To market! To market! A new dawn for community care?

The public sector in Britain has been subjected to over a decade of major reform aimed at breaking up public service monopolies, at containing costs while at the same time opening services up to greater consumer choice. Health and social services have not been exempt from this revolution in the organization and management of public sector services. The long-standing policy of care in the community is being subjected to market principles and the introduction of a ‘contract culture’ very similar to the NHS reforms introduced in 1991. This paper reviews the origins of these developments in the doctrines of ‘new public management’, a movement which has proved attractive to policy-makers in many countries. Local authority social services departments have been identified as the lead agency for the development of a mixed economy of care following a review of community care policy by the government's health adviser, Sir Roy Griffiths, and a subsequent white paper. This paper examines the limited empirical evidence available on how managers and providers are meeting the challenge bestowed upon them, and concludes that most authorities are moving ahead cautiously if at all. Only a handful of authorities studied have embraced the reforms with any degree of enthusiasm. The paper concludes with an assessment of the reforms from two perspectives: a pessimistic one and an optimistic one. There are many worrying features of the reforms, not least among these being a lack of clarity over their intended purpose. Tensions and contradictions are plentiful, which places in jeopardy the certainty of the reforms in becoming user led rather than provider driven. A more optimistic scenario is that the changes are leading to a loosening up of services and practices which have often suffered from sclerotic tendencies, paternalism and sometimes complacency. If the reform process is skilfully handled and not rushed and if the ends are clearly established and communicated then users and carers could prove to be the principal beneficiaries.     

Health policy, epidemiology and power: the interest web

The relation between epidemiological research results and policy-making is reviewed. Apparently, traditional models of policy-making(incrementalism, mixed scanning synoptic planning) do not explainwhy research findings are hardly used in policy-making procedures. It is suggested that this phenomenon is related to three determinantsof policy-making: (i) a bias stemming from sets of causal, finaland normative assumptions and presuppositions; (ii) interestwebs of groups in certain domains; and (iii) the power of organizationsto monitor and communicate. The conclusion is that epidemiologistsshould engage in the policy-making process more consciouslyand conscientiously.     

Should equity in health be target number 1?

Policy measures to reduce socioeconomic health differences (SEHD)must be preceded by an analysis of the possibilities and desirabilityof a reduction. This paper argues that it is necessary to pursueequality in health, conceived as equal opportunities to achievehealth. This principle is justified as part of the principleof maximizing individual freedom of choice, and requires thateveryone has the opportunity to be as healthy as possible. Bymeans of this principle a distinction can be made between unjust,unavoidable, and acceptable health inequalities. The determinantsof SEHD which lead to inequalities considered unjust must besubject to policy. These are living conditions (physical andsocial environment and health care) and conditions of choice(e.g. the knowledge of an individual about the health risksof a certain behaviour). Even if SEHD are considered inequities,sometimes conflicting interests will make it difficult to proposea health policy to redress these inequities. These are partlythe consequence of the intersectoral character of a policy aimedat equality of opportunities to attain health, in which theimportance of health has to be weighed against other goals.Moreover the impact of such a policy on the individual freechoice has to be critically weighed. Finally in the contextof health care policy, conflicts between the principle of equalityand maximizing health can be expected.     

Socioeconomic differences in food preference and their influence on healthy food purchasing choices

Background: Studies have shown that socioeconomic groups differ in their dietary behaviours, and it has been suggested that these differences partly account for health inequalities between social groups. To-date, however, we have a limited understanding of why socioeconomic groups differ in their dietary behaviours. This paper addresses this issue by examining the relationship between socioeconomic status, food preference (likes and dislikes) and the purchase of 'healthy' food (i.e. food consistent with dietary guideline recommendations). Methods: This study was based on a dual-sample, dual-method research design. One sample was systematically selected from the Australian Commonwealth electoral roll and the data collected using a mail-survey methodology (81% response rate, n =403). The second consisted of a convenience sample of economically disadvantaged people recruited via welfare agencies (response rate unknown, n =70). A mail survey methodology was deemed inappropriate for this sample, so the data were collected by personally delivering the questionnaire to each respondent. Results: Socioeconomic groups differed significantly in their food purchasing choices and preferences. The food choices of respondents in the welfare sample were the least consistent with dietary guideline recommendations, and they reported liking fewer healthy foods (all results were independent of age and sex). Notably, socioeconomic differences in preference explained approximately 10% of the socioeconomic variability in healthy food purchasing behaviour. Conclusion: Whilst it is not clear why socioeconomic groups differ in their food preferences, possible reasons include: reporting bias, differential exposure to healthy food as a consequence of the variable impact of health promotion campaigns, structural and economic barriers to the procurement of these foods, and subculturally specific beliefs, values, meanings, etc.     

Making poverty a practice issue

Trends in poverty and changes in service provision are combining to make the promotion of health in poverty a particular challenge to health and welfare practitioners. The evidence suggests that practitioner groups have failed to respond adequately to this challenge. Factors concerned with professional perceptions of poverty, the nature of qualifying and post-qualifying education and the difficulties associated with taking research into practice all appear, in some way, to contribute to practitioners’ failure to incorporate a poverty perspective in their work. A team training approach appears to offer one way forward in the practice-setting. Using a team training approach, the‘Health Promotion in Poverty Project’ has sought to enable the lessons learnt from the broad base of poverty theory and research to be used by practitioners to build responsive and integrated support strategies for low-income families with dependent children.     

Choosing a career in general practice: the influence of medical schools

Summary. This paper reviews the literature on career choice to investigate the undergraduate influences on the preference of Australian graduates for a career in general practice. Although isolation of influencing factors is difficult, admission criteria and undergraduate curricula may influence career preference. As the institutional environment of medical schools is weighted towards scientific research and specialized medicine, medical students may be socialized into choosing non-generalist careers. Medical schools should consider broadening selection criteria and curriculum exposure to produce graduates with a broad range of career interests.     

Paradigms for mental health nursing: fragmentation or integration?

Debate about the best paradigm for mental health nursing is compounded by threats from mainstreaming and genericism. In nursing education, integrated practice may have been devalued in a matrix of reductionist disciplines. The 'gendered' nature of professional knowledge may create a schismatic and self-defeating attitude in nurses. Conversely, nurses may be exhorted to adopt a 'male' paradigm in order to gain academic credibility, in which the caring dimension may be lost. Other polarities such as ideological distinctions between treatment in hospital and care in the community lead to conceptual confusion. These schisms in care are detrimental to both professionals and users. The writers argue that these tensions may be addressed in an 'androgenous' model which presents a challenge to both value systems, rejects the dominance of schismatic models, and offers the potential for a new professional integrity.     

House officers in general medicine: their perception of educational value of rotation components

Summary: As curriculum planners in general medicine residency training programmes we were concerned about house officers' anecdotal reports that hospital work requirements often overshadow individual learning goals. After each of five rotations, we asked residents to identify the educational 'usefulness' of certain rotation components which can be included in three categories; team members, work-related activities and educational events. Of 165 surveys distributed, 127 (77%) were returned. Data were analysed by residency year and by all years combined. The mean overall perception of learning was 3.9 out of a possible 5 points suggesting that residents do find some learning value. Results suggest that different residency years vary as to the significance of specific educational components. The importance of faculty/resident relationships to residents' perceptions of learning value was highlighted in particular.