Funding the NHS. Is the NHS sustainable?

The survival of the NHS lies largely in the hands of government, and this article suggests steps that it should take to deal with pressures on the NHS in terms of funding, managing efficiency, and demands. Changes to the system of funding may be unfeasible, but management could be improved by research to allow greater understanding of the local effects of national policies. Alternatively health authorities could be given more freedom to manage funds, although this would have to be accompanied by stiff sanctions for those who failed. Demand could be contained by strengthening policies to ensure that new technologies are cost effective. The government could try to reduce demands arising from increased expectations by encouraging informed public debate about priorities and influencing the availability of private health care. All these efforts should be guided by the values underpinning the NHS, which should be debated and decided collectively and confirmed in a new charter for NHS''s 50th anniversary in 1998.     

Devolving authority for health care in Canada's provinces: 4. Emerging issues and prospects

Devolution or authority for health care is evaluated in the context of 3 objectives of provincial governments--community empowerment to garner new allies for health care restructuring, service integration to create a true "system" and conflict containment as spending is cut. Devolved authorities cannot pursue each of these objectives with equal vigour because they must balance the competing pressures from their provincial government, their providers and their local citizens. Each devolved authority accommodates these pressures in its own way, through different trade-offs. Appointed board members are generally well intentioned in representing the interests of their entire community but are unlikely to overcome formidable barriers to community empowerment in health care. Unless future board elections attract large and representative voter turnouts, they may fragment board members'' accountability (by making them more accountable to multiple interest groups) rather than solidify it (by making them more accountable to the community). Although boards have integrated and rationalized parts of the institutional sector, integration of the community sector is hampered by structural constraints such as the lack of budgetary authority for a broader scope of services, including physicians'' fees and drugs. Devolved authorities will deflect blame from provincial governments and contain conflict only while they believe that there is still slack in the system and that efficiency can be improved. When boards no longer perceive this, they are likely to add their voices to local discontent with fiscal retrenchment. Continuing evaluation and periodic meetings of authorities to share experiences and encourage cross-jurisdictional policy learning are needed.     

Old people's homes: the relatives' view.

On 1 April new arrangements came into force for arranging and funding residential care for elderly people in Britain. From now on those who seem to need full time care will be assessed first by care managers employed by local authority social services departments. This may lead to admission to an old people''s home or a nursing home. Local authorities have been told to consult both users and carers about such decisions. But what about relatives who have not actually been giving care directly? The Relatives Association was set up last year as a voluntary organisation for the relatives and friends of older people living in residential homes. Below, its vice president, Mavis Nicholson, a journalist and broadcaster whose mother died of Alzheimer''s disease in a residential home last year, gives her personal view of being such a relative. And Dorothy White, the association''s founder, explains what the future may hold for elderly residents and their relatives.     

National survey of hospital patients.

OBJECTIVE--To survey patients'' opinions of their experiences in hospital in order to produce data that can help managers and doctors to identify and solve problems. DESIGN--Random sample of 36 NHS hospitals, stratified by size of hospital (number of beds), area (north, midlands, south east, south west), and type of hospital (teaching or non-teaching, trust or directly managed). From each hospital a random sample of, on average, 143 patients was interviewed at home or the place of discharge two to four weeks after discharge by means of a structured questionnaire about their treatment in hospital. SUBJECTS--5150 randomly chosen NHS patients recently discharged from acute hospitals in England. Subjects had been patients on medical and surgical wards apart from paediatric, maternity, psychiatric, and geriatric wards. MAIN OUTCOME MEASURES--Patients'' responses to direct questions about preadmission procedures, admission, communication with staff, physical care, tests and operations, help from staff, pain management, and discharge planning. Patients'' responses to general questions about their degree of satisfaction in hospitals. RESULTS--Problems were reported by patients, particularly with regard to communication with staff (56% (2824/5020) had not been given written or printed information); pain management (33% (1042/3162) of those suffering pain were in pain all or most of the time); and discharge planning (70% (3599/5124) had not been told about warning signs and 62% (3177/5119) had not been told when to resume normal activities). Hospitals failed to reach the standards of the Patient''s Charter--for example, in explaining the treatment proposed and giving patients the option of not taking part in student training. Answers to questions about patient satisfaction were, however, highly positive but of little use to managers. CONCLUSIONS--This survey has highlighted several problems with treatment in NHS hospitals. Asking patients direct questions about what happened rather than how satisfied they were with treatment can elucidate the problems that exist and so enable them to be solved.     

Randomised controlled trial of effects of coordinating care for terminally ill cancer patients.

