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.     

Devolving authority for health care in Canada's provinces: 2. Backgrounds,resources and activities of board members

OBJECTIVE: To obtain information from the members of the boards of devolved health care authorities and evaluate their orientations in meeting the expectations of provincial governments, local providers and community members. DESIGN: Mail survey, conducted in cooperation with the devolved authorities, in the summer of 1995. SETTING: Three provinces (Alberta, Saskatchewan and Prince Edward Island) with established boards and 2 (British Columbia and Nova Scotia) with immature boards. PARTICIPANTS: All 791 members of boards of devolved authorities in the 5 provinces, of whom 514 (65%) responded. OUTCOME MEASURES: Sociodemographic background, training, experience and activities of board members as well as their use of information. RESULTS: There were systematic differences between established and immature boards in regard to training, information use and actual and desired activities. Members spent 35 hours per month, on average, on work for their board. Members were largely middle-aged, well educated and well off. Only 36% were employed full time. Nine out of 10 had previous experience on boards, more often in health care than in social services. They were least pleased with their training in setting priorities and assessing health care needs and most pleased with their training in participating effectively in meetings and understanding their roles and responsibilities. The information for decision-making most available to them was information on service costs (68% said it was available "most of the time" or "always") and utilization (64%); the least available information was that on key informants'' opinions (47%), service benefits (37%) and citizens'' preferences (28%). Board activity was dominated by setting priorities and assessing needs, secondarily occupied with ensuring the effectiveness and efficiency of services and allocating funds, and least concerned with delivering services and raising revenue. The match between activities desired by members and actual activities was significantly poorer for members of immature boards than for those of established boards. CONCLUSIONS: The responses concerning these structural variables suggest that board members are most likely to meet the expectations of provincial governments. Fewer appear well equipped to accommodate the views of their providers and even fewer to incorporate the perspectives of their community.     

Devolving authority for health care in Canada's provinces: 3. Motivations,attitudes and approaches of board members

OBJECTIVE: To obtain information from the members of the boards of devolved health care authorities on their motivations, attitudes and approaches, to evaluate their relative orientations to the expectations of provincial governments, local providers and community members, and to evaluate the influence of members'' being employees in health care or social services and being willing to stand for election. DESIGN: Mail survey conducted in cooperation with the devolved authorities during the summer of 1995. SETTING: Three provinces (Alberta, Saskatchewan and Prince Edward Island) with established boards and 2 provinces (British Columbia and Nova Scotia) with immature boards. PARTICIPANTS: All 791 members of the boards of devolved authorities in the 5 provinces, of whom 514 (65%) responded. OUTCOME MEASURES: Respondents'' declared motivations, levels of confidence in board performance and attitudes toward accountability; differences between members who were willing to run for election to boards and others and differences between members who were employees in health care or social services and others. RESULTS: The main motivations of board members were an interest in health care and a desire to be part of decision-making and their main concern was inadequacy of data for decision-making. Almost all (93%) felt that they made good decisions, and 69% thought that they made better decisions than those previously made by the provincial government. Most (72%) felt that they were accountable to all of the local citizens, although nearly 30% stated that they represented the interests of a specific geographic area or group. Attitudes toward their provincial governments were polarized, with half agreeing and half disagreeing that provincial rules restrict the board members. The board members who were employed in health care and social services and those who were willing to stand for election did not differ substantially from their counterparts, although potential electoral candidates were less likely than others to feel accountable to provincial-level constituencies (such as taxpayers and the minister of health) and more likely to represent the interests of a specific geographic area or group. Only a modest number of differences were found among members from different provinces. CONCLUSIONS: Board members'' strong feelings of accountability to and representation of local citizens could counteract the structural influences leading board members to favour the interests of provincial governments and providers.     

区域生态风险评价的关键问题与展望

区域生态风险评价具有多风险因子、多风险受体、多评价终点、强调不确定性因素以及空间异质性的特点,它与传统的生态风险评价在风险源、胁迫因子和评价尺度上具有明显区别。尝试建立了一个基于陆地生态系统的区域生态风险评价框架,同时针对目前区域生态风险评价的研究现状,指出不确定性分析、尺度外推难、评价指标不统一、评价标准不统一、风险因子筛选及优先排序、区域内污染物复合、水生过渡到陆生生态系统风险评价、特殊的人为因素等是目前区域生态风险评价存在的关键问题及难点所在,并提出解决这些问题可能所需的工具、手段和理论方法突破。最后指出区域生态风险观测与数据采集加工、区域生态风险指标体系的统一与整合、区域生态风险评价方法论、区域生态风险的空间分布特征与表达以及区域生态风险评价反馈与管理机制5个方面是区域生态风险评价未来的研究重点。     

Quality of life measures in health care. I: Applications and issues in assessment.

Many clinicians remain unsure of the relevance of measuring quality of life to their clinical practice. In health economics quality of life measures have become the standard means of assessing the results of health care interventions and, more controversially, the means of prioritising funding; but they have many other applications. This article--the first of three on measuring quality of life--reviews the instruments available and their application in screening programmes, audit, health care research, and clinical trials. Using the appropriate instrument is essential if outcome measures are to be valid and clinically meaningful.     

Community care in London: the prospects.

Elderly and disabled people have been led to expect great improvements in the quality of community care after April 1993. The choice to live safely at home is to be offered as an alternative to residential care. The financial and organisational relationships are all intended to support this in practice. The Tomlinson recommendations will create instability for providers, and much new and overdue investment in primary and community services is needed if the community care reforms are to work. There are, however, other obstacles looming which pose an even greater threat to the smooth transition after April 1993. The formula by which government money for implementation will be distributed discriminates against London. The sheer complexity of the organisational transformation has also been underestimated; the machinery of government both locally and centrally is ill equipped to maintain the precedence of the consumer. There are examples of good practice in London boroughs, but the dangers of Londoners ending up with the worst of all worlds are great.