The impact of a general practice co-operative on accident and emergency services, patient satisfaction and GP satisfaction

BACKGROUND: The advent of general practice co-operatives represented a fundamental change in the delivery and organization of out-of-hours services. Concerns have been voiced that co-operatives might impact adversely on workload in accident and emergency (A&E) departments. OBJECTIVE: The purpose of this study was to assess the impact of establishing a general practice co-operative on use of A&E services, patient satisfaction and GP satisfaction. METHODS: A controlled before and after study of a GP co-operative in Sheffield, UK was carried out. A postal questionnaire was sent to 26 911 people, 13 442 before and 13 469 after the opening of the co-operative, to determine service use, in particular A&E attendance, in the previous 4 weeks. Patient satisfaction was assessed through structured interviews with 653 patients. GP satisfaction was assessed using a postal survey of all 98 Sheffield practices 2 years after the opening of the co-operative. RESULTS: There was no change in the use of A&E services, odds ratio = 1.08 (95% confidence interval 0.60-1.94). There was no change in patient satisfaction overall, mean difference 0.02 (-0.32 to 0.36). Sixty-seven per cent of doctors in member practices were much more satisfied with out-of-hours duty compared with 10% in non-member practices (P < 0.001). CONCLUSIONS: General practice co-operatives have been successful in achieving their policy objectives, improving GP morale without jeopardizing patient satisfaction or impacting adversely on A&E services.     

Barriers to dying at home: the impact of poor co‐ordination of community service provision for patients with cancer

For patients dying of cancer, there is an emphasis on giving choice regarding preferred location for care, with the option of dying at home, which is integral to UK government health initiatives such as the End of Life Care Programme. However, patients continue to be admitted to hospital in the terminal phase of their illness when they have expressed a desire to die at home. A qualitative study, using two audio tape‐recorded focus group interviews, with a purposive sample of district nurses and community specialist palliative care nurses (19) was undertaken across two primary care trusts in the north west of England. Data were analysed using a thematic analysis approach. From a service provision perspective, the results reveal that poor discharge planning and co‐ordination, difficulty in establishing additional equipment and services together with inadequate out of hours medical provision were all factors contributing to hospital admissions for patients with cancer in the last hours and days of life, and thus were barriers to dying at home.     

Avian and pandemic influenza: Progress and problems with global health governance

Abstract

Globalization has intensified the health risks posed by pandemic influenza. Effective governance to prepare for, and respond to, a pandemic depends on four key functions: surveillance, protection, response, and communication. Although the global nature of the threat posed is recognized, efforts to strengthen cooperation have only made limited progress. Disease surveillance and communication have benefited from new technologies and harnessing the capacities of both state and non-state actors. The protection and response functions, however, remain focused on domestic populations and are characterized by uncoordinated and, at times, competitive strategies. Global governance of influenza requires strengthening in order to prevent actions that undermine the need to protect the health of all populations.     

全球卫生治理面临的挑战及其应对策略

人人享有健康是一项基本人权。全球卫生治理的使命就是要在全世界范围内促进“人人享有健康”。目前,全球卫生治理面临诸多重大挑战,如治理主体众多但目标不一致导致领导权威难以确立,以国家为中心的国际体制使跨国集体行动的达成存在一定困难,各国对公共卫生事项设置的优先顺序存在分歧,全球卫生资金投入不足且分配不均,全球卫生治理严重缺乏国际协调,全球卫生治理基本框架尚未完全形成等。为了应对挑战,建议深化全球卫生改革,提高全球卫生治理的能力与效率;国际社会与各国政府必须审思与重构自身卫生法律与政策,把重点放在促进卫生公平而非提高经济竞争力上;各国政府必须重点关注民生和民权,重视非卫生领域政策与卫生政策的协调,从根本上改善健康的决定因素;增加全球卫生治理的透明度、建立新型问责制,增强世界卫生组织的权威性;在全球层面构建全球卫生治理基本框架,增强全球卫生治理的有序性。     

Networks and governance: the case of intermediate care

The present paper describes a novel approach to the study of services conceptualised as networks. It uses data collected as part of a case study evaluation of intermediate care, a 'joined-up government' policy that was explicitly intended to dissolve the boundaries between health and social care services. The evaluation was undertaken in five localities in England. Routine service use data were collated and standardised for the 12-month period from November 2002 to October 2003. A cohort of 258 service users was recruited during a census month (June 2003), and more detailed data on their personal characteristics and experiences prior to and during their intermediate care episode were collected. Information was obtained for 153 of these people, covering their experience during the 6 months following discharge. A graphical method of depicting individuals' movements between services was devised and a number of measures were used to investigate the network-like features of the data. User outcomes were explored by examining the relationship of characteristics of service users to their location at 6 months after discharge. The results of the analyses show that the five sites were developing service configurations that facilitated transitions between health, social care and other services, and that individual needs were taken into account in the decisions made about which people transferred into which services. While the results cannot be said to show that joined-up government works, they are consistent with the argument that joined-up government goes beyond partnership-type concepts, and in practice, involves the creation of what might be termed integrated service networks.     

