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PubMed2003

Nurse practitioner practice and deployment: electronic mail Delphi study.

BACKGROUND: The nature of modern government and needs of policy-makers demand accurate information that is delivered quickly. This study was part of a larger project for the Department of Health relating to nurse practitioner (NP) education and practice in UK. AIMS: The aim of the study was to identify the principal factors that help or hinder the development of NP roles in the National Health Service. METHODS: In order to facilitate a rapid response, a Delphi study was undertaken using electronic mail (e-mail) and was completed within 4 weeks. Key stakeholders in NP practice, education and research and (non-governmental) policy-making were invited to participate. Key themes relating to the deployment and practice of NPs were generated. These were refined and collated by the research team and then rated by the respondents. RESULTS: This approach generated valuable expert consensus data around NP deployment and practice. Nurse practitioners' practice is recognized as an integral part of health care that needs to be recognized by regulatory bodies to promote understanding of their potential at local levels. Nurse practitioners need freedom to innovate, adequate support and appropriate education to allow true autonomy. Limited prescribing and local restrictions on requesting investigations hinder practice. LIMITATIONS: Although this was a small-scale study, the expert panel was wide-ranging and achieved substantial consensus. CONCLUSION: The organisational and cultural changes that are required to foster the development of practice and deployment of NPs have yet to be instigated, according to the comments of the key stakeholders in this study. There appears to be a clear message that the government needs to take a more interventionist role in supporting nursing developments, rather than leaving this to local arrangements.

Delphi Technique↗
PubMed1993

The relevance of research to policy formulation: an Australian perspective.

This paper puts the role of research into perspective in the policy-making context. It points out that there are differing 'policy' goals of government and the use of research might be vital for one element, e.g. health policy, but of lesser significance in, say, international policy. The paper then goes on to describe case studies of where research has had a major impact on government decision making in Australia in the past 2 years, notably in the area of proposed changes to the marketing and sale of alcoholic beverages.

Advertising↗
PubMed1998

Creating a framework for clinical nursing practice to advance in the West Midlands region.

The West Midlands Regional Health Authority identified a lack of opportunities for nurses to develop advanced clinical practice through a recognized programme at Postgraduate diploma/Masters degree level. Education for clinical practice must be equally grounded in theory and practice. Advanced clinical practice requires more than just skills acquisition, it has a much wider remit incorporating elements of clinical expertise and higher level decision making, research awareness, teaching and role modelling, informing policy making and leading in the provision of patient care within individual Trusts. This initiative has encouraged universities, trusts and provider units to work together to identify and prepare students and staff for their changes in role, and to review existing boundaries for practice which will enable new approaches to team work and the provision of holistic patient care.

Career Mobility↗
PubMed1991

Legalizing drugs: lessons from (and about) economics.

Although applications of cost-benefit analysis (CBA) to the problem of drug policy are few in number and relatively primitive, they illustrate both the potential and limitations of CBA to produce critical insights that might improve drug policy making. But even the ideal CBA of drug policy could never produce a definitive conclusion about the desirability of drug legalization. Another tool of economics, analysis of price elasticity of demand, holds the potential to generate understanding of the likely effects of policy changes in the monetary and psychological prices associated with policy reforms.

Cost-Benefit Analysis↗
PubMed1979

Bioethical decision making: an approach to improve the process.

Current problems with the decision-making process for bioethical dilemmas are described, with emphasis on the social roles taken in this process by medical experts and laypersons. An approach is presented to improve bioethical decision making. Two consecutive steps are required. First, branching logic is used to separate the bioethical dilemmas into a series of independent, sequential decision points along a decision-making tree. This allows complex dilemmas to be dealt with more easily by resolving the individual component issues in a logical, stepwise fashion. Secondly, explicit criteria are used to decide whether each individual component is ethical or technical in nature. Using these two steps increases the likelihood that the professional and the layperson will assume their appropriate social roles and improve the overall decision-making process. How this approach can be applied to policy-making decisions, in addition to case-by-case deciding, is discussed, as are some of the settings in which the approach might be particularly helpful.

Amniocentesis↗
PubMed1993

Audit of public health medicine: the northern region's approach.