OBJECTIVES--To measure effects on terminally ill cancer patients and their families of coordinating the services available within the NHS and from local authorities and the voluntary sector. DESIGN--Randomised controlled trial. SETTING--Inner London health district. PATIENTS--Cancer patients were routinely notified from 1987 to 1990. 554 patients expected to survive less than one year entered the trial and were randomly allocated to a coordination or a control group. INTERVENTION--All patients received routinely available services. Coordination group patients received the assistance of two nurse coordinators, whose role was to ensure that patients received appropriate and well coordinated services, tailored to their individual needs and circumstances. MAIN OUTCOME MEASURES--Patients and carers were interviewed at home on entry to the trial and at intervals until death. Interviews after bereavement were also conducted. Outcome measures included the presence and severity of physical symptoms, psychiatric morbidity, use of and satisfaction with services, and carers'' problems. Results from the baseline interview, the interview closest to death, and the interview after bereavement were analysed. RESULTS--Few differences between groups were significant. Coordination group patients were less likely to suffer from vomiting, were more likely to report effective treatment for it, and less likely to be concerned about having an itchy skin. Their carers were more likely to report that in the last week of life the patient had had a cough and had had effective treatment for constipation, and they were less likely to rate the patient''s difficulty swallowing as severe or to report effective treatment for anxiety. Coordination group patients were more likely to have seen a chiropodist and their carers were more likely to contact a specialist nurse in a night time emergency. These carers were less likely to feel angry about the death of the patient. CONCLUSIONS--This coordinating service made little difference to patient or family outcomes, perhaps because the service did not have a budget with which it could obtain services or because the professional skills of the nurse-coordinators may have conflicted with the requirements of the coordinating role.     

Collecting ethnic group data for inpatients: is it useful?

Since April last year British hospitals have had to collect data on the ethnic group of every patient. Patients must categorise their own ethnic group using the categories of the 1991 census. Claire Hilton argues that such data collection is unhelpful and will not meet its stated aim of helping to provide equitable access to NHS services for all ethnic groups. Self categorisation is unreliable, and the number of ethnic groups available is inadequate, in particular for the white population. Additional data on the size of each ethnic group in the local population and on rates of illness in particular groups are necessary to assess whether services are being provided equitably. Moreover, ethnicity is a multidimensional concept, and information on patients'' language and cultural and religious practices, as well as their place of origin, is necessary if services are to be culturally sensitive.     

Devolving authority for health care in Canada's provinces: 1. An introduction to the issues

In 9 of Canada''s 10 provinces, much of the decision-making in health care has recently been devolved to local authorities. Provincial governments want this new governance structure to at least contain costs and improve service integration. However, there has been little evaluation of devolution to determine whether these and other goals are being met. Although devolved structures in the provinces vary somewhat with respect to the number of tiers, accountability mechanisms, degree of authority and method of funding, the only structural element that varies substantially is the scope of services under the authority of local boards. The real authority of the boards depends, however, on their negotiated compromises among 3 areas of tension: the provincial government''s expectations, the providers'' interests and the local citizens'' needs and preferences. The boards'' abilities to negotiate acceptable compromises will largely determine their effectiveness. This article introduces a survey of the members of 62 boards in 5 provinces for which the response rate was 65%, with 514 of 791 board members responding.     

Accounting for cross boundary flows.

RAWP (Resource Allocation Working Party) allows for cross boundary flows by adjusting regional or district health authorities'' (DHAs) targets at an average specialty cost. The previous paper in this series examined problems for an inner city district health authority arising from RAWP cross boundary flow adjustment. This paper examines the likely importance of these and other problems for the National Health Service as a whole. Cross charging has been proposed as an alternative method of funding flows. District health authorities would receive an allocation equivalent to their RAWP target and then all non-emergency flows would be agreed between the authorities where patients live and competing authorities offering treatment at previously negotiated charges based on local estimates of each type of case. The problem of cost estimation is usually cited as a difficulty with this proposed reform, but this paper also discusses other important issues that tend to be neglected.     

Quality and professionalism in health care: a review of current initiatives in the NHS.

Since the start of the 1990s the NHS and the clinical professions have made significant investments in quality management in health care, and a plethora of initiatives has been aimed at service improvement. From a patient''s perspective the extent to which these exercises have been cost effective is uncertain, although they have certainly involved great effort and enterprise on the part of many clinicians and managers. An important opportunity now exists to integrate this work into the mainstream of clinical and general service management. If clinicians can accept quality management concepts as central to their professional ethos and regulatory structures this could help them to maintain their professional authority and protect them and their patients from imposed decisions based on inadequate understanding of health care costs and benefits.     

Web database of molecular genetic data from fish stocks

Much research at the national and international level has been devoted to the development of several genetic methods for use in the characterization of fish stocks. We have developed a database that collates data from population genetic studies of fish. This database is accessible to researchers and control authorities on the Internet and should serve as a repository for genetic information of commercially important fish species. The prototype database has been developed in such a way that the new information can easily be updated by researchers in the field, who can submit their own data. The site can be found at http://fishgen.jrc.it.     

