding variables. We quantified inequalities using the relative index of inequality (RII) using Poisson regression. The contribution of concession cards and PHI in promoting equity/inequity was examined using mediating models.
Results: There was equality in the use of GP services, but socio-economically advantaged women were more likely than disadvantaged women to use specialist (RII=1.41, 95% CI:1.26–1.58), allied health (RII=1.21,1.12–1.30), alternative health (RII=1.29,1.13–1.47) and dental services (RII=1.61,1.48–1.75) after adjusting for need, and they were less likely to visit hospital doctors (RII=0.74,0.57–0.96). Concession cards reduced socio-economic inequality in GP but not specialist care. Inequality in dental and allied health services was partly explained by inequalities in PHI.
Conclusions and implications: Substantial socio-economic inequity exists in use of specialist and non-medical ambulatory care in Australia. This is likely to exacerbate existing health inequalities, but is potentially amenable to change.     

How does cost matter in health‐care discrete‐choice experiments?

Willingness‐to‐pay (WTP) estimates derived from discrete‐choice experiments (DCEs) generally assume that the marginal utility of income is constant. This assumption is consistent with theoretical expectations when costs are a small fraction of total income. We analyze the results of five DCEs that allow direct tests of this assumption. Tests indicate that marginal utility often violates theoretical expectations. We suggest that this result is an artifact of a cognitive heuristic that recodes cost levels from a numerical scale to qualitative categories. Instead of evaluating nominal costs in the context of a budget constraint, subjects may recode costs into categories such as ‘low’, ‘medium’, and ‘high’ and choose as if the differences between categories were equal. This simplifies the choice task, but undermines the validity of WTP estimates as welfare measures. Recoding may be a common heuristic in health‐care applications when insurance coverage distorts subjects' perception of the nominal costs presented in the DCE instrument. Recoding may also distort estimates of marginal rates of substitution for other attributes with numeric levels. Incorporating ‘cheap talk’ or graphic representation of attribute levels may encourage subjects to be more attentive to absolute attribute levels. Copyright © 2010 John Wiley & Sons, Ltd.     

Exploring variations in health‐care expenditures—What is the role of practice styles?

Variations in medical resource usage, both across and within geographical regions, have been widely documented. In this paper, we explore physician practice styles as a possible determinant of these variations. In particular, we exploit patient mobility between physicians to identify practice styles among general practitioners (GPs) in Austria. We use a large administrative data set containing detailed information on a battery of different health‐care services and implement a model with additive patient and GP fixed effects that allows flexibly for systematic differences in patients' health states. We find that, although GPs explain only a small part of the overall variation in medical expenses, heterogeneities in spending patterns among GPs are substantial. Conditional on patient characteristics, we document a difference of € 751.47 per patient per year in total medical expenses (which amounts to roughly 45% of the sample mean) between high‐ and low‐spending GPs.     

Hospice or home? Expectations of end‐of‐life care among white and Chinese older people in the UK

This paper presents findings from two linked studies of white (n = 77) and Chinese (n = 92) older adults living in the UK, which sought their views about end-of-life care. We focus particularly on experiences and expectations in relation to the provision of end-of-life care at home and in hospices. White elders perceived hospices in idealised terms which resonate with a 'revivalist' discourse of the 'good death'. In marked comparison, for those Chinese elders who had heard of them, hospices were regarded as repositories of 'inauspicious' care in which opportunities for achieving an appropriate or good death were limited. They instead expressed preference for the medicalised environment of the hospital. Among both groups these different preferences for instututional death seemed to be related to shared concerns about the demands on the family that may flow from having to manage pain, suffering and the dying body within the domestic space. These concerns, which appeared to be based on largely practical considerations among the white elders, were expressed by Chinese elders as beliefs about 'contamination' of the domestic home (and, by implication, of the family) by the dying and dead body.     

