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PubMed2001

Public release of information on quality of care: how are health services and the public expected to respond?

Public disclosure of the comparative performance of health care providers has been proposed as one mechanism of improving the quality of care. Performance data have been made public in the USA for over a decade and the provision of comparative information about quality of care is a central feature of current UK government health policy. The balance between the advantages and risks of pursuing such a policy in publicly funded health service is largely unknown. Advocates of public disclosure cite the role that comparative data can play in ensuring accountability, shifting the ownership of information (and therefore power) from professionals to service users and encouraging improvements in the processes and outcomes of care. However, these expectations are not necessarily realistic. There is some evidence that the public make little use of comparative data and there is a risk that public release may result in a loss of confidence in the health system and demoralisation of health service staff. In addition, there is a legitimate doubt that any early impact of disclosure will not be sustained and that the outcomes will not justify the necessary expenditure. In conclusion, we suggest that the theoretical benefits of promoting public disclosure as voiced by advocates of the policy may not be realised in practice.

Health Services Research↗

PubMedDate not supplied

Who's mind is it anyway?

As UK Health Minister John Bowis knew the challenges, the progress and the disasters of mental health provision and policy. He learned from service users, carers and practitioners that reality was usually different from theory. He came to believe a new structure was necessary to give patients a one-stop shop of care and treatment, that patients should be more involved in decisions that affect them and that stigma must be tackled by education and by wider understanding of services and crisis management. He now campaigns in the European Parliament and in many parts of the world for mental health to be higher on national agendas and to be based on effective and humane policies that ensure the appropriate treatment is provided and provided with dignity.

Community Participation↗

PubMed2006

Adaptive functioning, psychopathology and service use among 18-year-old boys with drunkenness-related alcohol use.

AIMS: To study the associations between drunkenness frequency and adaptive functioning, psychopathology and service use among 18-year-old Finnish boys in a nation-wide population-based study. METHODS: Information about drunkenness frequency within the previous six months was collected from the Finnish boys born in 1981 (n = 2306) at the boys' obligatory military call-up in 1999. Self-report questionnaires were used to study demographic factors, adaptive functioning, risk behaviour, life events, and mental health service use. Psychopathology and adaptive functioning was assessed with the Young Adult Self-Report (YASR) questionnaire. RESULTS: Of the boys, 85% reported drunkenness within the previous 6 months. Most of the subjects were occasionally drunk: 39% reported drunkenness less than a month, and 35% less than once a week, while 10% reported being frequently drunk once a week or more often. Occasional drunkenness was associated with better adaptive functioning and psychosocial well-being in general. Refraining from drunkenness was associated with suicidal ideation and internalizing problems in the YASR scale. Frequent drunkenness associated with daily smoking, illicit drug use, and externalizing problems in the YASR scale, especially delinquent behaviour. In the multivariate analysis, number of friends, having a regular relationship and cigarette smoking had a linear association with frequency of drunkenness, while drunkenness-related alcohol use was less common among those with poor friendship quality. Among the participants, entering substance use treatment was rare (0.2%). Frequent drunkenness was found to be common among mental health service users. CONCLUSIONS: Among late-adolescent boys, occasional drunkenness is a normative alcohol use pattern and associates with social competence and good psychosocial functioning. Late-adolescent boys refraining from drunkenness in addition to those with frequent drunkenness may be in a need of mental health assessment. As entering substance use treatment is infrequent, establishing integrated services with multi-professional co-operation for late-adolescent males with frequent drunkenness is emphasized.

Adaptation, Psychological↗

PubMed2001

Decision-making in teams: issues arising from two UK evaluations.

Interagency and interprofessional working has often been operationalised through the development of integrated, multiprofessional teams in the UK. However, there is considerable ambivalence reported about the success of such teams. This paper reports on two evaluations of different types of inter-agency/intra-agency, interdisciplinary/unidisciplinary teams. One study used a soft systems methodology to evaluate a health and social care team for people with enduring mental health needs and the other used a pluralistic framework to examine integrated nursing teams in primary care. In both studies, the team-working arrangements influenced the decisions made by the team members such that client care became increasingly responsive and proactive. These changes were made possible by two processes. First, information transaction was augmented and was instrumental in supporting effective client-related decision-making. Second, there was enhanced support for decision-making, especially in respect of problem solving. However, the increased autonomy of the team members had the potential to marginalise those outside the team from decision-making. It is suggested that working within a team can impact on the decisions made by team members, which exceeds a collection of individual decisions. The strengths of complex multiprofessional teams for service users may be realised if the processes of decision-making are respected.

Community Health Nursing↗

PubMedDate not supplied

[Utilization of preventive dental services by recent immigrants in Quebec].

