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Standards of competence for health and safety practitioners are being developed by the Occupational Health and Safety Lead Body (OHSLB) within the overall context of the national changes in vocational training. These changes focus on the development of National Vocational Qualifications (NVQs) and Scottish Vocational Qualifications (SVQs).
The authors examined national changes in socioeconomic differentials in mortality for middle-aged and older white men and women in the United States with the use of 1960 data from the Matched Records Study and 1971-1984 data from the first National Health and Nutrition Examination Survey (NHANES I) Epidemiologic Follow-up Study (NHEFS). In 1960, there was little difference in mortality by educational level among middle-aged and older men. Since 1960, death rates among men declined more rapidly for the more educated than the less educated, which resulted in substantial educational differentials in mortality in 1971-1984. In contrast, among women, death rates declined at about the same rate regardless of educational attainment, so that a strong inverse relation between education and mortality in 1960 remained about the same magnitude during 1971-1984. Trends in educational differentials for heart disease mortality are responsible for much of the change for all causes of death. Relative risk estimates based on the NHEFS indicate that after taking into account selected baseline risk factors the least educated are still at substantially elevated risk of death from heart disease, ranging from a relative risk of 1.38 for men aged 65-74 years at baseline to 2.27 for men aged 45-64 years. Reasons for the observed educational differentials and their changes over time are not easily explained and are likely to be multifactorial.
Chance often determines the names that are recorded in history. Among an earlier generation's gerontologists, Ivan Basilevich was distinguished by the promise of his career and recognition in the USSR by his peers. The military invasion of his nation changed the pattern of his life. From a professional level in his native land, at the age of 50, he became a resident in psychiatry in Rhode Island where he continued his work on aging. He became a citizen in 1954 and by 1962 was the senior psychiatrist of his hospital's staff. His contributions to gerontology included his participation in the Kiev Congress of Aging in 1938 and a monograph in English (unpublished) on the medical aspects of natural old age. He wrote some 70 articles. In his papers on the subject of aging he heralded the transition of gerontology to its modern stage.
OBJECTIVE: To determine how changes in the number of admissions from waiting lists and changes in the number of additions to the lists are related to list size and waiting times, in the context of local waiting list initiatives. DESIGN: Review of national and Körner statistics. SETTING: England (1987-94) and districts of the former Oxford region (1987-91). MAIN OUTCOME MEASURES: Correlation of quarterly changes in the number of admissions from waiting lists in England with changes in total list size, numbers of patients waiting one to two, or over two years, and number of additions to the lists; examination of changes in waiting list statistics for individual district specialties in one region in relation to funding for waiting list initiatives. RESULTS: Nationally, changes in the number of admissions to hospital from lists closely correlated with changes in the number of additions to lists (r = 0.84; P < 0.01). After adjusting for changes in the number of additions to lists, changes in the number of admissions correlated inversely with changes in list size (r = -0.62; P < 0.001). Decreases in the number of patients waiting from one to two years were significantly associated with increases in the number of admissions (r = -0.52; P < 0.01); locally, only six of 44 waiting list initiatives were followed by an increase in admissions and a fall in list size, although a further 11 were followed by a fall in list size without a corresponding increase in admissions. CONCLUSIONS: An increase in admissions improved waiting times but did not reduce list size because additions to the list tended to increase at the same time. The appropriateness of waiting list initiatives as a method of funding elective surgery should be reviewed.
STUDY OBJECTIVE: To examine the impact of a comprehensive periodic health examination programme on health care utilisation and costs in a working population. DESIGN: A cohort method was used to observe the trends in health care utilisation and costs for a group of local government employees from 1 February 1986 until 31 January 1992, during which time (in 1988) a comprehensive periodic health examination programme had been introduced. Health care utilisation was measured by a claim rate per employee (number of claims in a year divided by number of employees) and a utilisation rate per 100 employees (number of employees who submitted at least one claim in a year divided by number of employees x 100). Health care costs were measured by claim costs per employee (total cost of claims divided by number of employees). National and prefectural changes in per capita health care costs were used for the adjustment of claim costs. Internal comparisons were made in relation to the intensiveness of the periodic health examinations administered before the introduction of the comprehensive programme. SETTING: Fukuoka Prefecture, Japan. PARTICIPANTS: A total of 19,146 local government employees (12,455 men, 6691 women) who worked in small cities, towns, and villages in Fukuoka Prefecture throughout the study period participated. MAIN RESULTS: Both the claim and utilisation rates showed an increase in 1988 when the comprehensive programme was introduced. After adjustment for the national changes in per capita health care costs and the aging effect of the study participants, substantial increases in claim costs were noted after introduction of the comprehensive programme. The programme had a greater but short term effect of increasing the health care utilisation of those who had received less intensive periodic health examinations before 1988, but no similar effect on claim costs was noted. CONCLUSIONS: The comprehensive programme had some role in increasing health care utilisation and costs. Its effect on costs was confirmed when the general population or another population was used as a reference. When comparisons were made internally, the comprehensive programme was seen to have had a greater but short term effect of increasing the utilisation of those who had previously received less intensive health examinations to equalise the health care utilisation and costs within the study population.