Public health doctors are required to audit their work, a principle endorsed by the Faculty of Public Health Medicine. Although general concepts of audit in clinical medicine are likely to apply to public health medicine, the practical problems are likely to be different. Public health medicine, therefore, needs to experiment with approaches to audit until general principles are established. The implementation of public health medicine audit in the Northern Region is reviewed here, highlighting the establishment of structures (e.g. a public health medicine audit promotion group and audit link-persons), processes (e.g. study days, exchange of information) and outcomes (e.g. audits undertaken and standards devised). The foundations for audit of public health medicine have been built upon wide debate and consultation, locally written documents detailing the arguments and making practical suggestions for change, ownership of policy-making decisions by a regional forum of public health doctors, day-to-day responsibility resting in an audit group, a heavy emphasis on communication including the gauging of opinions, attitudes and behaviour by survey, a perception that public health medicine has the same rights and obligations towards audit as other medical specialties, and the view that audit in our specialty will require time and patience to implement. The challenge remains of ensuring the implementation of cost-effective audit in the routine practice of public health medicine.

Data Collection↗
PubMed1997

Policy-relevant program evaluation in a national substance abuse treatment system.

This article discusses recent trends in public and private substance abuse services and offers suggestions on how the evaluation of such services can inform clinical practice and policy making. This analysis focuses particularly on the Department of Veterans Affairs (VA), which operates the largest substance abuse treatment system in the United States. In recent years, there has been an erosion of services for substance abuse outside the VA. In contrast, due to increased funding from the U.S. Congress, the VA significantly expanded substance abuse treatment from 1990 to 1994. However, efforts to "reinvent" and downsize government initiated a reversal of this growth trend in 1994, and VA services may shrink further as the system becomes more decentralized and adopts managed care strategies from the private sector. Drawing from the VA Program Evaluation and Resource Center's (PERC) experience of evaluating the VA system and working with federal policy makers, this article presents examples and suggestions for making evaluations of substance abuse treatment systems more useful in policy discussions and in day-to-day clinical practice.

Forecasting↗
PubMed1989

Medicaid eligibility, benefits, and provider payment: state preferences and the implications for national goals.

This research relates the economic concept of preference to a political theory of policy-making. It regresses measures of state Medicaid eligibility, benefit coverage, and payment rate policies on sets of economic and political variables. Results suggest that political factors may help to determine state preferences for a trade-off between generosity to the poor (eligibility and benefits) and generosity to providers (reimbursement rates). Because the federal-state Medicaid financing scheme implies some national goals for the program, these results are important. If state decisions regarding the trade-off between eligibility/benefits and provider payment are based in part on political factors, then policy-makers may have to look to a stronger federal presence to ensure that national Medicaid financial and access-related objectives are met.

Decision Making↗
PubMed2003

Politics of leprosy segregation in Japan: the emergence, transformation and abolition of the patient segregation policy.

The segregation of leprosy patients, a practice introduced early in the 20th century, was maintained in Japan after World War II. It locked in the viability of subsequent policy choices, and patients' isolation was sustained long after it was proven to be scientifically unnecessary. For leprologists and leprosarium directors, there was little opportunity to conceptualize and test the epidemiological validity and effectiveness of outpatient services as alternatives to the existing policy, since most of the patients were already hospitalized. Since leprosy was no longer a threat to the general public, bureaucratic officials, as well as legislators, lacked strong incentives to reformulate the overall policy. Within the Ministry of Health and Welfare, daily tasks were largely transferred to the section for leprosarium management, and the search for other options lost importance. For patients, long institutionalization elevated their dependency on life in leprosaria. These conditions must be emphasized as policy legacies, the results of past policies, since they posed obstacles to effective policy innovation in accordance with changing scientific knowledge. To make policies reflective of scientific knowledge, it is essential to understand and foresee the effect of policy legacy, when introducing and appraising public health policies.

Attitude to Health↗
PubMed1999

Evaluating the impact on public policy of foundation-sponsored programs in the health professions.

The leaders of national philanthropic foundations have long been active in informing public policy makers about their organizations' accomplishments and lessons learned in health care and other issues. The public policy context also is seen increasingly as an important factor influencing changes in the health care market. This article outlines how public policy was monitored and evaluated in a recent initiative in health care by a prominent national foundation. The markers of policy change in the evaluation of this initiative represented a mixture of the initiative's efforts to inform policy makers, the success the participant projects had in making policy makers aware of the initiative's goals, and actual changes in policy outcomes.

Allied Health Personnel↗
PubMed2002

Policy mapping for establishing a national emergency health policy for Nigeria.

