Lay perceptions of type 2 diabetes in Scotland:bringing health services back in

The growing prevalence of type 2 diabetes is placing Scottish health services under considerable strain. Consequently, diabetes services are undergoing a major process of reorganisation, including the devolvement of routine diabetes care/diabetic review from secondary to primary healthcare settings. This qualitative study was devised to explore newly diagnosed type 2 diabetes patients' perceptions of their disease and the health services they receive at a time when this restructuring of services is taking place. The sample comprised 40 patients resident in Lothian, Scotland, who had diverse experiences of services, some receiving GP-based care only, others having varying contact with hospital diabetes clinics. In-depth interviews were undertaken with patients, three times at six monthly intervals over 1 year, enabling their experiences to be tracked at critical junctures during the post-diagnostic period. Disease perceptions and health service delivery were found to be mutually informing and effecting. Not only did (different types of) health service delivery influence the ways in which patients thought about and self-managed their disease, over time patients' disease perceptions also informed their expectations of, and preferences for, diabetes services. We thus argue that there is a need for a reconceptualisation within the medical social sciences to take into account the context of healthcare and the economic/policy factors that inform health service delivery when looking at patients' disease perceptions. We also discuss the logistical and ethical challenges of drawing upon patients' perspectives, preferences and views in the design and delivery of future health services. © 2004 Elsevier Ltd. All rights reserved.

Patient anxiety and experiences associated with an outpatient "one-stop" "see and treat" hysteroscopy clinic

BACKGROUND: "One-stop" outpatient hysteroscopy clinics have become well established for the investigation and treatment of women with abnormal uterine bleeding. However, the advantages of these clinics may be offset by patient factors such as anxiety, pain, and dissatisfaction. This study aimed to establish patients' views and experiences of outpatient service delivery in the context of a one-stop diagnostic and therapeutic hysteroscopy clinic, to determine the amount of anxiety experienced by these women and compare this with other settings, and to determine any predictors for patient preferences. METHODS: The 20-item State-Trait Anxiety Inventory was given to 240 women attending a one-stop hysteroscopy clinic: to 73 consecutive women before their appointment in a general gynecology clinic and to 36 consecutive women attending a chronic pelvic pain clinic. The results were compared with published data for the normal female population, for women awaiting major surgery, and for women awaiting a colposcopy clinic appointment. In addition, a questionnaire designed to ascertain patients' views and experiences was used. Logistic regression analysis was used to delineate the predictive values of diagnostic or therapeutic hysteroscopy, and to determine their effect on the preference of patients to have the procedure performed under general anesthesia in the future. RESULTS: Women attending the hysteroscopy clinic in this study reported significantly higher levels of anxiety than those attending the general gynecology clinic (median, 45 vs 39; p = 0.004), but the levels of anxiety were comparable with those of women attending the chronic pelvic pain clinic (median, 45 vs 46; p = 0.8). As compared with the data from the normal female population (mean, 35.7) and those reported for women awaiting major surgery (mean, 41.2), the levels of anxiety experienced before outpatient hysteroscopy clinic treatment were found to be higher (mean, 45.7). Only women awaiting colposcopy (6-item mean score, 51.1 +/- 13.3) experienced significantly higher anxiety scores than the women awaiting outpatient hysteroscopy (6-item mean score, 47.3 +/- 13.9; p = 0.002). Despite their anxiety, most women are satisfied with the outpatient hysteroscopy "see and treat" service. High levels of anxiety, particularly concerning pain but not operative intervention, were significant predictors of patients desiring a future procedure to be performed under general anesthesia. CONCLUSIONS: Outpatient hysteroscopy is associated with significant anxiety, which increases the likelihood of intolerance for the outpatient procedure. However, among those undergoing operative therapeutic procedures, dissatisfaction was not associated with the outpatient setting.

