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Biomedical subjects

L Malcolm

Publications and source records attributed to L Malcolm.

At least 37 records · Page 2Linked to original sources
PubMed1995

Decentralisation, integration and accountability: perceptions of New Zealand's top health service managers.

This paper reports on the findings of a representative survey of senior managers within New Zealand's health system. Respondents report most favourably upon the implementation of a new organisational structure, service management, which appears to have largely replaced the traditional division of health services into hospitals and community services. Service management, which is the decentralisation of decision making to integrated patient groupings, i.e. medicine, surgery, mental health, women's health, primary health care etc., appears to have been remarkably successful, in the view of the respondents, in achieving greater efficiencies, better quality care, better decision making about priorities and greater accountability of doctors. A majority of respondents consider that services have replaced hospitals as organisational entities. Significant progress is reported in the integration of hospital and community services, primary and secondary care, preventive and treatment services and of public, private and voluntary services through service management. The findings point to a new paradigm which may be of fundamental significance in the future organisation of health services.

Administrative Personnel↗
PubMed1995

Implementing managed care in New Zealand.

Reforms at the level of the national government and regional health boards have encouraged the principles of budget-holding and managed care in New Zealand. The author describes how each principle is implemented in New Zealand and draws comparisons with managed care in the United States.

Budgets↗
PubMed1995

Radical reforms for primary health care in New Zealand.

Financial, social and political forces have combined to produce radical reforms in New Zealand's health system. These are characterized by decentralized management; the integration of services that have traditionally been kept separate, such as the hospital and the community, and public and personal health; and focusing on the population rather than institutions as the basis of the system. These changes are accompanied by a shift of emphasis from secondary towards primary health care.

Health Care Reform↗
PubMed1994

Decentralisation of general management within the New Zealand health system.

The radical organisation changes implemented in the New Zealand health system in recent years are discussed and analysed in this study which is based upon a review of documents and interviews with general managers of area health boards. Service management, which involves the decentralisation of general management to programme or product groupings (medicine, child health etc) has been widely implemented in almost all boards completely replacing the traditional disciplinary hierarchies. It is also leading to a population-rather than an institutional-based system of management. General managers report positively on the achievements of service management including greater accountability and commitment of clinical staff, innovation and team building, improved performance and service quality, the integration of hospital and community-based care and a customer rather than an occupational orientation. There is an increasing trend towards the recognition of primary health care as a key service entity.

Data Collection↗
PubMed1993

Trends in primary medical care related services and expenditure in New Zealand 1983-93.

AIMS: To analyse recent trends in primary medical care (PMC) related expenditure, general medical services (GMS), pharmaceuticals, laboratory, Accident Compensation Corporation (ACC) and other categories, as a basis for general practitioners, other primary health care providers and regional health authorities becoming better positioned to make more effective decisions about the use of this expenditure. METHODS: Data from the Department of Health, Accident Compensation Corporation and other sources of this expenditure over the period 1983-93 were obtained and analysed. RESULTS: Primary medical care related expenditure between 1982-3 and 1990-1 increased annually at an inflation adjusted rate of 6.1% to a total of $1006.2M. In 1991-2 there was a slight inflation adjusted decrease in overall primary medical care related expenditure of 0.5% although maternity benefits increased by 20.7%. An overall increase of 2.7% occurred in 1992-3 with a 10.1% increase in laboratory benefits and 16.4% in maternity benefits. Price, volume, mix and other factors were analysed to explain these increases. The overriding determinants of the cost increases are the volume of primary medical care related services such as pharmaceuticals, laboratory and maternity services and the mix effect ie, more expensive drugs, tests, etc. CONCLUSION: Alternative strategies for control of primary medical care related service utilisation costs are discussed. It is suggested that the most effective strategy is some form of general practitioner or community based budget holding within which general practitioners and/or communities are empowered to make decisions about their priorities in achieving the best possible quality and quantity of primary health care.

Financing, Government↗
PubMed1992

Inflammation but not autoimmunity occurs in transgenic mice expressing constitutive levels of interleukin-2 in islet beta cells.

Transgenic mice expressing murine interleukin (IL)-2 constitutively in islet beta cells were generated (RIP-IL-2 mice). They died at an early age, when higher levels of IL-2 were produced, because of a predominant macrophage inflammatory response that destroyed the exocrine pancreas. Animals with lower levels of IL-2 survived and had islets that became increasingly infiltrated with lymphocytes over time. However, in spite of the presence of impressive peri- and intra-islet infiltrates, autoimmunity to islet antigens was not seen. Autoimmunity was also not induced to extrathymic H-2Kb molecules known to induce tolerance by a peripheral mechanism when the RIP-IL-2 mice were mated to other mice expressing H-2Kb in islet beta cells (RIP-Kb mice). Apparently, IL-2 can act only on activated T cells and is unable to reverse tolerance in T cells that have been made unresponsive through inappropriate presentation of antigen.

Animals↗
PubMed1992

Identification of childhood disability in Jamaica: the ten question screen.

