Public health leadership in primary care practice in England: Everybody's business?

This article analyses the concept of leadership in relation to the UK Government's current approach to ‘modernizing’ the NHS in England. Focusing on public health in primary care, the authors consider current developments in the public health workforce, in particular attempts to differentiate between public health ‘specialists’ and ‘practitioners’ by different levels of leadership function. It looks at leadership in policy, theory and practice, and draws attention to a number of key challenges along the leadership path. The concept of ‘leadership skills’ as a taught competence is questioned, and Shelton and Darling's (2001 Shelton, CK and Darling, JR. 2001. The quantum skills model in management: a new paradigm to enhance effective leadership. Leadership and Organisation Development Journal, 22(6): 264–273.  [Google Scholar]) ‘quantum skills’ model of leadership is provided to suggest new ways in which public health leadership in a primary care context might be approached. Whilst this article focuses on public health and primary care in England, the complexity of primary care settings and public health delivery in other international contexts extends its relevance to non-UK settings.     

Wither? Public health in a changing Europe

Large parts of the population of the wealthier countries havenot enjoyed the health benefits of their more fortunate citizens.We have not reached the limits of what we can achieve in healthby any means.¹ The conditions and determinants of population health have changedmarkedly over the last decades, and so has the context of publichealth. We are living in a globalized world. Health is seenas a major driving force for economic and social development.The public     

Information and access to health care: is there a role for trust?

In many countries health policy has been guided by a focus on the supply side factors of access to health care, a lot of attention being directed at the availability of services. This paper concentrates on the demand side of access and investigates relational factors that may limit people's subjective choice sets or their freedom to utilise health services, emphasising that relations between service providers and individuals are based on an interchange of information. It develops an argument for health communication strategies based on an interactive exchange of information as a means of improving access and is intended as a conceptual basis for further debate. Trust assumes a key position within this transactional process of information exchange or communicative interaction. Information may enlarge individual choice sets and increase the freedom to use health care; it serves as a stimulus for access. The paper argues that trust plays a role in the utilisation of provided information. Trust emerges as a prerequisite of the effectiveness of information with regard to access. A discussion of the origins of trust shows that, while trust enhances communicative interaction, it is the process of communicative interaction that generates trust in the first place. Culturally diverse societies are often low-trust environments. The paper analyses the driving forces of trust and distrust in health care within these societies and delineates barriers for the individual and the community to the transfer of information. Specific characteristics of health communication turn out to be key determinants of access. In conclusion, principles for health policy on equity and information are derived which are rooted in a distinctive notion of democratic societal structure.     

Primary health care in Turkey: a passing fashion?

The Alma-Ata Declaration has long been regarded as a watershed in the health policy arena. The global goal of the World Health Organization, 'Health for All by the Year 2000' through primary health care, has attracted many countries both in the developed and the developing world and commitments to this end have been made at every level. However, albeit this consensus on the paper, a common and explicit definition of the concept has not been reached yet. This paper aims at discussing various definitions of primary health care that emerged after the Declaration and also presenting a case study from Turkey, a country that advocates primary health care in her recent health policy reform attempts. After setting the conceptual framework for discussion the Turkish case is presented by using research carried out among Turkish policy-makers at different levels of the State apparatus. It has been concluded that application of primary health care principles as defined in the broad definition of the concept requires major changes or rather shake-ups in Turkey. These areas are outlined briefly at the end of the paper.     

Improving on‐time performance in health care organizations: a case study

In this paper, we propose a strategy to build a measurement system that helps improve ontime performance in health care organizations. We analyze the measurement system for monitoring the performance of daily start times of first surgeries in a U.S. hospital. Although surgeons appear to be the main cause of delay, efforts to improve their ontime performance alone are not sufficient to improve ontime performance for first surgeries. Therefore, working on the main source of delay to improve performance, as the Pareto principle suggests, does not always work in the health care context. Rather, we found that ameliorating the hospital's overall ontime performance achieves the desired result of improving surgeons' performance through a snowball effect (a selfreinforcing effect) and, consequently, the ontime performance for first surgeries also improves.     

Public spending on health care in Africa: do the poor benefit?

Health care is a basic service essential in any effort to combat poverty, and is often subsidized with public funds to help achieve that aim. This paper examines public spending on curative health care in several African countries and finds that this spending favours mostly the better-off rather than the poor. It concludes that this targeting problem cannot be solved simply by adjusting the subsidy allocations. The constraints that prevent the poor from taking advantage of these services must also be addressed if the public subsidies are to be effective in reaching the poor.     

Public health policies: a Scandinavian model?