A comparative study of 'joined-up' working in three regeneration programme case studies

This research concerns the development of coordination and co-governance within three different regeneration programmes within one Midlands city over the period from 1999 to 2002. The New Labour government, in office since 1997, had an agenda for ‘joining-up’ government, part of which has had considerable impact in the area of regeneration policy. Joining-up government encompasses a set of related activities which can include the coordination of policy-making and service delivery. In regeneration, it also includes a commitment to operate through co-governance. Central government and local and regional organisations have sought to put this idea into practice by using what may be referred to as network management processes. Many characteristics of new policies are designed to address the management of networks. Network management is not new in this area, it has developed at least since the early 1990s with the City Challenge and Single Regeneration Budget (SRB) programmes as a way of encouraging more inclusive and effective regeneration interventions. Network management theory suggests that better management can improve decision-making outcomes in complex networks. The theories and concepts are utilised in three case studies as a way of understanding how and why regeneration attempts demonstrate real advances in inter-organisational working at certain times whilst faltering at others. Current cases are compared to the historical case of the original SRB programme as a method of assessing change. The findings suggest that: The use of network management can be identified at all levels of governance. As previous literature has highlighted, central government is the most important actor regarding network structuring. However, it can be argued that network structuring and game management are both practised by central and local actors; Furthermore, all three of the theoretical perspectives within network management (Instrumental, Institutional and Interactive), have been identified within UK regeneration networks. All may have a role to play with no single perspective likely to succeed on its own. Therefore, all could make an important contribution to the understanding of how groups can be brought together to work jointly; The findings support Klijn’s (1997) assertion that the institutional perspective is dominant for understanding network management processes; Instrumentalism continues on all sides, as the acquisition of resources remains the major driver for partnership activity; The level of interaction appears to be low despite the intentions for interactive decision-making; Overall, network management remains partial. Little attention is paid to the issues of accountability or to the institutional structures which can prevent networks from implementing the policies designed by central government, and/or the regional tier.

The relationship between transformational leadership and customer-orientated boundary-spanning behaviours:examining the role of compassion

Customer-oriented boundary-spanning behaviours (COBSBs) are critical to the success of service organisations. Transformational leadership, with its emphasis on the social elements of the leader-subordinate dyad, is a likely antecedent to COBSBs. Similarly, the interpersonal nature of services suggests leader compassion could have a significant effect on the saliency of the relationship between transformational leadership and COBSBs. This paper reports on a study of the moderating effect of leader compassion on the relationship between transformational leadership and COBSBs (service delivery behaviours, internal influence and external representation). Transformational leadership and compassion both have significant and positive influences on COBSBs. However, compassion plays no moderating role. These findings are discussed and avenues for further research are proposed.

Municipal benchmarking:organisational learning and network performance in the public sector

The main purpose of this dissertation is to assess the relation between municipal benchmarking and organisational learning with a specific emphasis on benchlearning and performance within municipalities and between groups of municipalities in the building and housing sector in the Netherlands. The first and main conclusion is that this relation exists, but that the relative success of different approaches to dimensions of change and organisational learning are a key explanatory factor for differences in the success of benchlearning. Seven other important conclusions could be derived from the empirical research. First, a combination of interpretative approaches at the group level with a mixture of hierarchical and network strategies, positively influences benchlearning. Second, interaction among professionals at the inter-organisational level strengthens benchlearning. Third, stimulating supporting factors can be seen as a more important strategy to strengthen benchlearning than pulling down barriers. Fourth, in order to facilitate benchlearning, intrinsic motivation and communication skills matter, and are supported by a high level of cooperation (i.e., team work), a flat organisational structure and interactions between individuals. Fifth, benchlearning is facilitated by a strategy that is based on a balanced use of episodic (emergent) and systemic (deliberate) forms of power. Sixth, high levels of benchlearning will be facilitated by an analyser or prospector strategic stance. Prospectors and analysers reach a different learning outcome than defenders and reactors. Whereas analysers and prospectors are willing to change policies when it is perceived as necessary, the strategic stances of defenders and reactors result in narrow process improvements (i.e., single-loop learning). Seventh, performance improvement is influenced by functional perceptions towards performance, and these perceptions ultimately influence the elements adopted. This research shows that efforts aimed at benchlearning and ultimately improved service delivery, should be directed to a multi-level and multi-dimensional approach addressing the context, content and process of dimensions of change and organisational learning.

