The use of the FHSA (family health services authority) registration index for a health needs survey.

The FHSA patient registration index was used as a sampling frame for a population questionnaire survey. The main survey of 3,359 was preceded by a pilot study of 250. Ethical issues such as anonymity and release of data were addressed in order to obtain the approval of the ethical committee and LMC. The acceptability to GPs and the public of using FHSA Registration data was tested. The validity of the survey was indicated by the proportion of wrong addresses, the response rate and the representativeness of the sample and responders. Appropriate software is needed for selecting a random sample and producing address labels.     

The quality of community nursing services: report of an exploratory study in a UK health authority

Describes a study of three community nursing services provided by North Staffordshire Health Authority, which was carried out during the summer of 1991. Both the type and focus of quality measurement reported here are fairly unique. While the development of quality measures is yet at an early stage, most measures to date are quantitative. These can inform about volume of use of a service, but not its quality. The measures designed for this study were qualitative. These, when combined with quantitative data (statistics, routinely collected), yield much richer and more complete information as a basis for decision making in service planning. Quality data on the use of community services are also under-represented in the quality literature--most studies to date have used hospital patient services as their source for data collection. Goes some way towards redressing the imbalance.     

Access to complementary medicine in general practice: survey in one UK health authority.

Complementary therapy (CT) has become increasingly popular with the general public and interest from the health professions has been rising. There has been no study focusing on the pattern of availability of CT within urban and inner-city general practice. We aimed to describe the prevalence and pattern of access to complementary therapy in this setting, identifying the characteristics of practices offering CT and the perceived barriers to service provision. We sent a postal questionnaire to all 254 general practices on the Birmingham Family Health Services Authority list. Practices were asked whether they offered any access to CTs, how services were organized and which therapies were available and to identify any barriers to provision. 175 practices (68.9%) responded. Half of the practices offered access to CT. Of these, half offered an in-house service, usually provided by the doctor (81.8%). Of GPs practising therapies themselves, 58% began in or after 1990. Seventeen separate therapies were offered, most commonly acupuncture, osteopathy, chiropractic, hypnotherapy and homoeopathy. Practices significantly more likely to offer access to CT were of larger list size and training or teaching practices. They were equally likely to be fundholders or non-fundholders. Practices offering an in-house service tended to be fundholding, training and of larger list size. Finance was perceived as the major barrier. In the area studied, many patients now have some access to CT within primary care, often within their own practice. In the main, therapies offered are the 'medically acceptable face' of complementary medicine.     

Enhancing social networks: a qualitative study of health and social care practice in UK mental health services

People with severe mental health problems such as psychosis have access to less social capital, defined as resources within social networks, than members of the general population. However, a lack of theoretically and empirically informed models hampers the development of social interventions which seek to enhance an individual's social networks. This paper reports the findings of a qualitative study, which used ethnographic field methods in six sites in England to investigate how workers helped people recovering from psychosis to enhance their social networks. This study drew upon practice wisdom and lived experience to provide data for intervention modelling. Data were collected from 73 practitioners and 51 people who used their services in two phases. Data were selected and coded using a grounded theory approach to depict the key themes that appeared to underpin the generation of social capital within networks. Findings are presented in four over‐arching themes – worker skills, attitudes and roles; connecting people processes; role of the agency; and barriers to network development. The sub‐themes which were identified included worker attitudes; person‐centred approach; equality of worker–individual relationship; goal setting; creating new networks and relationships; engagement through activities; practical support; existing relationships; the individual taking responsibility; identifying and overcoming barriers; and moving on. Themes were consistent with recovery models used within mental health services and will provide the basis for the development of an intervention model to enhance individuals’ access to social capital within networks.     

Males' use of public health department family planning services.

Information was obtained from over 200 males visiting a family planning service either to obtain free-of-charge condoms or incidental to accompanying their female partner. The former group was younger and more likely to reside near the health department: over 40 percent of this group used the health department as sole condom source. Both groups indicated willingness to share in costs for male services. Future programs need to more effectively plan public health family planning for these males.     

Variations in practice nursing: implications for family health services authorities

Differences between Family Health Services Authorities (FHSAs) in practice nurse activities are described and interpreted, using the results of postal questionnaires to all practice nurses in England and Wales in late 1992. There were an estimated 15000 practice nurses of whom 12589 (85%) returned a completed questionnaire, which asked about 30 tasks, including domiciliary visits, carried out by practice nurses; employment conditions, professional qualifications, experience, and clinical grading; and practice characteristics. The proportion of nurses undertaking four out of five tasks varied by a factor of two or more across FHSAs. Just over a third (39%) of the variation in nurses' activities could be explained by professional and practice characteristics. The analysis distinguished between FHSAs where nurses were more likely to engage in tasks requiring diagnostic and clinical skills, including assisting with minor surgery, and FHSAs where nurses were more likely to conduct domiciliary visits, help with chronic disease management, and provide advice on welfare benefits, incontinence and health promotion. The former FHSAs were characterized by larger practices with four or more partners employing several nurses, training practices, and practices with a manager. The latter group was characterized by smaller inner city or urban practices, including single-handed partnerships, and practices often employing one nurse. The 1990 general practitioner (GP) contract boosted nurses' involvement in those activities attracting new payments but its impact on their roles and responsibilities was mediated by their professional skills and experience and the type of practice where they worked. The contribution of practice nursing to the delivery of primary and community health care varies considerably. Further research is required to find out whether role diversity reflects uncertainty about the appropriate use of their skills. FHSAs need to develop a variety of strategies to support and promote practice nursing.     