A significant contribution could be made to patient care if nutritional biochemists, basic and clinical toxicologists, and pharmacologists in the various fields were to mount the studies needed to understand the nature of food-drug interactions. If only a small fraction of the 120 billion dollars per year spent for food or the 10 billion dollars expended for drugs were allocated for research in this area, advances might be made for the health of the nation. Changes in man's diet produce marked effects on drug metabolism. We know that changing a customary diet to one high in protein and low in carbohydrate increases the rates of metabolism of antipyrine and theophylline, and shifting to an isocaloric diet of low protein-high carbohydrate slows the rates of metabolism of these drugs. Presumably, high-protein-low carbohydrate diets in man resemble the animal studies with high protein diets that show enhanced hepatic drug metabolism. However, numerous studies emphasize the considerable individual variability to changes in human diets; some people have dramatic changes, whereas others exhibit little or no response. Similar individuality has been found in the response to enzyme induction by smoking. Numerous foods and food ingredients affect drug metabolism in human beings and apparently follow the same patterns as found in experimental animal studies with changes in the levels of cytochrome P-450 dependent monooxygenases in the liver and intestine. These changes presumably exert some protective action against environmental carcinogens, cocarcinogens, or promoters. Dietary modifications are brought about by use of weight-reducing diets, vegetarian diets, hospitalization, or post-operative regimens. These diets are often continued for long periods of time and it is likely they result in changes in the metabolism by the body of subsequently administered drugs or exposure to environmental chemicals. Methods are needed to measure inter-individual and inter-group differences in metabolism of foreign compounds in order to accurately assess dietary influences on drug metabolism and vice versa. Epidemiologic studies of rigorously selected human populations, coupled with the newer sensitive chemical analytical methods, will provide the necessary data base for these investigations.
Survey results show that the American public comes to the health care reform debate with ambivalent feelings and a relatively low base of specific knowledge. But Americans also hold a set of core values that will shape their response to various proposals for national change. These include (1) a moral commitment to the uninsured; (2) a desire to achieve personal peace of mind; (3) a lack of self-blame; (4) a limited willingness to sacrifice; (5) reasoned self-interest in what changes are enacted; (6) a distrust of government; and (7) a healthy cynicism about the behavior of our major institutions.
This study investigates national changes between 1973-74 and 1985 in women's use of three preventive health services based on data from the National Health Interview Survey. Smoothed proportions of women with recent preventive care were estimated using weighted least squares for subgroups categorized by age (20-39, 40-59, 60-79), race (White, Black), income (poor, nonpoor), and year of interview. Older women and Black women experienced the largest increases in recent use of clinical breast examinations and Pap tests. Between 1973 and 1985 changes in recent breast examination ranged from zero for White women ages 20-39 years to a 23 percentage point increase (95% CI = 17,30) for Black women ages 60-79 years. A similar pattern was found for Pap testing. Changes between 1974 and 1985 in recent blood pressure testing ranged from zero for women ages 20-39 years to an 8 percentage point increase (95% CI = 6, 10) for women ages 60-79 years. Despite the increases among older women, in 1985 recent use of breast exams and Pap tests remained lower among older women. Further, the poor remained less likely than the nonpoor to have recent preventive care (except blood pressure testing among older women). Most women without recent cancer screening tests had a recent physician contact, highlighting the need for greater emphasis on cancer prevention by health care providers.
The fundamental need for better information management capabilities in health care is at risk of being overlooked in the proposals for major national changes aimed at providing health security, controlling costs, enhancing quality, and expanding access for citizens. In addition to these proposed macro changes (e.g., universal access, guaranteed benefit package, national health board, regional health alliances), successful reform will require transformation of health care delivery at the micro level. We must overcome provider-dependent variations in clinical practice patterns, in quality of performance, and in costs of services. We must ensure movement toward appropriate care rather than simple rationing. Individual health care professionals and institutions must acquire and use tools that will enable them to provide their services cost-effectively with consistent results. We must be able to assess and ensure value--i.e., appropriateness, effectiveness, and cost--of health services, apply that knowledge in each and every patient encounter, and track the impact of clinical decisions through an analysis of aggregated databases.
Recent national changes in the de facto system of health and mental health care are described. Although the percentage of people without health insurance (always or sometimes) has not decreased, the organization of insured care has changed dramatically. Of the insured population, 75% are under some form of managed care. For 88% of the managed care population, mental health care has not been integrated with health care: the so-called carve-out. The author argues that system integration (carve-ins), for a variety of reasons, will begin soon and will occur very rapidly. A tilt toward carve-ins will have substantial impact on psychologists' training, service delivery, and research.