Globalization and emerging governance modalities

This paper explores the possibilities for global governance effectively dealing with the international transmission of disease. First, zoonotic regulation and control pose a special case for public health agencies, and this paper proposes a propositional model for an effective public health stance. Second, globalization dynamics are briefly reviewed in terms of an emerging consensus on the need for global governance in public health. Third, a brief examination of global governance modalities suggests that a strong global governance case has distinct limitations (despite its possible justification); an exploration of contemporary directions in global governance follows. Finally, the paper examines the phenomenon of contemporary zoonotic control within the conditions of an effective regulatory regime.     

The general practitioner and older people: strategies for more effective home visits?

This paper is based on findings from a pilot research project funded by the Primary Health Care Development Fund in Scotland. The researcher's remit was to examine home visiting patterns by general practitioners (GPs) to older people on Tayside following the community care reforms. Fieldwork was conducted in three general practices on Tayside, using an anthropological perspective. This research confirms that community care changes have not to date effected a significant shift in GP perceptions, which are that the probable destiny of frail older people is to enter some kind of residential setting. The researcher examines how and why GPs label certain patients as a “problem” and uses this categorization process to suggest that such patients are seen by GPs as having a “moral career”. It is argued that GPs may also see some older patients as a “problem”, the solution to which may be to recommend that the patient enter residential or nursing home care. The research identifies a point in the career of the older “problem” patient at which doctors could usefully refer to other agencies. A model for communication or collaboration is posited as a way of enabling GPs to continue to provide sensitive and individually appropriate care for frail older patients in collaboration with appropriate others. Funding has been obtained to pilot this model in selected general practices on Tayside in 1996/97.     

卫生部门治理:战略与机制

在将健康作为一个要素融入所有政府部门与社会团体政策制定中的大健康整合战略下,政府各部门及社会团体在共识基础上形成广泛性治理目标,由政府主导卫生系统的运行,通过加强政府各部门间及与社会组织的协调与合作,统筹卫生系统的服务及管理功能,建立社会参与的绩效问责机制,实现提升卫生部门治理水平,改善社会健康结果的目标。     

我国公立医院法人治理——研究现状与未来展望

中国学术界和实务界对公立医院法人治理问题进行了较有价值的研究和探讨。文章从公立医院法人治理结构的界定、对其他国家和地区公立医院法人治理结构的研究、国内试点公立医院法人治理结构研究及建议等方面对中国相关研究文献进行了系统的梳理,指出了中国当前公立医院法人治理结构研究的问题,指出了有关研究应完善的方向。     

Attitudes toward working conditions: are European Union workers satisfied with their working hours and work-life balance?

Objective

To describe the satisfaction with working hours and satisfaction with work-life balance and their association in the European Union (EU-28).

Good governance and sustainability: a case study from Pakistan

OBJECTIVE: On the basis of a case study in Pakistan, the paper argues that good governance, characterized by transparency, accountability and meaningful community participation, plays a critical role in the sustainability of donor-funded health systems projects in the public health sector. METHODS: The Family Health Project (FHP) (1992-1999), funded by the World Bank, has been used as a case study. Critical analysis of secondary data mainly obtained from the Department of Health (DoH) in the province of Sindh in Pakistan is the major tool used for the study. Data from other sources including the World Bank have also been used. RESULTS: The analysis reveals that the existing health care system could not fully absorb and sustain major "sociopolitical" thrusts of the project, meaningful community participation and "democratic" decision-making processes being the most important ones. The hierarchical structure and management process made it difficult to produce a sense of ownership of the project among all managers and the rank and file staff. The Provincial Health Development Center (PHDC) and District Health Development Centers (DHDCs) established by the FHP did not receive adequate financial and political support from DoH and the Ministry of Health to have much control of the project at the local level. Consequently, these Centers largely failed to institutionalize a continuing training program for district level health officials/professionals. Due to lack of political support, the District Health Management Teams (DHMTs) could not be institutionalized. Community participation in the DHMTs was symbolic rather than forceful. Improved coordination among all stakeholders, more stable and competent leadership, more meaningful community participation, greater devolution of project management to the district level, and better management of resources would have resulted in more effective and efficient implementation of the project. Based on these findings, the paper introduces a Sustainable Management Approach (SMA) as a tool that can be used to ensure the sustainability of health systems projects, particularly those funded by international organizations in developing countries. CONCLUSIONS: Good governance and a conducive organizational culture are important prerequisites for incorporating any new project within an existing system. This includes prior consensus building among all stakeholders, a meaningful and inclusive participatory planning, implementation and evaluation process involving communities, political commitment, and the identification and use of appropriate leadership for project management.     

