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Personal medical services pilot schemes remain internally focused. In many areas hospital doctors' willingness to work with general practice has been hampered by chief executives' fear of loss of income. Health authorities have generally failed to take responsibility for the pilot schemes. There are some fears of the schemes creating inequity at local level.
New test methods are being developed to improve the prediction of human and environmental risks and to benefit animal welfare by reducing, refining, and replacing animal use. Regulatory adoption of new test methods is often a complex and protracted process, requiring test method validation, regulatory acceptance, and implementation. Assessments of new test methods have not always been uniform within or among regulatory agencies. Thus, there have been increased pressures for a harmonized approach to test method evaluation and acceptance. In 1997, in response to these pressures and to U.S. Public Law 103-43, the National Institute of Environmental Health Sciences (NIEHS) established the Interagency Coordinating Committee on the Validation of Alternative Methods (ICCVAM) to coordinate interagency consideration of new and revised test methods. This article describes the validation and acceptance criteria and process used for the first test method evaluated by ICCVAM, the murine local lymph node assay (LLNA). Based on ICCVAM's conclusions and recommendations, the LLNA has been accepted by U.S. regulatory agencies as a stand-alone assay for allergic contact dermatitis. Two related articles in this series of three present the results of the independent peer review evaluation of the LLNA and summarize the performance characteristics of the database substantiating the validity of the LLNA.
The success of mandating memoranda of understanding (MOU) in promoting collaboration between Medicaid managed care (MCMC) plans and local health departments (LHDs) was examined in this research project. The mandate resulted in MOUs that contributed to increases in collaborative activities, increased perceived quality of health care, and successful management of reimbursement to LHDs. Factors associated with success included a local initiative type of health plan, longer length of time that the MOUs were in place, and higher interorganizational collaborativeness. Concerns related to the MOU approval process and lack of contribution of the MOUs to quality of public health services were identified. MOUs promote collaborative relationships between MCMC plans and LHDs on health care issues important to both sectors.
This research aimed to identify the issues considered important by primary stakeholders in the amalgamation of two college of nursing and midwifery and to explore differences in issue perceptions between stakeholder groups. The purpose was to provide data which would facilitate the amalgamation process. The research was carried out in two stages, the first of which was issue identification, whereby a qualitative approach to exploration was employed. This was followed by the stage of issue validation, carried out using a quantitatively oriented questionnaire. Stage 1 identified 38 specific issues relating to 13 separate issue topics. These could be further categorized into structural, teaching/learning/curricular and affective themes. Stage 2 demonstrated that these 38 issues were all considered important by all staff groups, but highlighted important, significant differences in the perceptions of how well these issues were perceived to be addressed.
During the past decade, the role of private employers in the purchase of health benefits has assumed critical importance. Purchaser-provider relationships are almost certain to grow more contentious in the current climate of escalating costs and recrimination about the sources of this escalation. This study reports the findings of structured, in-depth interviews with a sample of employee benefits managers from medium- to large-sized firms. The study focused on how these managers approach the health benefits buying process. A key finding is the wide variation observed in the buying process among a relatively homogeneous group of employers. Several prescriptive implications for health services managers are derived from the interviews, including the critical need to promote expanded and improved provider-employer communication.
Increasing emphasis is being placed on the role of the private sector in health in South Africa. This article uses the private hospital (PH) industry in the greater Cape Town area as a case study. The development and structure of the industry is described. Access to PHs is found to depend largely on membership of a medical aid fund. The PHs offer a relatively limited service, concentrating mainly on surgical cases. Problems between the PH industry and the medical aid schemes relating to the fixing of tariffs are outlined. Controversy exists over the future of PHs. It is concluded that PHs do not form an alternative to public sector services and may in fact weaken them.
This article presents the results of a qualitative analysis of 80 articles, chapters, and practitoners' guides focused on collaboration and coalition functioning. The purpose of this review was to develop an integrative framework that captures the core competencies and processes needed within collaborative bodies to facilitate their success. The resulting framework for building collaborative capacity is presented. Four critical levels of collaborative capacity--member capacity, relational capacity, organizational capacity, and programmatic capacity--are described and strategies for building each type are provided. The implications of this model for practitioners and scholars are discussed.