BACKGROUND: The number of potential life years lost due to accidents and injuries though poorly studied has resulted in tremendous economic and social loss to Nigeria. Numerous socio-cultural, economic and political factors including the current epidemic of ethnic and religious conflicts act in concert in predisposing to and enabling the ongoing catastrophe of accident and injuries in Nigeria. METHODS: Using the "policymaker", Microsoft-WindowscircledR; based software, the information generated on accidents and injuries and emergency health care in Nigeria from literature review, content analysis of relevant documents, expert interviewing and consensus opinion, a model National Emergency Health Policy was designed and analyzed. A major point of analysis for the policy is the current political feasibility of the policy including its opportunities and obstacles in the country. RESULTS: A model National Emergency Health Policy with policy goals, objectives, programs and evaluation benchmarks was generated. Critical analyses of potential policy problems, associated multiple players, diverging interests and implementation guidelines were developed. CONCLUSIONS: "Political health modeling" a term proposed here would be invaluable to policy makers and scholars in developing countries in assessing the political feasibility of policy managing. Political modeling applied to the development of a NEHP in Nigeria would empower policy makers and the policy making process and would ensure a sustainable emergency health policy in Nigeria.

Journal Article↗
PubMed1998

"Changing childbirth" in the United Kingdom: lessons for U.S. health policy.

This article examines the process that led to the "changing childbirth" initiative in the United Kingdom and its possible lessons for U.S. health policy making. Changing childbirth involves substantial changes in maternity care policy, including increased independence for midwives; greater choice for mothers of birthplace and attendant; and a narrower, more specialized role for obstetricians. Potential lessons for U.S. health policy include the following points: Even narrow, targeted reform is generally slow to develop, and bureaucracies continue to show ingenuity in delaying their response to initiatives; systematic research and control over problem definition powerfully shapes the policy debate (in the United Kingdom the debate focused on normal birth, rather than on the traditional inquiry into perinatal death); a few well-placed individuals (e.g., female legislators) can bring maternity care issues to the policy agenda; and politically skilled consumer groups (which in the case of maternity care essentially do not exist in the United States) can influence the process.

Female↗
PubMed2000

Technology assessment and the sociopolitics of health technologies.

In a growing number of countries, health technology assessment (HTA) has come to be seen as a vital component in policy making. Even though the assessment of the social, political, and ethical aspects of health technology is listed as one of its main objectives, in practice, the integration of such dimensions into HTA remains limited. Recent social scientific research on the inherently political nature of technology strongly supports such a comprehensive approach. The growing claims by and on behalf of consumer groups also suggest that HTA should be informed by a broader set of perspectives. Using the example of the cochlear implant in children, this essay compares the professed objectives of HTA with typical practice and explores possible explanations for the discrepancies observed. A second example, home telemonitoring for elderly persons, demonstrates how the types of evidence considered by HTA and the process through which assessments are produced may be reconsidered. We argue for the formal integration of the sociopolitical dimensions of health care technologies into assessments. The ability of HTA to more fully address important issues from a public policy point of view will increase by making explicit the sociopolitical nature of health care technologies.

Aged↗
PubMed2003

Selecting methods for the prediction of future events in cost-effectiveness models: a decision-framework and example from the cardiovascular field.

Evidence on the cost-effectiveness of healthcare interventions is increasingly required by decision-makers. Economic models can provide timely information on the long-term impact of new technologies. However, models have been criticised because of the implicit assumptions they make, in particular the methods used to extrapolate data are rarely documented. This paper presents a systematic process for choosing a method of predicting events in economic models. This process is illustrated using a model examining the cost-effectiveness of a new HMG-CoA reductase inhibitor (statin) for primary prevention of cardiovascular disease (CVD). The prediction of future CVD events is a central component of the model, and the choice of method for predicting events was an important issue in the model's development. A literature review identified 11 studies with the information required to predict CVD events. A set of criteria were developed to assess the different methods of risk estimation, covering issues like scientific validity and acceptability to decision-makers. Risk equations derived from the Framingham Heart Study were found to be most suitable for predicting future events in the economic model. The paper illustrates how the development of economic models can be made more transparent, and suggests that the process outlined may be applied to other disease areas where there are several event prediction methods to choose from. In disease areas where published methods for predicting events are not available, the process outlined can make the uncertainty this leads to explicit, and highlight where further research is required. Such transparency can help decision-makers understand the scientific basis underpinning models, and therefore make these models more acceptable and useful for health policy-making.