OBJECTIVES: Studies conducted in Canada show that recent immigrants tend to under-utilize preventive services provided by the health care system. The objective of our study was to learn whether this phenomenon also applies to dental care. METHODS: Our sample was composed of 5,795 women who live in Quebec and are between 30 and 44 years old. These women filled out a self-administered questionnaire regarding their immigration status and their habits concerning dental visits. In our analyses, we compared the use of dental services of recent immigrants (10 years or less in Canada), long-term immigrants (more than 10 years), and non-immigrants (Canadians of origin). RESULTS: 55% of recent immigrants are preventive service users compared to 69% of long-term immigrants and 76% of non-immigrants. The financial barrier partly explains this result: immigrants often have a modest income and rarely benefit from dental coverage. However, having private dental insurance does not in itself explain the gap between these groups. This suggests that there is a cultural barrier in dental services access. CONCLUSIONS: Under-use of preventive services by immigrants is not limited to the medical field, it extends to dental services as well. In order to facilitate immigrants' adaptation to the health system, we recommend that the government provide them with free dental services that respect their culture.

Adult↗

PubMed1998

Linking injection drug users to medical services: role of street outreach referrals.

Street outreach workers in HIV prevention have expanded their role to include referring injection drug users to medical services. However, little is known about whether drug users act on these referrals. The study discussed in this article examined the level of exposure to street outreach reported by injection drug users, the most common medical referrals acted on as a result of such contacts, and the predictors of acting on these referrals. Findings indicate that injection drug users with four or more contacts with street outreach workers during the preceding six months were more likely to report acting on referrals. To maximize the relevance of outreach for encouraging medical treatment, both street outreach workers and social workers in health care could benefit from cross training that focuses on strengthening the referral process.

Adult↗

PubMed1991

Coordinating community and public-institutional mental health services: some unintended consequences.

Where a target group such as the mentally ill tend to use multiple and varied services over a long period of time, service coordination is often seen as the key to continuity of care. This article argues that coordination also has its perverse effects. To demonstrate, two types of community organizations (COs) working in mental health in the Canadian province of Québec are examined: alternative COs, which have their roots in community action and maintain few formal links with each other or with institutional resources; and transitional structures, COs which are developed with the cooperation of psychiatric professionals, are closely linked to hospitals and are often part of a tightly coordinated system of community services. With respect to access, continuity, programs, internal structure and flexibility, each type of community resource has particular strengths and weaknesses. In the first part of the article, these are described and compared. In the second part of the article, we examine the possible effects of Québec's new mental health policy on COs working in mental health. The policy seeks to create comprehensive systems coordinating all services at the regional level-including alternative organizations, transitional structures and public institutions. The imperatives of the complex planning process risk diluting or even eradicating the differences between the two types of mental health COs described earlier. The process may thus rob certain service users of the particular advantages they found in alternative COs. For those mentally ill who, by choice or by chance, remain marginal to the coordinated system, there may ultimately be no resources available at all.

Community Mental Health Services↗

PubMed1998

Health-care reforms in the People's Republic of China--strategies and social implications.

Analyses the features, strategies and characteristics of health-care reforms in the People's Republic of China. Since the 14th Central Committee of the Chinese Communist Party held in 1992, an emphasis has been placed on reform strategies such as cost recovery, profit making, diversification of services, and development of alternative financing strategies in respect of health-care services provided in the public sector. Argues that the reform strategies employed have created new problems before solving the old ones. Inflation of medical cost has been elevated very rapidly. The de-linkage of state finance bureau and health service providers has also contributed to the transfer of tension from the state to the enterprises. There is no sign that quasi-public health-care insurance is able to resolve these problems. Finally, cooperative medicine in the rural areas has been largely dismantled, though this direction is going against the will of the state. Argues that a new balance of responsibility has to be developed as a top social priority between the state, enterprises and service users in China in order to meet the health-care needs of the people.

China↗

PubMed2005

Trust and managerialism: exploring discourses of care.

AIM: This paper reports a study that explored the relationship between trust and managerialism through an analysis of professional discourse. BACKGROUND: Managerialism is a distinct set of discourses and practices related to managerial effectiveness, flexibility and consumer responsiveness that have come to characterize debates over the provision of health and welfare services across the developed world. At the same time, trust has attracted increasing academic and political interest. Managerial discourses are critical of healthcare professions and the way they operate. Professional opinions are challenged as representing the interests of professions rather than service users; as a consequence trust is contested. However, where practitioners are both professionals and managers, the boundaries between these discourses become blurred. Moreover, paradoxical development occurs where increasing autonomy for practitioners is accompanied by a strengthening of managerial controls over their activity. METHOD: Discourse analysis was used to explore the text from two genres, academic literature and interviews (n = 17), in the context of community residential services for people with learning disabilities. The study was conducted in 2001. FINDINGS: Two broad themes were identified, each with a number of sub-themes. The first focuses on the relationship between managerialism and trust located around the management of expectations. The second, 'the politics of care', explores the way professional and managerial discourse articulate to produce complementary and contradictory positions. CONCLUSION: The colonization of professional activity by managerial discourse has produced a context where professional activity is defined by a series of managerial imperatives; trust, which was once the product of intimate social activity is now shaped through techniques based on distrust such as audits and quality monitoring. Nevertheless, the persistence of tensions between trust and managerialism suggest an ongoing struggle for professional autonomy in the face of increasing managerial controls.

