Pharmaceutical Policy and the Lay Public*

Almost every national and supranational health policy document accords high importance to the need to listen to and ‘empower’ patients. The relationship between pharmaceutical policy and the lay public is not direct but mediated by several actors, including health care workers, patient organisations, industry and, most recently, the media. Although the overall aim of health and pharmaceutical policy is to address the needs of all citizens, there are only a few, well organised groups who are actually consulted and involved in the policymaking process, often with the support of the industry. The reasons for this lack of citizen involvement in health and pharmaceutical policymaking are many, for example: there is no consensus about what public involvement means; there is a predominance of special interest groups with narrow, specific agendas; not all decision makers welcome lay participation; patients and professionals have different rationalities with regard to their views on medicine. Because the lay public and medicine users are not one entity, one of the many challenges facing policy makers today is to identify, incorporate and prioritise the many diverse needs. The authors recommend research which includes studies that look at: lay attitudes towards pharmaceutical policy; lay experiences of drug therapy and how it affects their daily lives; the problem of identifying lay representatives; the relationship between industry and the consumers; the effect of the media on medicine users and on pharmaceutical policy itself. The authors acknowledge that although lay involvement in policy is still in its infancy, some patient organisations have been successful and there are developments towards increased lay involvement in pharmaceutical policymaking. This article is the fourth in a series of articles on this topic that will appear in Pharmacy World & Science during 2005.     

Laparoscopic nephrectomy is cost effective compared with open nephrectomy in a large county hospital.

BACKGROUND AND OBJECTIVES: To evaluate the experience with laparoscopic nephrectomy in a large county hospital and perform a cost comparison between uncomplicated open and laparoscopic nephrectomy. METHODS: Eleven consecutive patients who underwent an uncomplicated laparoscopic nephrectomy in a large county hospital were compared with 8 patients who underwent uncomplicated open nephrectomy during the same period. Patient charts and corresponding billing records were reviewed to determine overall hospitalization cost and individual cost components. RESULTS: No perioperative complications occurred in either the laparoscopic or open group, and no statistically significant differences existed between groups with regard to patient demographics or operative parameters. The overall operating room costs favored the open nephrectomy group by dollars 1070 (P=0.003). However, the overall cost of hospitalization, surgeon professional fees, duration of hospitalization, room and board costs, laboratory, and radiology costs, pharmacy costs, intravenous solution and infusion pump costs all significantly favored the laparoscopic patient group. The mean difference in overall hospital cost between laparoscopic and open nephrectomy was dollars 1211 in favor of laparoscopy (P=0.037). CONCLUSIONS: Our experience with laparoscopic nephrectomy in a large county hospital demonstrates a clear economic advantage in favor of the laparoscopic approach. Given limited funding for public hospitals and a clear patient benefit, laparoscopic nephrectomy should constitute first-line therapy when nephrectomy is indicated.     

Insults to the body civil: Mistreatment of elderly in two Plains Indian tribes

The mistreatment of elderly is subject to various social constructions. On two geographically distinct Plains Indian Reservations which we call Lone Mountain and Abundant Lands, the abuse or neglect of elderly is construed as a health problem which is a dysfunction of the community as a whole. Both physical abuse and neglect are more common on the Lone Mountain Reservation, occurring in association with other indicators of community disorganization such as unemployment and substance abuse. On the Abundant Lands Reservation physical abuse was categorically denied and what neglect existed appeared to be a function of role strain, geographic dispersal, climate and terrain. We attribute differences in the prevalence of mistreatment of elders to variations in economic opportunities for younger residents. Examining the historical and present contexts of intergenerational relationships on the reservations, we discuss the implications of this study for social exchange theory and policy applications.This research was supported by the Gerontological Society of America AppliedThis research was supported by the Gerontological Society of America AppliedThis research was supported by the Gerontological Society of America AppliedThis research was supported by the Gerontological Society of America AppliedThis research was supported by the Gerontological Society of America AppliedThis research was supported by the Gerontological Society of America Applied     

