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.     

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.     

MANAGEMENT OF SEMINOMA OF THE TESTIS: RECOMMENDATIONS BASED ON TREATMENT RESULTS

Background : The results of management of seminoma of the testis at the Department of Radiation Oncology St Vincent's Hospital, Sydney were evaluated retrospectively to: (i) establish that outcomes were in keeping with published results from centres in Australia and overseas; (ii) assess the impact of chemotherapy on management; and (iii) to determine ‘best practice’ management protocols based on our results and a review of the relevant literature. Methods : (i) Assessment of treatment results for stage I and II seminoma of the testis treated by post-orchidectomy radiotherapy and/or chemotherapy at St Vincent's Hospital between 1979 and 1993; (ii) literature review of published data from Australian and overseas centres on the management of seminoma of the testis, and in particular the use of surveillance or chemotherapy either alone, at time of relapse or combined with radiotherapy; and (iii) development of recommendations for use as management protocols in our department. Results : Our data and a review of the literature suggest that post-orchidectomy radiotherapy with chemotherapy for relapse in stage I and IIA disease results in long-term cure rates approaching 100%. Treatment with chemotherapy either routinely or selectively or using a surveillance policy is unlikely to show any improvement in outcome and may be less cost-effective and/or produce increased morbidity and the risk of secondary leukaemia. For stage IIB disease (5–10 cm) the use of initial combination chemotherapy with or without subsequent radiotherapy did not appear to give better outcomes than initial radical radiotherapy alone, reserving chemotherapy or further radiotherapy for relapse. For bulkier stage IIB disease (> 10cm). the use of initial chemotherapy plus consolidation radiotherapy appeared to be an appropriate treatment. Conclusions : Management protocols for seminoma of the testis at St Vincent's Hospital, Sydney Department of Radiation Oncology currently are (i) stage I, IA and IIB (5–10 cm): post-orchidectomy radiotherapy alone with chemotherapy or further radiotherapy for relapse; and (ii) stage IIB (> 10 cm) disease: initial chemotherapy post-orchidectomy followed by radiotherapy to sites of initial disease involvement.     

A call for a gender specific approach to address the worldwide cardiovascular burden

Cardiovascular diseases (CVD) among non-communicable diseases are already a major public health challenge worldwide. A further increase in CVD is projected to occur over the next 25 years as a result of both adverse lifestyle changes and demographic shifts in the population age profile. The adverse impact of these health problems will affect women in particular, given the steady rise in the proportion of the aging population that will be women.The critical issue presently in the management of CVD is that we are not even adequately using the data that are available. Women still remain unaware that they are at risk, and information about women is not easily accessible to their physicians. This is a global issue and the need remains for worldwide initiatives with greater vigilance to identify these factors and make efforts to control them effectively.Currently, in scientific research, it is expected that the results of clinical research be analyzed for sex differences, sex- and gender-appropriateness, and sex- and gender-specific approaches for prevention, diagnosis, treatment, and counseling. To address the care discrepancy, the global community needs to develop a conducive environment within a comprehensive policy and operational framework to achieve favorable lifestyles, and CVD risk factor reduction for both men and women.     

Science, scientists, and drug policy: A conversation with harry

An imaginary conversation between an advocate of drug policy reform and a defender of thestatus quo.