Reforming the public sector: personalised activation services in the UK

This paper highlights the degree of flexibility and personalisation in the UK’s welfare to work programmes. The Labour Government’s New Deals as originally designed were meant to provide personalised and tailor-made services and to meet the needs of individuals. The programmes have evolved and become more personalised and promote flexible service delivery. The chapter explores the Personal Adviser model and focuses on the development of New Deal for Young People and New Deal 25 Plus. In recent years a number of factors appear to have encouraged the development of more personalised activation services in the UK.

A Letter of Consequence: Referral Letters from General Practitioners to Secondary Mental Health Services

The referral letter is a key instrument in moving patients from primary to secondary care services. Consequently, the circumstances in which a referral should be made and its contents have been the subject of clinical guidelines. This article is based on a project that demonstrated that physicians do not adhere to clinical guidelines when referring patients to secondary mental health services. This research supports earlier findings into noncompliance with guidelines by general practitioners (GPs). The authors briefly note possible reasons, which have been the subject of some debate. They also present a content analysis of referral letters to demonstrate the important ways in which they differ from guideline criteria. However, their central argument is that the role of the referral letter in relation to the GP’s repertoire of treatments has not been understood fully. Such understanding implies the need for a reexamination of the support available for GPs.

Organisational justice and smoking: the Finnish Public Sector Study

Study Objective: To examine the extent to which justice of decision-making procedures and interpersonal relations is associated with smoking. Setting: Ten municipalities and 21 hospitals in Finland. Design and Participants: Cross-sectional data derived from the Finnish Public Sector Study were analysed with logistic regression analysis models with generalized estimating equations. Analyses of smoking status were based on 34 021 employees. Separate models for heavy smoking (>20 cigarettes per day) were calculated for 6295 current smokers. Main results: After adjustment for age, education, socio-economic position, marital status, job contract, and negative affectivity, smokers who reported low procedural justice were about 1.4 times more likely to smoke >20 cigarettes per day compared with their counterparts with high justice. In a similar way, after adjustments, low justice in interpersonal treatment was significantly associated with an elevated prevalence of heavy smoking (odds ratio (OR) = 1.35, 95% CI = 1.03 to 1.77 for men and OR = 1.41, 95% CI = 1.09 to 1.83 for women). Further adjustment for job strain and effort-reward imbalance had little effect on these results. There were no associations between justice components and smoking status or ex-smoking. Conclusions: The extent to which employees are treated with justice in the workplace seems to be associated with smoking intensity independently of established stressors at work.

Effort-reward imbalance at work and the co-occurrence of lifestyle risk factors: cross-sectional survey in a sample of 36,127 public sector employees

Background In occupational life, a mismatch between high expenditure of effort and receiving few rewards may promote the co-occurrence of lifestyle risk factors, however, there is insufficient evidence to support or refute this hypothesis. The aim of this study is to examine the extent to which the dimensions of the Effort-Reward Imbalance (ERI) model – effort, rewards and ERI – are associated with the co-occurrence of lifestyle risk factors. Methods Based on data from the Finnish Public Sector Study, cross-sectional analyses were performed for 28,894 women and 7233 men. ERI was conceptualized as a ratio of effort and rewards. To control for individual differences in response styles, such as a personal disposition to answer negatively to questionnaires, occupational and organizational -level ecological ERI scores were constructed in addition to individual-level ERI scores. Risk factors included current smoking, heavy drinking, body mass index ≥25 kg/m2, and physical inactivity. Multinomial logistic regression models were used to estimate the likelihood of having one risk factor, two risk factors, and three or four risk factors. The associations between ERI and single risk factors were explored using binary logistic regression models. Results After adjustment for age, socioeconomic position, marital status, and type of job contract, women and men with high ecological ERI were 40% more likely to have simultaneously ≥3 lifestyle risk factors (vs. 0 risk factors) compared with their counterparts with low ERI. When examined separately, both low ecological effort and low ecological rewards were also associated with an elevated prevalence of risk factor co-occurrence. The results obtained with the individual-level scores were in the same direction. The associations of ecological ERI with single risk factors were generally less marked than the associations with the co-occurrence of risk factors. Conclusion This study suggests that a high ratio of occupational efforts relative to rewards may be associated with an elevated risk of having multiple lifestyle risk factors. However, an unexpected association between low effort and a higher likelihood of risk factor co-occurrence as well as the absence of data on overcommitment (and thereby a lack of full test of the ERI model) warrant caution in regard to the extent to which the entire ERI model is supported by our evidence.

Representativeness, legitimacy and power in public involvement in health-care management

Public participation in health-service management is an increasingly prominent policy internationally. Frequently, though, academic studies have found it marginalized by health professionals who, keen to retain control over decision-making, undermine the legitimacy of involved members of the public, in particular by questioning their representativeness. This paper examines this negotiation of representative legitimacy between staff and involved users by drawing on a qualitative study of service-user involvement in pilot cancer-genetics services recently introduced in England, using interviews, participant observation and documentary analysis. In contrast to the findings of much of the literature, health professionals identified some degree of representative legitimacy in the contributions made by users. However, the ways in which staff and users constructed representativeness diverged significantly. Where staff valued the identities of users as biomedical and lay subjects, users themselves described the legitimacy of their contribution in more expansive terms of knowledge and citizenship. My analysis seeks to show how disputes over representativeness relate not just to a struggle for power according to contrasting group interests, but also to a substantive divergence in understanding of the nature of representativeness in the context of state-orchestrated efforts to increase public participation. This divergence might suggest problems with the enactment of such aspirations in practice; alternatively, however, contestation of representative legitimacy might be understood as reflecting ambiguities in policy-level objectives for participation, which secure implementation by accommodating the divergent constructions of those charged with putting initiatives into practice.