Cardiovascular Diseases↗
PubMed2001

Science and precaution in the appraisal of electricity supply options.

The technological risks associated with electricity generating options are a crucial consideration in the governance of energy strategies. Conversely, many central issues in the broader social debate over the governance of environmental risk (such as acid gas emissions, radioactive waste management, nuclear safety and global climate change) relate very strongly to technology choice in the electricity supply sector. The particularities of this field, therefore, offer a topical and pertinent case with which to explore the relationship between science and precaution in the governance of technological risk. By reference to the electricity sector, the present paper examines the contrasts between 'risk-based' and 'precautionary' approaches to the governance of risk, paying particular attention to the problems of intractable uncertainties and divergent values. A number of theoretical and methodological issues in conventional risk-assessment and cost-benefit analysis are examined and their practical implications for appraisal explored. Attention then turns to the form that might be taken by approaches to the governance of energy risks that are at the same time scientifically well-founded and precautionary. Conclusions are drawn for decision and policy making in this area.

Decision Making↗
PubMed1998

The role of state maternal and child health programs in the issue of newborn discharge.

OBJECTIVES: Since dramatically shortened newborn hospitalization has shifted the focus of care from the hospital, a central policy question has become how to assure a system of care that extends into the home and community. The objective of this study was to examine the role of the state Maternal and Child Health Title V programs in the assessment of the issue of newborn discharge, the development of policies, and the assurance of appropriate care. METHOD: The director or their designee in all 50 states and the District of Columbia participated in a structured telephone interview lasting 30-60 minutes. RESULTS: Twenty-eight states reported new or previously implemented mandates for 48 hours of private insurance coverage for postpartum hospitalization. Only 6 states reported mandates concerning private insurance coverage of inpatient services, but 20 states reported mandates for postdischarge services. In the assessment function, only 18 maternal and child health (MCH) programs reported that they had undertaken specific studies on the effects of discharge timing in their states. In policy development, 18 of the 51 respondents reported that the MCH program initiated newborn discharge discussions, 23 reported that the agency participated in discussions, and 10 indicated that they did not participate. In assurance, 29 programs reported that they had taken action to provide technical assistance to local communities in developing follow-up systems. The relationship between the performance of core functions and the development of specific discharge policies in the state was minimal. CONCLUSIONS: The MCH programs appear to have played varied, but often limited, roles in the development of discharge policies. It is essential for MCH programs to engage actively in the policy-making process. But in the political environment surrounding newborn discharge policy, where laws and regulations consistent with the well-being of infants and mothers were being enacted, the limited MCH program roles may have been appropriate. Arguing against this conclusion, however, is that only 15 programs believed they had been effective and only 19 were satisfied with the discharge policies in their states, which suggests that a more proactive role may be necessary.

Aftercare↗
PubMed1995

Health care reform in Norway: the end of the "profession state"?

From the early nineteenth century until about 1980, a close relationship developed in Norway between the state and the medical profession. Medicine became integrated into the state at all levels of government, and the profession assumed important roles in initiating and formulating health policy. Another, and perhaps also causally related, development has been that health policy--and most strikingly during postwar expansion--tended to be formulated and implemented in its own policy sector, with few links to other parts of the welfare state. Important elements of the "profession state" in Norway have thus been professional integration with the state and institutional isolation from other policy sectors. Health reforms of the 1980s and 1990s brought changes in institutional relations: Other professions have replaced physicians as experts at central and local levels, and health policy making has become more politicized and integrated into welfare state policies. Thus there are clear indications that the profession state is waning.

Cross-Cultural Comparison↗
PubMed1989

International migration, international relations and foreign policy.

Recent literature on migration, international relations, and foreign policy is reviewed in this article, stressing applications of global systems paradigms, studies of state entry and exit rules, and anatomies of domestic policy-setting processes on migration. After a concise assessment of the contemporary theory of global political economy, the paper argues for seeking mid-range generalizations on the international relations of migration. It also suggests that analysis begin with the policy-setting processes of the state. Especially through the use of comparative perspectives available from domestic policy making studies and from the field of international comparative public policy, this approach offers the opportunity to fix empirically the political roles of transnational social forces, which often present themselves as participants in domestic policy contests. Promising future directions in the study of state-to-state relations are also evaluated, with the anticipation that verifying regional or other intermediate patterns of world migration politics may contribute to more general theories of international political economy.

Demography↗