Trends in Romanian biodiversity conservation policy

Romania's commitment and ability to protect its environment inthe long term is challenged by several problems: insufficient financialmechanisms, monitoring, enforcement, and the information dissemination capacityof local environment protection agencies. History indicates that periods ofeconomic and social transition are very dangerous to biodiversity conservation.The demonstrated tendency during such periods gives priority to short-termincome-generating activities. Romanian conservation policy has had to adapt tothis change of circumstances. New sites have been included in the nationalprotected system and new legislation has been developed. But is this enough? Dothese satisfy progressive concepts and IUCN recommendations? This paper isintended to make recommendations, based on intersectoral participatoryplanning, for nature resources management. It focuses on how biodiversityconservation is being encouraged and developed at a national level.     

中国首批国家公园体制试点的经验与成效、问题与建议

建立国家公园体制是建设生态文明制度的重要内容,是解决我国自然保护地发展过程中存在的重叠设置、多头管理、边界不清、权责不明、保护与发展矛盾突出等问题的重大举措。根据国家统一部署,2020年要设立一批国家公园,分级统一的管理体制基本建立。在跨时2年的资料收集、实地考察基础上,全面总结首批10个国家公园体制试点的经验与成效,梳理试点过程中存在的问题,并提出针对性建议,以期全面展现国家公园体制试点的最新进展,为国家公园深化建设提供参考和依据。结果显示,各试点区基本建立起分级统一的管理体制,创新了运行机制,保护力度持续加强,资金投入不断加大,科研合作不断深化,社会参与逐渐扩大。体制试点产生了明显的生态成效,民生改善初步显现,社会效益充分彰显。但是,仍然存在管理机构级别和类型参差不齐,法律制度不健全,资金保障长效机制未建立,人才队伍建设滞后,保护与发展的矛盾突出,空间范围不合理等问题。建议采取必要措施改进存在的问题,积极推广有效经验,加快健全国家公园体制。     

超声刀在乳腺癌手术教学中的应用体会

目前,超声刀因其手术效率高、术中创伤小、术后并发症少等优势已在乳腺外科手术中得到广泛使用。近几年来通过对超声刀在乳腺外科手术教学中的应用进行探索,我们发现超声刀在乳腺癌手术教学中的应用具有实践性、直观性的优势。借助超声刀行乳腺癌手术的临床教学方式可激发临床实习和见习学员学习的积极性,增强其对临床乳腺外科学习的兴趣。临床实习和见习学员在乳腺癌手术中学习并掌握超声刀的使用原理与操作方法可提高学员对乳腺外科手术的直观认识,有助于提高外科临床带教的效率和质量。本文结合超声刀在乳腺外科手术中的特点,重点分析了应用超声刀在乳腺癌手术教学中的主要优势与现存问题,对借助超声刀进行乳腺癌手术的教学进行了几点思考。     

Ten years of co-management in Greek protected areas: an evaluation

The present study attempts an evaluation of the first co-management framework that has been adopted and implemented in Greece over the last 10 years for the management of its protected areas. To get insight as to how efficient it has been, we evaluate the performance and outcomes of the 28 management authorities of the protected areas of the country that substantiate it and the conditions under which they have been operating. The study involved a large part of the Greek conservation community. It was conducted via a questionnaire dealing with issues of financing and administration, environmental management and guarding, and connection with the local community. For co-management, it is essential that the actors involved undertake their share of responsibility, which should be clearly defined and delimited; this was not usually the case. Decentralization of the power of management requires capacity building locally and active involvement of the local community; these have been addressed and achieved only to a limited degree. Most importantly, the support and commitment to conservation of state actors were often missing. Funding discontinuities, delays in responding to needs associated with biodiversity monitoring and protection and inefficient guarding were the major problems resulting from the inadequacies detected. Despite its weaknesses, the co-management framework contributed considerably to the conservation of environmental values of Greece. We propose improvements and measures that can substantially increase its overall effectiveness towards nature conservation. However, under the severe crisis that the country has been facing, its future is currently unknown.     

National survey of current arrangements for diversion from custody in England and Wales.