The Japanese health care system is sometimes considered one of the best in the world because it appears to have achieved universal coverage, high quality, and a comparatively low level of expenditure. But under compulsory national health insurance and the uniform fee schedule which has worked well so far, various problems have been produced in Japan. A growing number of persons believe some reform or readjustment may be required. Following a brief review of the Japanese health care system which includes health insurance mechanisms, the relationship among physicians, hospitals and clinics, and the impact of these structures on access to care are explored. The resulting cost of care and the quality of care are then addressed. The lack of consumer information and the nature of the physician-patient relationship related to cultural factors are important components of this health care system. These latter factors are in the process of change and the likely direction of their influence upon the Japanese health care system is explored.
Exposures to low levels of lead in the environment are believed to have potentially significant health effects, especially in children; such exposures to the general population come from many sources. Responsibility for regulating lead exposures has been derived from a multitude of laws passed by the Congress, and thus ultimate protection of people depends on actions taken by several agencies of the federal government. For this reason, the history of efforts to reduce exposures to lead is an excellent case study in the way that federal agencies do or do not work well together. The issue of reduction of lead in gasoline is discussed in relation to the evidence generated by HUD concerning the relationship of blood lead in urban children in New York City to seasonal variations in consumption of leaded gasoline in that area. Some recommendations for developing interagency cooperation in such controversies are presented.
Partnership work with service users and carers in social work education is a policy requirement, and it is also central to the anti-oppressive and rights-based values of social work. This paper reports research findings which are drawn from an educational context, but are also relevant to the wider field of health and social care. The research team undertook a systematic knowledge review using the Evidence for Policy and Practice Information and Coordinating Centre system, which had been used in health and education, but which had not previously been used in social care and social work. This involved an extensive search of electronic databases and rigorous screening to identify studies which had sufficient relevance to be subjected to detailed analysis. The research team also undertook a practice survey of the teaching, learning and assessment of partnership in prequalifying programmes in England, Wales and Northern Ireland. This involved three stages: a document search; telephone interviews; and focus groups held with students, academic staff, and service users and carers. Throughout the research process, the interdisciplinary team was advised and supported by a stakeholder group which consisted of service users and carers, students, and employer representatives. In the second part of the paper, subsequent discussion explores key findings from the research, including the disputed nature of the concept of partnership, models of partnership work within social work education and the dearth of research on partnership outcomes. Five related questions are identified as a means of interrogating the robustness of the research process and findings. The paper concludes by arguing for work to be done to theorise partnership, and to develop effective strategies for improving the quality of partnership working in education, and health and social care practice.
This article describes the process to formally accredit existing in-house education courses in a continuing professional development (CPD) framework. The partnership was between two Lothian NHS organisations and a higher education institution (HEI). The nature of the partnership and the differing approaches taken by the organisations are discussed. The authors explore the context of learning in the NHS in relation to the different organisations, and describe the issues identified and the strategies used to address these. The benefits to all stakeholders are listed. Although this case study refers to an initiative in Scotland, the framework model for flexible and work-based education could be adopted across the UK.
Many of Australia's river systems have been seriously degraded by inappropriate management of regulated flows. Other systems are facing threats from future water resources developments. There is a lack of information available to aid in allocation of environmental flows to rivers in order that they are managed in an ecologically sustainable manner. The Environmental Flows Initiative (EFI) is a major Australia-wide R&D program into environmental flows, funded through the Natural Heritage Trust (NHT), and administered by Environment Australia (EA). The program aims to identify environmental values, undertake targeted research to identify risks to river systems and flow requirements to sustain environmental values, to trial flow management options, and to evaluate these trials. The NHT relies on matching funding provided by the State and Territory authorities, and supports integrative approaches with emphasis on works on-the-ground where possible. While the EFI will close significant knowledge gaps, other gaps remain. Some of these relate to development and validation of rapid assessment techniques, understanding the importance of flow variability and how to define it, manipulation of flows to control alien species, developing a system of prioritising rivers for environmental flows, and enhancing flows with other catchment, channel and floodplain rehabilitation measures.
1. Community health plans must include comprehensive approaches to meeting employment related health care needs. 2. To be effective, occupational health services should be based on a complete assessment of the needs of employers in the community. 3. Integration of community health care resources requires strong communication links, cooperation, and collaboration among providers.