Recruitment and retention of general practitioners (GPs) has become an issue of major concern in recent years. However, much of the evidence is anecdotal and some commentators continue to question the scale of workforce problems. Hence, there is a need to establish a clear picture of those instabilities (i.e. imbalances between demand and supply) that do exist in the GP labour market in the UK. Based on a review of the published literature, we identify problems that stem from: (i) the changing social composition of the workforce and the fact that a large proportion of qualified GPs are significantly underutilized within traditional career structures; and (ii) the considerable differences in the ability of local areas to match labour demand and supply. We argue that one way to address these problems would be to encourage greater flexibility in a number of areas highlighted in the literature: (i) time commitment across the working day and week; (ii) long-term career paths; (iii) training and education; and (iv) remuneration and contract conditions. Overall, although the evidence suggests that the predicted 'crisis' has not yet occurred in the GP labour market as a whole, there is no room for lack of imagination in planning terms. Workforce planners continue to emphasize national changes to the medical school intake as the means to balance labour demand and supply between the specialities; however, better retention and deployment of existing GP labour would arguably produce more effective supply-side solutions. In this context, current policy and practice developments (e.g. Primary Care Groups and Primary Care Act Pilot Sites) offer a unique learning base upon which to move forward.
This paper discusses the national changes taking place in school nursing and describes a consultation undertaken to clarify the training needs of school nurses in relation to child and adolescent mental health. It encompasses the types of problems encountered, levels of knowledge and confidence, and training priorities.
In April 1991 the Daphne Heald Research Unit at the Royal College of Nursing (RCN) started a three-year research project to assess the job satisfaction of nurses working in the community. This took place against a backdrop of considerable change in the organisation and funding of community health care. Initially four NHS Trusts participated, one withdrew after the first year. A measure of job satisfaction was administered to the entire community nursing and practice nursing workforce in each area. The response rate varied from 74% (year 1) to 54% (year 2). Differences in satisfaction were detected between trusts, different groups of nurse and over time. Some nurses added comments to their questionnaire, voicing concerns over uncertainty, paperwork and a perceived change in ethos within their organisations. Trust managers interviewed as part of the study spoke of their strategies for local implementation of the national changes.
Many managed care plans propose short-term economics, without stressing quality, assuring universal access, supporting research, or caring for the poor. None provide much in the way of preventive services. In the absence of any major national changes to assure universal access to health services, local health care providers and state regulatory agencies need to be freed from many restrictive federal laws and regulations. Relief is needed from well-intended federal controls which have usually made the health care system more expensive 1) by applying federal anti-trust regulations to prevent physicians from self-regulation and working to improve the health care system, 2) by making it difficult for physicians to do office laboratory work for their patients' convenience, 3) by making "safe" drugs expensive because of FDA regulations, 4) by sequentially spawning PRO, PSRO, and now the Health Care Quality Improvement Program (HCQIP) to "assure quality control" (they probably have not paid for themselves), 5) by not using the RBRVS system (accepted by HCFA as a way to relate a physician's fees to the resources required to perform a service) to stimulate physicians to enter primary care practice, 6) by giving tax breaks for insurance costs to big corporations but not to small businesses, and 7) by protecting self-insured businesses from state regulations. States should be allowed to obtain waivers from ERISA (which incidentally would improve competition) so states could regulate health insurers, try such proposals as a single payer system, or at least restore community rating and equity. This should improve access to technological advances in prevention and health care for all. More commissions and studies and federal laws are not the answer. Health care providers should be able to work together freely to deliver efficient, cost-effective health care. States should be able to assure preventive services, clinical research, public health support, professional education and care for the poor.
INTRODUCTION: Variations in local population age structure have attracted less attention than national population ageing. As moderate and severe cognitive impairment is a major cause of need for long-term care, population-based estimates of the numbers and characteristics of this group were calculated, to explore the effects of local differences. METHOD: The UK Office of Population Census and Surveys (OPCS) study of disability in adults (N > 14000) was reanalysed. A group with moderate or severe cognitive impairments was identified and age-specific estimators of sociodemographic characteristics, household types, disabilities and service use were combined with population estimates for district health authorities in England and Wales. RESULTS: The proportion of the 65 plus population who are 85 plus varies from 8% to 15% across districts, equivalent to national population projections for 1986 and 2031 respectively. The estimated prevalence of the study group varies from 53 to 70 per 1000 population aged 65 plus, with 34-48% of cases aged 85 plus. Curiously, the proportion with severe disabilities varies little across districts. If national norms applied, local rates of institutionalization would vary from 18 to 27 per 1000 aged 65 plus. CONCLUSION: Local differences in population age structure age large compared to national changes over decades. Local differences have substantial effects on overall prevalence and on the proportion of the cognitively impaired who would be institutionalized if national patterns applied. Service design should be influenced by these complex variations, with estimates modified by local surveys.
Sweeping national changes in health care financing and delivery are forcing major modifications in the numbers, types, and distribution of physician manpower thought to be appropriate for the new paradigms. Not surprisingly, these changes are exerting great pressure on medical education institutions to also adapt to the changing requirements. In Oklahoma, these financial and policy changes are accompanied by demands upon the colleges of medicine to increase the numbers of physicians who locate their practices in rural locations. The maintenance of a comprehensive and well balanced basic and advanced medical education effort within these complex and shifting requirements continues to tax the abilities of all faculties, including the Oklahoma University College of Medicine (OUCOM).
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