OBJECTIVES--To assess the extent and nature of psychiatric assessment schemes based at magistrates'' courts in England and Wales for the early diversion of mentally disordered offenders from custody and to determine the response of the NHS to new initiatives concerning alternatives to custody for this group. DESIGN--Postal survey of the probation service, petty sessional divisions, mental health provider units, and district purchasing authorities in England and Wales. SUBJECTS--All chief probation officers (n = 55), clerks to the justices (n = 284), managers of mental health provider units (n = 190), and purchasers of mental health services (n = 190) in each of the district health authorities. MAIN OUTCOME MEASURES--Number of psychiatric assessment schemes, practical difficulties in their operation, extent of regular liaison with health and social services; current and future intentions to purchase or provide services for diversion from custody. RESULTS--Data were obtained from every magistrates'' court. Forty eight psychiatric assessment schemes were identified with another 34 under development. Particular problems were lack of adequate transport arrangements, difficulties with hospital admissions, and overdependence on key people. There was little liaison between health, social services, and members of the criminal justice system. Twenty five of the 106 purchasers who responded had a policy dealing with diversion, and 39 had a scheme under development; 56 purchasers had no current or future plans about diversion. Sixty nine of the 150 providers who responded reported that diversion was included in their current or next business plan. CONCLUSION--Schemes to divert mentally disordered offenders from the criminal justice system are often hampered by lack of adequate transport arrangements, difficulties in hospital admissions, and overdependence on key people.     

Contesting the “Nature” Of Conformity: What Milgram and Zimbardo's Studies Really Show

Understanding of the psychology of tyranny is dominated by classic studies from the 1960s and 1970s: Milgram''s research on obedience to authority and Zimbardo''s Stanford Prison Experiment. Supporting popular notions of the banality of evil, this research has been taken to show that people conform passively and unthinkingly to both the instructions and the roles that authorities provide, however malevolent these may be. Recently, though, this consensus has been challenged by empirical work informed by social identity theorizing. This suggests that individuals'' willingness to follow authorities is conditional on identification with the authority in question and an associated belief that the authority is right.     

What Makes Eco‐Transformation of Industrial Parks Take Off in China?

This article focuses on the effects of policy instruments for developing viable eco‐industrial parks (EIPs) in China. We analyzed the root of China's national EIP program and inventoried the general instruments available to local authorities to shape and promote eco‐industrial development. Empirical research conducted in Tianjin Economic‐technological Development Area and Dalian Development Area led to the activities and actions conducted by local authorities. A quantitative method, technique for order of preference by similarity to ideal solution, was adopted to reveal the effects of policy instruments for comparative analysis. We conclude that the planned EIP model is useful in the early stage of EIP development, and, subsequently, it should be combined with a facilitated model to achieve long‐term goals for eco‐transformation. To this end, the policy package of economic, regulatory, and voluntary instruments should be integrated and tailored in alignment with the local situation.     

Multiculturalism,culturalism and public incorporation

In the name of ‘multiculturalism’, Western societies have witnessed since the 1980s a proliferation of discourses concerning the general place of minorities, programmes designed to foster equality, institutional structures created to provide better social services, and resources extended to ethnic minority organizations. Despite much goodwill and not inconsiderable evidence of progress in local and national initiatives concerning minorities, however, such developments have often in effect excluded minorities from, rather than facilitated their engagement with, the majority public domain. In significant ways this has been because many public policies and wider political discourses surrounding multiculturalism tend to employ ill‐defined ideas and implicit notions ‐ particularly regarding ‘culture’ ‐ which, when operationalized, function socially and politically to separate and distance members of given minorities. These ‘culturalist’ underpinnings found in a variety of multi‐culturalist initiatives can be seen to echo or to parallel views espoused in the so‐called ‘new cultural racism’. Examples on the level of local government authorities in Britain are cited. Clearly, initiatives promoting all forms of equality for minorities must be encouraged while ‘culturalism'‐in‐multi‐culturalism must be overcome. Instead of attempting to redefine ‘culture’ for policy‐makers, the author suggests that in rethinking and restructuring modes of public incorporation affecting minorities (roughly following certain key ideas of M.G. Smith on plural societies, John Rex and Bhikhu Parekh on the public domain), we may be able to begin to move beyond some currently exclusive and divisive aspects of institutionalized multiculturalism. Certain modes of local government interface in the British city of Leicester which have been co‐developed by local government authorities, by a complex range of local Islamic organizations, by a uniquely successful Muslim representative federation, and by prominent Muslim individuals are examined by way of suggesting one new model of public incorporation.     

OxDONS syndrome: the inevitable disease of the NHS reforms.

The financial demise of Oxford''s department of neurosurgery (OxDONS) was precipitated by the financial rules of the reformed NHS. In particular it was produced by the failure of "resources to follow patients"; the requirement that "prices have to follow costs"; and the use of private income for revenue expenditure, not capital expenditure. This process will eventually affect all hospital departments, but it affected the unit in Oxford sooner as it started as "efficient"--that is, underresourced--and has depended on income from extracontractual referrals and private work. Current NHS accounting rules act as a disincentive to private income being generated in NHS hospitals, and consultants should be aware of this.