In 1990 Kapolowé was, without a doubt, the site of the only surgical centre in Zaire dealing with handicaps which developed in as an after-effect of leprosy. It would be useful to explain the hazards involved in such a venture for reasons which do not pertain to medicine but, rather, to particularly trying socio-political circumstances. The best surgical expertise was thrown out for political reasons. Insecurity and economic hardships practically halted movement and, consequently, the wider application of such expertise. During a mission in 1994, there was a partial resumption of activities. The surgical team was reinstalled and made operational. It had been possible to state that multidrug therapy (MDT) had always ensured that the disabled leprosy patients, living in groups, and treated before 1990 under regular supervision, did not experience serious relapses. That fact corroborates earlier information relating particularly to surgical decompression. Although most of them were able to resume a certain measure of professional activity, social factors must still be borne in mind and the concept of partial permanent disability must be applied.
The case of Dr. Nancy Olivieri, the Hospital for Sick Children, the University of Toronto, and Apotex Inc. vividly illustrates many of the issues central to contemporary health research and the safety of research participants. First, it exemplifies the financial and health stakes in such research. Second, it shows deficits in the ways in which research is governed. Finally, it was and remains relevant not only in Toronto but in communities across Canada and well beyond its borders because, absent appropriate policies, what happened in Toronto could have happened (and could well still happen) elsewhere. In Part One of this paper, we review the facts of the Olivieri case relevant to the issues we wish to highlight: first, the right of participants in a clinical trial to be informed of a risk that an investigator had identified during the course of the trial and the obligation of the investigator to inform participants (both her own and those of other investigators); and second, the obligation of institutions to protect and promote the well-being of research participants as well as academic freedom and research integrity, the obligations of research sponsors to inform participants, research regulators, and others about unforeseen risks, and the obligations of research regulators to ensure that participants are informed of unforeseen risks and to otherwise protect and promote research integrity. In Part Two, we relate these facts and issues to New Zealand and Australia. We also make detailed recommendations for changes to the various instruments used for the governance of research involving humans in Australasia.
General hospital emergency departments (EDs) are obvious places for individuals in distress or in a mental health crisis to seek assistance. However, triage nurses admit to a lack of expertise and confidence in psychiatric assessment which can result in less accurate assessments than for medical or trauma presentations. The objectives of a collaborative project between an Adult Mental Health Program and an Adult Emergency Program in a Canadian regional health authority were to: provide education and training to triage nurses regarding mental health and illness; monitor the transit of mental health patients through the ED; monitor wait times; and determine the adequacy of the Canadian Triage Acuity and Assessment Scale in the triage of psychiatric presentations. Although the percentages of patients triaged as "emergent" did not change as a result of the education, the percentage of patients who were triaged as "not urgent" but required hospitalization was significantly reduced. Although average lengths of stay in the ED were also reduced after the education, this may or may not have been related to the educational sessions. The project was successful in increasing collaboration between the two departments and has resulted in enhanced, on-going mental health education for ED nurses.
The United Kingdom is ostensibly one country and yet public policy often varies between its constituent territories - England, Scotland, Wales and Northern Ireland. Health policy illustrates the dilemmas inherent in an apparently unitary system that permits scope for territorial variation. Administrative devolution has now been accompanied by political devolution but their interaction has yet to produce policy outcomes. This paper describes recent health policy reform with regard to primary care in terms of the tension inherent in current policy between notions of a 'one nation NHS' and the territorial diversity wrought by devolution. The paper provides a framework for understanding the emergent outcomes by exploring various concepts. In particular, the existing character of territorial policy networks, the properties of policies in devolved territories and intergovernmental relations are considered from various disciplines to examine whether greater diversity or uniformity will result from the dual reform process. Whilst this evaluation can, at this stage, only be preliminary, the paper provides a framework to appraise the emerging impact of devolution upon primary care in the UK.
In an era where funding for social service and related agencies is becoming increasingly scarce, the sharing of staff, resources, and expertise between multiple agencies is one way to compensate and by so doing, improve therapeutic recreation service delivery. This concept, known as networking, is one that was adopted by a group of agencies located in Toledo, Ohio. Through the communication of recreation and recreation related staff, these agencies have joined to provide therapeutic recreation programs and services to children and youth in the area. This article examines the concept of interagency programming and provides a historical discussion of the program's formation, the present services offered, as well as its applicability to other agencies and areas.