This is the first in a series of papers that report the testing of two instruments for the identification and assessment of childhood disability by community workers (CWs) in Third World countries. It is part of the International Epidemiologic Study on Childhood Disability. The Ten Question Screen (TQ) was used as the main instrument to identify disability in a two stage population-based survey of 5478 children aged 2-9 years in Clarendon, Jamaica. In the second stage, TQ positive and 8% of the screen negative controls were professionally assessed by a doctor and a psychologist using standard criteria based on the main classification system of the ICIDH. Sensitivity of the TQ as a whole varied in different strata of the group and amongst different disabilities, from perfect in girls under 6 years, fits and motor disabilities and for serious disability in all group except boys over 5 years with cognitive disability. Specificity was good but the false positive rate was unacceptably high at 74%. It was concluded, firstly, that the validation of a simple questionnaire of perceptions of behaviour against objective measurements of impairments was perhaps not fair to the TQ. In spite of this, the TQ would be a very useful instrument in collecting disability data or for identifying people in need of rehabilitation help, if a way of reducing false positives could be found.

Child↗
PubMed1992

Implementing the post-hospital age.

A 650-bed teaching hospital abolished and a programme for enhancement of the role of primary health care: these are some of the organisational changes taking place in New Zealand at present. Laurence Malcolm and John Mollett report.

Governing Board↗
PubMed1991

Overexpression of beta 2-microglobulin in transgenic mouse islet beta cells results in defective insulin secretion.

Overexpression of heavy chains of the class I major histocompatibility complex in islet beta cells of transgenic mice is known to induce nonimmune diabetes. We have now overexpressed the secretory protein beta 2-microglobulin in beta cells. Transgenic mice of one lineage had normal islets. Mice of another lineage did not become overtly diabetic but showed significant depletion of beta-cell insulin. When mice were made homozygous for the transgene locus, they developed diabetes. Introduction of the beta 2-microglobulin chain into class I heavy chain transgenic mice resulted in a significant improvement in their islet morphology and insulin content, and the female mice remained normoglycemic. These results suggest that different transgene molecules overexpressed in beta cells can cause islet dysfunction, though not necessarily overt diabetes, and that this effect is mediated by the level of transgene expression. Evidence is provided to show that beta-cell disruption by transgene overexpression occurs at the level of protein and involves a defect in insulin secretion.

Animals↗
PubMed1991

Inherent beta-cell dysfunction induced by transgenic expression of allogeneic major histocompatibility complex class I antigen in islet cells.

Insulin-dependent diabetes mellitus (IDDM) is generally believed to be an autoimmune disease resulting from T-cell dysfunction that produces beta-cell damage, but it is conceivable that some forms of IDDM are not immunologically mediated. The effect of the expression of a foreign transgenic MHC class I antigen (H-2Kb), restricted to pancreatic islet beta-cells, was tested in vitro and in nude (athymic) mice to determine whether beta-cell dysfunction was due to non-immune mechanisms. The models used clearly excluded immune involvement in beta-cell damage. Fetal pancreas from transgenic and littermate control mice was maintained in organ culture for up to 18 days and insulin secretion into the medium assessed. For the initial 3-4 days in vitro, fetal control and transgenic pancreas secreted similar amounts of insulin, but thereafter insulin secretion by the transgenic tissue decreased in comparison with the controls. When the cultured pancreas was transplanted into nude mice, the transgenic issue produced smaller grafts than the control pancreas, but there was wide variation in graft size. Expression of H-2Kb antigens in beta-cells of nude transgenic mice also resulted in early-onset diabetes. The insulin content in the pancreas of young H-2Kb transgenic euthymic mice, (previously shown not to have insulitis), was reduced but glucagon content was normal. The reduction in in vivo insulin production was similar chronologically to the reduced insulin production by transgenic islets in vitro. These data confirm the non-immune loss of beta-cell function in MHC-transgenic mice and they may be a model for atypical Type I diabetes.

Animals↗
PubMed1991

The New Zealand experience: integrating management development into a rapidly changing health system.

New Zealand has seen sweeping changes in recent years in its economic and social policies. Central to these has been the concept of better management in all phases of government activity with an emphasis upon performance, outcomes, and efficiency in achieving economic and social goals. There has been a massive reform of the health sector with restructuring of the Department of Health, devolution of most health delivery responsibilities to fourteen geographically defined area health boards, and the implementation of the principle of general management throughout the system. National health goals have been formulated to be implemented largely through area health boards. These developments have had important effects on educational programs in health services management, public health, and health policy. Collaboration through a New Zealand network of providers has been developed and a rapid growth in those seeking education and training programs has occurred. Education and training inputs are seen to be a major factor in the successful implementation of the major transformational change in New Zealand health systems.

Curriculum↗
PubMed1990

Service management: New Zealand's model of resource management.

The health system in New Zealand, which in many respects is similar to that of the United Kingdom NHS, is currently undergoing massive change. In 1989 fourteen area health boards were formed, each board being accountable to the minister of health for achieving health goals and providing comprehensive health services for its defined population. This process has been assisted by the promulgation of a set of national health goals and a national health charter. Within area health boards the principle of general management is being implemented. Organisational structures are moving away from hospitals to services in a process which is being called service management which may be defined as the decentralisation of general management to the clinical workface. Similar in many respects to the resource management initiatives in the NHS it brings together medical, nursing and business management at the operational level with one person being accountable for the achievement of quality of care objectives within a budgetary framework. Budgetary restraints in excess of 10% have been achieved in the last 12 months partly through the service management process. Service management is seen to be a major paradigm shift in health services organisation and could be of international significance in its potential for achieving medical accountability for cost containment and quality assurance, and for coordinating care across agency and disciplinary boundaries.

Governing Board↗