Multicultural Health Care in Practice

This study presents a first assessment of the challenges faced by Dutch health care providers dealing with the increasing cultural diversity in Dutch society. Qualitative interviews with 24 Dutch caregivers and policy-makers point to a number of important difficulties encountered when confronted with the growing diversity of patient populations. The study focuses explicitly on the challenges health care providers perceive in their direct interactions with patients. On the basis of the observations of the 24 respondents five strategies were formulated to improve the delivery of care in a multicultural environment. Their findings were further evaluated by confronting the empirical data with care-ethical notions (attentiveness, responsibility, competence, and responsiveness) and intercultural communication-theory.     

Integrating children's services in England: national evaluation of children's trusts

Background Poor co‐ordination of services can have severe consequences for disadvantaged children with complex needs. Since 2003 national and local governments in England embarked on sweeping reforms aimed at improving and integrating local health, education and social services for children. These were to be organized locally by children's trusts and piloted by 35 children's trust pathfinders. Methods This study described and compared the experience of integrating children's services in all 35 children's trust pathfinders, covering 20% of children in England. It had a prospective mixed‐methods design. Over 3 years we interviewed 147 managers and professionals working in the children's trusts, including 172 semi‐structured interviews, carried out two questionnaire surveys of the 35 children's trusts and analysed official documents. Results In most areas different agencies jointly commissioned children's services, especially for mental health, disabilities and multi‐purpose children's centres, and increasingly pooled finances. Provision of multi‐agency and multi‐professional services was increasing. Professionals generally supported these changes but found them stressful. All children's trusts appointed directors of children's services and established boards representing multiple agencies. Systems for sharing information about individual children were mostly in place but were still underused. Health services were generally less involved in joint work than were local authorities' education and social care services, with notable exceptions. Areas where local authorities and health authorities shared geographical boundaries made most progress. Some children's trusts made few changes beyond their statutory obligations. Conclusion Children's trusts enabled major changes to services in areas where local actors and organizations were motivated and empowered. In other areas the remit of children's trusts was often too broad and vague to overcome entrenched organizational and professional divisions and interests. Policymakers need to balance facilitation of change in areas with dynamic change agents with methods for ensuring that dormant areas and agencies are not left behind.     

Predictors of employment in substance-using male and female welfare recipients

This study examined predictors of employment among substance-using men and women enrolled in welfare-to-work programs. Participants were 394 welfare applicants assigned to either coordinated care management or usual care for treatment services and job training and followed up for 1 year to track employment outcomes. Common barriers to work were assessed at baseline in four key domains: disabilities, situational barriers, labor capital, and motivation. Results indicated substantial gender differences in the number and profile of work barriers. Among men, work experience and job motivation were the only significant predictors of employment; among women, multiple factors from each barrier domain predicted job acquisition even when controlling for all other significant predictors. Findings suggest that welfare-to-work programs should emphasize job training and job seeking during the early stages of welfare interventions for men and for many women.     

The role of the nurse in health promotion

This paper describes and discusses issues concerned with therole of the nurse in health promotion work. It represents thefirst phase of a research project designed to explore this role,and presents the evolving philosophical framework for the study.The study is taking place currently in the United Kingdom andhas been made possible by the (first) award of a Post DoctoralNursing Research Fellowship to the project director. Against the backdrop of the World Health Organization's ‘Healthfor All by the year 2000’ (WHO HFA 2000) movement therehave been repeated calls for nurses to be the leaders in healthpromotion. Policy makers and educators have responded to thesecalls by claiming a central role for nursing and putting healthpromotion high on policy and training agendas. Very little attention,however, has been devoted to exploring the legitimacy and developmentof this role in nursing. Generally, nurses seem enthusiasticabout health promotion, and sure that they have a role to play.What is less certain is what this role is. The study seeks toclarify this by exploring policy, behaviour, and attitudes.Policy provides the framework for practice, and operates ata number of levels. In this early paper we review the literatureto explore policy and practice from international to grassrootslevels. We also make some initial observation derived from ourpilot work.