The driver's license list as a population-based sampling frame in Iowa.

Driver's license lists are infrequently used for population-based sampling, presumably because of suspicions of poor population coverage. The 1990 Iowa driver's license list was compared with the 1990 census to evaluate coverage by 5-year age group, sex, resident county, and urbanicity. Coverage exceeded 90% among 15- to 74-year-old men and 15- to 64-year-old women, with uniform coverage by county and county urbanicity group in these age ranges. In Iowa, these lists are convenient and cost-effective and appear to be representative for 25- to 64-year-olds. The representativeness of driver lists in regard to other factors and in other geographic regions deserves further evaluation.     

Equity of access to health care services: theory and evidence from the UK

The pursuit of equity of access to health care is a central objective of many health care systems. This paper first sets out a general theoretical framework within which equity of access can be examined. It then applies the framework by examining the extent to which research evidence has been able to detect systematic inequities of access in UK, where equity of access has been a central focus in the National Health Service since its inception in 1948. Inequity between socio-economic groups is used as an illustrative example, and the extent of inequity of access experienced is explored in each of five service areas: general practitioner consultations; acute hospital care; mental health services; preventative medicine and health promotion; and long-term health care. The paper concludes that there appear to be important inequities in access to some types of health care in the UK, but that the evidence is often methodologically inadequate, making it difficult to draw firm conclusions. In particular, it is difficult to establish the causes of inequities which in turn limits the scope for recommending appropriate policy to reduce inequities of access. The theoretical framework and the lessons learned from the UK are of direct relevance to researchers from other countries seeking to examine equity of access in a wide variety of institutional settings.     

A partial solution: a local mental health authority for the UK

BACKGROUND: the structural problems of the mental health system in the UK have been analyzed by a number of authors over the past several years as the "reforms" of the health and social service systems have continued (Kavanagh and Knapp, 1995; Mechanic, 1995). In a recent article, Hadley and Goldman (1995) suggest that one possible solution to some of these issues may be the creation of a local mental health authority. Such an authority would consolidate the funding, authority and responsibility in a single entity. We believe this model, which is typical of many local public mental health systems in the US, is at least part of the solution to the current problem of financial and service fragmentation of the current system in the UK. The numerous "reforms" of the health and social service systems (which include the Community Care Act, the development of the Internal Market, GP fundholding and the purchaser-provider split) were not designed for the care of the mentally ill (Han, 1996). These policy changes in the design of health and social services have created a complicated and difficult context in which services must be delivered. Too many agencies play a significant role in the delivery and management of mental health services. Health authorities, social service agencies and GP fundholders are direct and indirect funders of the system while community care trusts, social service agencies and GPs are service providers (Hadley, 1996a). RESULTS AND A PROPOSAL: We believe that the development of local mental health authorities may be part of the solution to the structural and economic problems of the current system in the UK. It is not the answer to limited resources or limited skills, but can create a new structure, which will permit and encourage the cooperation and innovation that is now possible only with unusual effort. Local mental health authorities have a number of crucial characteristics, but, most importantly, they refocus the system on the provision of care to the seriously mentally ill. This is the expressed priority of government, advocates and providers, alike.These new entities could be created at either the purchaser or provider level or, as exists in a number of jurisdictions in the US, at both levels, where a single purchaser may be responsible for multiple consolidated providers. This combination is now the emerging model for innovative services in the US. In the UK, the development of a local mental health authority at the purchaser and/or provider level might be relatively simple. Although the creation of a statutory authority would require primary legislation and is therefore probably not a short-term solution, there appears to be a variety of administrative options that would have the same effect. IMPLICATIONS FOR HEALTH POLICY FORMULATION: The creation of a local mental health authority may be a necessary first step towards the development of a coordinated and comprehensive system of care. It seems likely that there is currently more "political" support for the development of a purchaser model but the development of a sophisticated purchsaer is also likely to take considerable time and effort. Although all the structural and policy problems of the mental health system in the UK will not all be solved by local mental health authorities, they may be beneficial if responsibility for mental illness care is to be centralized and fragmentation is to be reduced. Without making structural changes, the best efforts by clinicians, policymakers and managers are most likely to be in vain. Without a clear point of ultimate purchasing and service responsibility, the fragmentation and inefficiency of the current system will remain (Hadley et al., 1996).     