Can managers empower nurse‐midwives to improve maternal health care? A comparison of two resource‐poor hospitals in Tanzania

Maternal mortality is very high in Tanzania. Competent hospital care is key to improving maternal outcomes, but there is a crisis of availability and performance of health workers in maternal care. This article uses interviews with managers, nurse‐midwives, and women who had given birth in two hospitals providing virtually all the emergency maternal care in one Tanzania city. It contrasts women's experience in the two hospitals, and analyses interconnections with nurse‐midwives' and managers' experiences of working conditions. The conceptual literature on nurse empowerment identifies some key explanatory variables for these contrasts. Staff experienced less frustration and constraint in one of the hospitals; had more access to structurally empowering resources; and experienced greater congruence between job commitment and working culture, resulting in better work engagement. Conversely, nurse‐midwives in the other hospital were constrained by supply shortages and recurrent lack of support. Contrasting management styles and their impacts demonstrate that even in severely resource‐constrained environments, there is room for management to empower staff to improve maternal care. Empowering management practices include participatory management, supportive supervision, better incentives, and clear leadership concerning ward culture. Structural constraints beyond the capacity of health facility managers must however also be addressed. © 2015 The Authors. International Journal of Health Planning and Management published by John Wiley & Sons, Ltd.     

‘If they’re helping me then how can I be independent?’ The perceptions and experience of users of home‐care re‐ablement services

Home‐care re‐ablement is a short‐term, intensive service that helps people to (re‐) establish their capacity and confidence in performing basic personal care and domestic tasks at home, thereby reducing needs for longer term help. Home‐care re‐ablement is an increasingly common feature of English adult social care services; there are similar service developments in Australia and New Zealand. This paper presents evidence from semi‐structured interviews conducted in early 2010 with 34 service users and 10 carers from five established re‐ablement services in England. The interviews formed part of a larger, mixed‐methods study into the immediate and longer term impacts and cost‐effectiveness of home‐care re‐ablement services. There was clear evidence that interviewees felt that they had benefitted from re‐ablement services; most service users and their families valued the intervention. However, the interviews also identified potential barriers to optimal independence for some service users, particularly those with progressive conditions, sensory impairments, specific cultural needs, or who lived alone. The beneficial impacts of re‐ablement could also be reduced if users failed to understand the aims of the service, or if the service failed to provide support with activities or outcomes that were particularly important to the service user or carer. Putting the lived experiences of people receiving re‐ablement at the centre of analysis, this paper concludes that re‐ablement services have the potential for enhanced effectiveness, particularly if there is more understanding of users’ own priorities and concepts of independence.     

Organisation and delivery of home care re‐ablement: what makes a difference?

Home-care re-ablement or 'restorative' services are a cornerstone of preventive service initiatives in many countries. Many English local authorities are transforming their former in-house home-care services to provide intensive, short-term re-ablement instead. The focus of this paper is on the organisation and content of re-ablement services and the features of their organisation and delivery that have the potential to enhance or detract from their effectiveness. Qualitative data were collected from five sites with well-established re-ablement services. Data included semi-structured interviews with senior service managers in each site; observation of 26 re-ablement visits to service users across the five sites (four to six in each site) and a focus group discussion with front-line staff in each site (in total involving 37 front-line staff). The data generated from all three sources were analysed using the framework approach. All five services had developed from selective pilot projects to inclusive 'intake' service, accepting almost all referrals for home-care services. A number of features were identified as contributing to the effectiveness of re-ablement services. These included: service user characteristics and expectations; staff commitment, attitudes and skills; flexibility and prompt intervention; thorough and consistent recording systems; and rapid access to equipment and specialist skills in the team. Factors external to the re-ablement services themselves also had implications for their effectiveness; these included: a clear, widely understood vision of the service; access to a wide range of specialist skills; and capacity within long-term home-care services. The paper argues that re-ablement can be empowering for all service users in terms of raising their confidence. However, the move to a more inclusive 'intake' service suggests that outcomes are likely to be considerably lower for service users who have more limited potential to be independent. The paper discusses the implications for practice.     

What has influenced patient health‐care expenditures in Japan?: variables of age,death, length of stay,and medical care

This study considers variables related to health-care expenditures associated with aging and long-term hospitalization in Japan. We focused on daily per capita inpatient health-care expenditures, and examined the impact of inpatient characteristics such as sex, age, survived or deceased, length of stay, adult disease, and type of medical care received during the duration of each stay. We analyzed data from the Survey of Medical-Care Activities in Public Health Insurance by multinomial logistic regression analyses. Age of patient had little impact on per capita inpatient health-care expenditures per day. As regards length of stay, inpatient stays of 8-14 days had a little impact on health-care expenditures. This study suggested that these results might be due to the kind of medical care received. More research is needed to determine the appropriate medical services to reduce long-term hospitalization. In the last month of care for patients who died, medical examinations had a great influence on health-care expenditures. This study showed that increasing medical examinations in the end-of-life care needs further investigation.