Attitude of Health Personnel↗

PubMed2004

Evaluating the impact of training in psychosocial interventions: a stakeholder approach to evaluation--part II.

Part I of this article presented an examination of the methodology used in previous psychosocial interventions (PSI) research and the rationale for the collaborative, qualitative design used in this study. In this second article the findings from an evaluation of five short PSI training courses are presented. Findings demonstrated that while the training was positively evaluated by participants and seen to be relevant to practice, the actual dissemination of PSI training into practice was a complex and context dependent process. There was difficulty for course participants in using PSI in practice as discrete, formal interventions. Rather the predominant way participants used PSI in practice was via a process of modifying PSI. The course philosophy, content and mode of delivery impacted on how the respondents constructed PSI as an overall approach to care and working relationships. Participants reported other 'hidden' benefits of training, such as reaffirming practice, increasing confidence and perhaps most powerfully, a change in attitude linked to the importance and impact attached to the service user and carer involvement in delivering the courses. Discussion locates the findings within the findings from previous PSI training evaluations and recommendations are made for a reappraisal of approaches to PSI training and research.

Education↗

PubMed1995

Contracting for palliative care.

In this paper the role of purchasing authorities, as set out in the current U.K. policy literature, is reviewed in the context of recent developments in palliative care. The notion of the purchasing cycle, from need assessment and strategic planning through to contracting and monitoring is outlined, along with core features of recent health and social care legislation in Britain: quality assurance, consumer choice and value for money. The role of providers and service users in the purchasing process is examined and the relationship between purchasers across the health/social care divide is explored. The implications of contracting for the voluntary sector provision of palliative care are also assessed. The review highlights the difficulties under the new legislation in reconciling the aim of efficiency with that of quality assurance, and of separating out the roles of purchasers and providers in a context where palliative care service developments have been provider-led. These factors reinforce the requirement to turn the purchaser-provider split into an effective partnership. Finally, the review highlights the need to address the current imbalances in the purchasing cycle by giving adequate attention to aggregate need assessment and strategic planning.

Contract Services↗

PubMed2002

Bridge to services: drug injectors' awareness and utilization of drug user treatment and social service referrals, medical care, and HIV testing provided by needle exchange programs.

Using qualitative interviews conducted in 1999, we examine awareness and use of drug user treatment and social service referrals, medical care, and HIV testing provided by needle exchange programs (NEPs) among injectors who use NEPs (N=26) and injectors who get their syringes from other sources (N=20). A four-category typology of NEP service knowledge and use emerges from these interviews: "Active involvement--use of services; "Stepping stone"--no use of services but knowledge that specific services are available; "Vague awareness"--nonspecific knowledge of service availability: and "Unaware:--no awareness of the service provision function of NEPs. We describe patterns of distribution of respondents among these categories and suggest policy implications.

Adult↗

PubMed2001

Psychiatric reform in Germany.

OBJECTIVE: To describe the ongoing process of German psychiatric reform and the structure and functioning of mental health services. METHOD: Information sources used include official reports describing mental health services, relevant publications related to organization and functioning of services. RESULTS: There has been far-reaching change in mental health care since the late 1960s: psychiatric hospitals have lost about 50% of their beds and one psychiatric hospital has been closed. One hundred and sixty-five general hospital psychiatric units have been built up. Out-patient, community and residential services have been developed. There is a lack of diversified residential and rehabilitation services, particularly for the most severely ill. Co-ordination of care is not always ensured, transfer of patients to remote nursing homes has occurred in some places. Carers and service users articulate their views to an increasing degree. CONCLUSION: Political and professional enthusiasm have been important in implementation of the German reform. Evolving it further will require major efforts.

Germany↗

PubMed2005

Self-assessment of health and social care needs by older people: a review.