AIM: To identify how public health problems are identified, explained, and addressed in Scandinavian public health programmes. METHODS: Recent public health white papers from Denmark, Norway, and Sweden have been studied asking the following questions. How are policies and activities justified? Which problems and causes are identified? What is to be done? To what extent are the interpretations and suggested interventions in accordance with liberal or social democratic political ideals? RESULTS: The programmes studied give similar reasons for dealing with public health, namely the wish to create good lives for citizens and to improve the economy of society. The health problems identified are almost the same: cancer, heart disease, diabetes, musculoskeletal diseases, and mental illness. The Danish programme differs from its Norwegian and Swedish counterparts with regard to explanations and suggested solutions to the problems. It may be characterized as more liberal. While the Danish programme stresses the importance of individual behaviour, responsibility, and autonomy, the two others emphasize social relations, living conditions, and participation in addition to behavioural factors. Political responsibility for the health of the population is emphasized in the Norwegian and Swedish programmes. The Swedish programme, in particular, stresses common values such as equality and equal rights, and the significance of the welfare state. The Norwegian programme underlines the importance of empowering the individual, an ambition that could also be seen as a social liberal ambition to increase the self-determination of citizens. CONCLUSION: There is not one Scandinavian model in public health policy but several: a Danish model mainly adhering to liberal ideals, a Norwegian one that could tentatively be labelled social liberal, and a Swedish model adhering to more social democratic ideals.     

Acute hospital medical care for the elderly: is there a valid performance indicator?

Many clinicians have doubts about the validity of using activity data to measure the efficiency of health services, since they take no account of outcome. In elderly patients presenting with acute illness, minimising the time spent in hospital or institutional care is a justifiable aim in itself. If allowance is made for deaths and readmissions, valid performance indicators might be derived from the distribution of the resulting 'Adjusted Length of Stay'. By surveying all medical patients aged 65 and over, admitted as emergencies to the hospitals of one large health district, this study investigated whether such an index (the Adjusted length of Stay) could be of practical value. The influence of the following characteristics on the patient's length of stay were assessed; age, social circumstances, premorbid disability and the nature of the presenting complaint. Patients admitted to general medical and health care of the elderly wards were compared and investigated, to determine whether their outcome was similar after adjusting for differences in these characteristics. Although there was some overlap, marked differences emerged in age distribution, nature of the presenting illness and prevalence of previous disability. These factors were all found to have a substantial effect on the time spent in hospital. The Adjusted Length of Stay Index could be calculated with little change to existing methods of data collection. It provides a fairer basis for overall evaluation of acute medical services for the elderly than current performance indicators.     

Patient performance standards: the next bold policy initiative in health care?

Performance standards have become a driver for accountability and quality improvement in health care, sometimes as part of payment-for-performance programmes. This essay discusses the novel concept of performance standards for patients - specifically, standards for enrolled groups - and the option of payments for patient performance. Might these ideas define the next logical step to improve quality in health care and help reduce health inequalities between population groups? After considering some possible arguments for patient performance standards, we suggest what these standards might look like, discuss the main concerns regarding their possible development and use, and indicate how these concerns might be appropriately answered.     

Does more investment in primary care improve health system performance?

This study examines the association between primary care investment and performance, in 34 OECD countries for 2005–15. Specifically, we explore whether an increasing investment in primary care is associated with improved performance, and whether particular characteristics of organisation and delivery are associated with a better return on primary care investment. We take advantage of new data sources that provide rich information on health and health systems as well as economic and distributional characteristics. Multilevel modelling was utilised to analyse cross-country variation. The results show that greater investment in primary care does not improve health system performance for complex targets (i.e., no reduction in preventable hospital admissions) though there is modest improvement in breast and cervical cancer screening rates. We also found that those countries in which GPs are more aware of health promotion/preventive activities achieve higher screening rates with the same amount of investment. The findings imply that primary care investment strategies need to look beyond high-level expenditure and characteristics of primary care strength, to institutional and funding arrangements and how these link to policy goals. Despite broad enthusiasm for strengthening primary care in general, we conclude that primary care policy needs to be appropriately targeted to improve health system performance.     

Are attributes of organizational performance in large health care organizations relevant in primary care practices?

Are organizational attributes associated with better health outcomes in large health care organizations applicable to primary care practices? In comparative case studies of two community family practices, it was found that attributes of organizational performance identified in larger health care organizations must be tailored to their unique context of primary care. Further work is required to adapt or establish the significance of the attributes of management infrastructure and information mastery.     

Is health care a need?

This paper aims to provide an argument for saying that a publicly funded health care system, available to all free at the point of delivery, is morally superior to a market system, and to provide a framework for deciding questions about which forms of health care should be included in such a public system. The argument presents health care as a ‘head’, in the sense of something to which human beings are morally entitled as a necessary condition for a life worthy of human dignity. Alternative arguments for similar conclusions, proposed by Daniels and Buchanan, are critically examined and rejected. This revised version was published online in July 2006 with corrections to the Cover Date.     

Does corruption undermine trust in health care? Results from public opinion polls in Croatia

Health and health care provision are one of the most important topics in public policy, and often a highly debated topic in the political arena. The importance of considering trust in the health care sector is highlighted by studies showing that trust is associated, among others, with poor self-related health, and poorer health outcomes. Similarly, corruption has shown to create economic costs and inefficiencies in the health care sector. This is particularly important for a newly democratized country such as Croatia, where a policy responsive government indicates a high level of quality of democracy (Roberts, 2009) and where a legacy of corruption in the health care sector has been carried over from the previous regime. In this study, I assess the relationship between health care corruption and trust in public health care and hypothesize that experience with health care corruption as well as perception of corruption has a negative effect on trust in public care facilities. Data were collected in two surveys, administered in 2007 and 2009 in Croatia. Experience with corruption and salience with corruption has a negative effect on trust in public health care in the 2007 survey, but not in the 2009 survey. While the results are mixed, they point to the importance of further studying this relationship.