Learning theory and the design of training in a health authority

Gives an explanation of the salient factors which affected the design of a training intervention aimed at clinicians in West Birmingham Health Authority. Discusses the theoretical considerations relevant to learning in an organization, using a case study to illustrate.     

Community-based adolescent health services in Israel: from theory to practice

Despite their engagement in health-risk behaviors and their health-related concerns, adolescents have the lowest rate of health service utilization of any age group. Time constraints during routine medical encounters generally leave little opportunity for professional screening for health-risk behaviors or for discussing psychosocial problems. In addition, providers express low levels of perceived competency in areas such as sexuality, eating disorders or drug abuse. To address these needs, a walk-in Adolescent Health Service was established by the Sheba Medical Center to provide diagnosis and short-term treatment for individual adolescents, as well as counseling and support for local care providers. A three-way model of cooperation and partnership was developed and implemented. A professional and financial partnership with local authorities were established to help define the particular needs of the community's youth and to improve the ability to reach youth with special health needs. The partnership along with the main medical provider (Kupat Holim Clalit) helped define local health needs, served as a referral source of patients with unmet health needs, and improved the continuity of care. The regional medical center (Sheba Medical Center) provided supervision and consultation for the medical staff of the service, as well as a referral center for patients. It was emphasized that the service staff was intended as a professional source for the primary physician and should not be considered a rival. The core staff included a specialist in adolescent medicine, gynecologist, mental health specialist and social worker. A structured intake procedure was developed for assessing health concerns and problems of adolescents in the context of a community clinic. Findings from the first years of services showed that the first 547 female adolescents demonstrated that a majority of adolescents presented with primary complaints of a somatic nature, while one third were diagnosed with psychosocial problems and one-fifth with a sexuality-related problem. A considerable percentage of those diagnosed with psychosocial or sexuality-related problems had not stated these issues as their "reason for encounter". This additional increment probably represents the contribution of the Health Concern Checklist (HCC), in which the adolescent was asked to mark each item for which she had concerns or would like to receive further information. The HCC can help primary care physicians as well as adolescent medical specialists approach the teenage patient and initiate productive communication. A practical approach to confidential health care for adolescents: The issue of confidentiality has not been sufficiently clarified by Israeli law or by the medical community. The need for confidentiality was strongly felt in the adolescent health service. A policy which provides all adolescents with the opportunity to meet with a physician and receive health guidance or advice at least once, even without parental knowledge or consent, was formulated and implemented. If parental consent was not feasible, the minor was allowed to give informed consent for medical and psychosocial care for himself/herself, with certain limitations.     

From theory to practice: improving the impact of health services research

Background  

While significant strides have been made in health research, the incorporation of research evidence into healthcare decision-making has been marginal. The purpose of this paper is to provide an overview of how the utility of health services research can be improved through the use of theory. Integrating theory into health services research can improve research methodology and encourage stronger collaboration with decision-makers.     

Graduate education in family practice: a ten-year review.

Assessment of the progress of graduate education in family practice after ten years shows that the original goals established for residency training in this specialty are being effectively met. There are now more than 360 approved family practice residencies in the United States with over 6,000 residents in training. Student interest in these programs has remained at a high level, and attrition has been low. Graduates of these programs have favored partnership and group family practice, and are well distributed in rural, suburban, and metropolitan areas. Heavy emphasis has been placed upon quality control mechanisms for both internal and external review of family practice residency programs. This paper outlines some concerns regarding the present status of family practice residencies, and suggests some directions for future development of these programs.     

Intergenerational continuity and reciprocity through the use of community-based services: theory and practice

This paper aims to expand the current debate on intergenerational issues by examining the interactions of the generations and their sentiments as represented in recent community program studies, participant-observation reports, and autobiographical work. The error in intergenerational inequity thinking is asserted to be in its belief that a generation that otherwise would have had to support its parents would be in favor of cutting social security benefits. Two, if researchers and policy makers take into account only economic exchange, they will never be able to predict usage or plan appropriate programs. Three, the state has a stake in supporting informal caregivers. Finally, real equity lies in normative social exchange.     

Privatization and trade in health services: a review of the evidence.

Health care provision, like other areas of welfare, has increasingly been subject to processes of privatization and contracting out, leading in some cases to an increased involvement of for-profit corporations. Such processes are likely to interact with processes of liberalization at the international level in ways that we would expect to lead to a growth in the international trading of such services. However, health service provision is usually deeply embedded in state structures at the national level, and the form of such structures varies greatly. The degree and type of private involvement allowed for or facilitated by national-level systems defines the scope for the potential development of international trade in health services. The author reviews existing sources of data on the levels of private provision across advanced capitalist countries, countries in transition from Soviet-type systems, and developing countries, and highlights processes of change that are likely to increase such provision. Private provision is growing slowly but steadily in most countries. While levels of international trade in health services are difficult to ascertain, the interaction between national processes of reform and international processes of liberalization is likely to increase such trade.