National poverty reduction strategies and HIV/AIDS governance in Malawi: A preliminary study of shared health governance

The public health and development communities understand clearly the need to integrate anti-poverty efforts with HIV/AIDS programs. This article reports findings about the impact of the Poverty Reduction Strategy Paper (PRSP) process on Malawi’s National HIV/AIDS Strategic Framework (NSF). In this article we ask, how does the PRSP process support NSF accountability, participation, access to information, funding, resource planning and allocation, monitoring, and evaluation?     

A review of health governance: Definitions,dimensions and tools to govern

Background

The premise that good governance will ultimately lead to better health outcomes has been central to the proliferation of work in this area over the past decade.

Objective

To consolidate and align literature on governance by presenting an overview of efforts to define, describe and operationalize the health governance function.

Methods

A targeted review of governance literature.

Results

(1) A variety of terms have been assigned to precede health governance definitions. These terms commonly describe governance ideals (e.g. good, democratic) or characteristics of the organization of actors in governance arrangements (e.g. hierarchical, networked). (2) Dimensions of governance are defined from different perspectives and in varied combinations, capturing values, sub-functions and/or outcomes of governance. (3) Tools used to govern remain to be cataloged, however, measures can be aligned according to dimensions of governance or their ability to create specific relationships between actors.

Discussion

Resolving the conceptual confusion around health governance requires recognition for the differences in the premise and approaches taken to defining governance, as well as specifying core dimensions and aligning applicable tools.

Conclusion

Despite a growing literature base, a concerted effort is needed for a more accessible understanding of health governance that is both practical at present and actionable for policy-makers.     

Consultants' attitudes to clinical governance: barriers and incentives to engagement

OBJECTIVE: To explore medical specialists' attitudes to clinical governance in acute hospitals and factors influencing these attitudes. METHODS: A semi-structured interview study with a purposeful sample of 24 medical specialists from two contrasting hospitals. Hospital A had a low level of consultant involvement in quality improvement initiatives and Hospital B had higher levels of engagement. RESULTS: Specialists from both hospitals acknowledged that quality improvement was a major part of their role. Among specialists from Hospital A, the lack of a commonly held focus on quality-improvement, poor inter-professional relationships and little clinical engagement in management were the main factors generating negative attitudes towards clinical governance. Effective communication of the hospital's goal of continuous quality improvement to all staff groups, a sense of being able to get issues affecting the quality of care heard by senior management, and a perception that there were clear structures and processes to support clinical governance, were factors that resulted in a more positive attitude to clinical governance among specialists in Hospital B. Specialists from both hospitals identified lack of time across all professional groups and availability of accurate data as barriers to involvement in clinical governance activities. CONCLUSION: The cultural context, level of technical support available, ability to communicate clear goals and strategies and the presence of structures to support delivery, all contribute to shaping specialists' attitudes to clinical governance and in turn influence levels of engagement and ultimately the success of quality improvement initiatives.     

国外公立医院治理结构特点及对我国的启示

随着医药卫生体制改革的不断深化,公立医院的治理结构也在逐渐建立和完善中。通过研究分析美国、英国、日本、澳大利亚、新加坡等公立医院治理结构的特点,并总结其成功经验,希冀为我国健全公立医院治理结构提供借鉴。     

三明市医共体支付方式改革的协同治理模式及效果分析——以尤溪县总医院为例

目的：系统梳理三明市医共体支付方式改革的协同治理模式,以尤溪县总医院为例分析改革效果。方法：基于协同治理理论,采用主题分析法分析定性资料。采用描述性分析、间断时间序列分析分别评价尤溪县总医院支付方式改革年度数据、月度数据。结果：支付方式改革多元治理主体间、改革政策间存在协同机制。改革后,尤溪县医保基金结余率提高至2.84%,医共体牵头医院的门急诊人次、住院人次、手术人次上升趋势明显减缓,基层医疗卫生机构的诊疗人次数占比从50.8%提高至68.5%,高血压、糖尿病、重性精神障碍的公共卫生管理指标均呈现上升趋势,城乡居民医保患者出院次均自付费用降幅达20.1%。结论：政府主导促进了治理主体间协同,多元治理主体间协同促进改革政策协同,明确、协同的改革政策促进医共体、管理者、医务人员的服务行为从以治疗为中心转向以健康为中心,改革具有可持续性。