This article explores the meaning and significance of 'self-assessment', a term that is increasingly being used in relation to developments affecting community practice. Self-assessment for health and social care needs has been used over a considerable period of time and for purposes as diverse as case finding for depression to assessment of housing options. Self-assessment has usually involved the use of short scales and questionnaires, but it can involve the use of physiological tests (such as testing urine for glucose) or complex, computerized decision-support systems. Although often explored as a simple means for extending the 'reach' of professional assessments (e.g. mass screening) and ensuring 'appropriate' use of health services (e.g. self-care algorithms), self-assessment is increasingly being advocated as a means of actively involving and empowering service users. However, a recent review of the topic (Griffiths et al, 2005) revealed the complexity of the topic and the pitfalls of a simplistic approach to self-assessment, which those engaged in developing the process should bear in mind.

Aged↗

PubMed2005

An OGSA Middleware for managing medical images using ontologies.

This article presents a Middleware based on Grid Technologies that addresses the problem of sharing, transferring and processing DICOM medical images in a distributed environment using an ontological schema to create virtual communities and to define common targets. It defines a distributed storage that builds-up virtual repositories integrating different individual image repositories providing global searching, progressive transmission, automatic encryption and pseudo-anonimisation and a link to remote processing services. Users from a Virtual Organisation can share the cases that are relevant for their communities or research areas, epidemiological studies or even deeper analysis of complex individual cases. Software architecture has been defined for solving the problems that has been exposed before. Briefly, the architecture comprises five layers (from the more physical layer to the more logical layer) based in Grid Technologies. The lowest level layers (Core Middleware Layer and Server Services sc layer) are composed of Grid Services that implement the global managing of resources. The Middleware Components Layer provides a transparent view of the Grid environment and it has been the main objective of this work. Finally, the highest layer (the Application Layer) comprises the applications, and a simple application has been implemented for testing the components developed in the Components Middleware Layer. Other side-results of this work are the services developed in the Middleware Components Layer for managing DICOM images, creating virtual DICOM storages, progressive transmission, automatic encryption and pseudo-anonimisation depending on the ontologies. Other results, such as the Grid Services developed in the lowest layers, are also described in this article. Finally a brief performance analysis and several snapshots from the applications developed are shown. The performance analysis proves that the components developed in this work provide image processing applications with new possibilities for large-scale sharing, management and processing of DICOM images. The results show that the components fulfil the objectives proposed. The extensibility of the system is achieved by the use of open methods and protocols, so new components can be easily added.

Computer Communication Networks↗

PubMed2005

Personality disorders in people with learning disabilities: follow-up of a community survey.

BACKGROUND: A sample of community-based service users with intellectual disability (ID) was re-examined after 5 years to determine the impact of a diagnosis of personality disorder (PD). METHODS: Seventy-five of the original 101 participants were followed up. Of these, 21 people had a PD identified during the original study. RESULTS: Compared with controls, people with a PD were significantly more likely to receive central nervous system (CNS) drugs, have more contact with psychiatric services, show increased offending behaviour, score higher on the Aberrant Behaviour Checklist and score above the threshold on the Psychiatric Assessment Schedule for Adults with Developmental Disability (PAS-ADD). Participants with PD recorded were more likely to have a recorded psychiatric disorder, have contact with specialist teams, and have more hospital admissions. CONCLUSION: People with ID and PD are able to live in the community with specialist support but improved assessment, diagnosis and support services need to be targeted more effectively to them.

Adult↗

PubMed2006

Rehabilitation service utilization and determinants among people with an intellectual disability: preliminary findings in Taiwan.

Improving rehabilitation services for people with intellectual disabilities (ID) remains an ongoing challenge in the public health system. The purpose of this article was to investigate the types of rehabilitation services used by people with ID and determine what factors predict resource utilization in Taiwan. Samples of 957 people with ID were recruited from the Taiwan National Disability Register in a cross-sectional study in 2001. The findings indicated that 24.5% of individuals with ID had received rehabilitation services in the past 7 months. The main types of services used were speech and communication therapy (50%), psychotherapy (32.1%), occupational therapy (30.3%) and physiotherapy (25.2%). Stepwise logistic regression was carried out for the utilization of rehabilitation services (yes/no). The model revealed that the following factors: (i) Major Illness Card holder, (ii) time spent in medical care, (iii) having a family physician, (iv) having illnesses, (v) age of ID individual, and (vi) gender of the main carer, were all significantly associated with the utilization of rehabilitation services. We should reorient the healthcare system to respond adequately to the health needs of rehabilitation service users and its determinants, and further research should focus on the effectiveness and efficiency of rehabilitation for people with ID in Taiwan.

Adolescent↗

PubMedDate not supplied

The role of the mental health support time recovery worker.

Today in the NHS new ways of working that aim to improve care for service users, address staff shortages and increase job satisfaction are continually being created, piloted and introduced in phases. This article examines one such role in the adult mental health arena--the support time recovery worker.

Adaptation, Psychological↗