Competitive edge through operations management

A view has emerged within manufacturing and service organizations that the operations management function can hold the key to achieving competitive edge. This has recently been emphasized by the demands for greater variety and higher quality which must be set against a background of increasing cost of resources. As nations' trade barriers are progressively lowered and removed, so producers of goods and service products are becoming more exposed to competition that may come from virtually anywhere around the world. To simply survive in this climate many organizations have found it necessary to improve their manufacturing or service delivery systems. To become real ''winners'' some have adopted a strategic approach to operations and completely reviewed and restructured their approach to production system design and operations planning and control. The articles in this issue of the International journal of Operations & Production Management have been selected to illustrate current thinking and practice in relation to this situation. They are all based on papers presented to the Sixth International Conference of the Operations Management Association-UK which was held at Aston University in June 1991. The theme of the conference was "Achieving Competitive Edge" and authors from 15 countries around the world contributed to more than 80 presented papers. Within this special issue five topic areas are addressed with two articles relating to each. The topics are: strategic management of operations; managing change; production system design; production control; and service operations. Under strategic management of operations De Toni, Filippini and Forza propose a conceptual model which considers the performance of an operating system as a source of competitive advantage through the ''operation value chain'' of design, purchasing, production and distribution. Their model is set within the context of the tendency towards globalization. New's article is somewhat in contrast to the more fashionable literature on operations strategy. It challenges the validity of the current idea of ''world-class manufacturing'' and, instead, urges a reconsideration of the view that strategic ''trade-offs'' are necessary to achieve a competitive edge. The importance of managing change has for some time been recognized within the field of organization studies but its relevance in operations management is now being realized. Berger considers the use of "organization design", ''sociotechnical systems'' and change strategies and contrasts these with the more recent idea of the ''dialogue perspective''. A tentative model is suggested to improve the analysis of different strategies in a situation specific context. Neely and Wilson look at an essential prerequisite if change is to be effected in an efficient way, namely product goal congruence. Using a case study as its basis, their article suggests a method of measuring goal congruence as a means of identifying the extent to which key performance criteria relating to quality, time, cost and flexibility are understood within an organization. The two articles on production systems design represent important contributions to the debate on flexible production organization and autonomous group working. Rosander uses the results from cases to test the applicability of ''flow groups'' as the optimal way of organizing batch production. Schuring also examines cases to determine the reasons behind the adoption of ''autonomous work groups'' in The Netherlands and Sweden. Both these contributions help to provide a greater understanding of the production philosophies which have emerged as alternatives to more conventional systems -------for intermittent and continuous production. The production control articles are both concerned with the concepts of ''push'' and ''pull'' which are the two broad approaches to material planning and control. Hirakawa, Hoshino and Katayama have developed a hybrid model, suitable for multistage manufacturing processes, which combines the benefits of both systems. They discuss the theoretical arguments in support of the system and illustrate its performance with numerical studies. Slack and Correa's concern is with the flexibility characteristics of push and pull material planning and control systems. They use the case of two plants using the different systems to compare their performance within a number of predefined flexibility types. The two final contributions on service operations are complementary. The article by Voss really relates to manufacturing but examines the application of service industry concepts within the UK manufacturing sector. His studies in a number of companies support the idea of the ''service factory'' and offer a new perspective for manufacturing. Harvey's contribution by contrast, is concerned with the application of operations management principles in the delivery of professional services. Using the case of social-service provision in Canada, it demonstrates how concepts such as ''just-in-time'' can be used to improve service performance. The ten articles in this special issue of the journal address a wide range of issues and situations. Their common aspect is that, together, they demonstrate the extent to which competitiveness can be improved via the application of operations management concepts and techniques.

Servitization of the manufacturing firm:exploring the operations practices and technologies that deliver advanced services

Purpose: This paper aims to explore practices and technologies successfully servitised manufacturers employ in the delivery of advanced services. Design/methodology/approach: A case study methodology is applied across four manufacturing organisations successful in servitization. Through interviews with personnel across host manufacturers, their partners, and key customers, extensive data are collected about service delivery systems. Analyses identify convergence in their practices and technologies. Findings: Six distinct technologies and practices are revealed: facilities and their location, micro-vertical integration and supplier relationships, information and communication technologies (ICTs), performance measurement and value demonstration, people deployment and their skills, and business processes and customer relationships. These are then combined in an integrative framework that illustrates how operations are configured to successfully deliver advanced services. Research limitations/implications: The analyses are reductive and rationalising. Future studies could identify other technologies and practices. Case study as a method is inherently limited in the extent to which findings can be generalised. Practical implications: Awareness and interest in servitization is growing, yet adoption of a servitization strategy requires particular organisational capabilities on the part of the manufacturer. This study identifies technologies and practices that underpin these capabilities. Originality/value: This paper contributes to the understanding of the servitization process and, in particular, the implications to broader operations of the firm. © Emerald Group Publishing Limited.

Discretion and control in education:the teacher as street-level bureaucrat

This article assesses the impact of education reform and the new public management (NPM) on the discretion of school teachers. The focal point of the study is Michael Lipsky's theory of discretion which casts public service professionals and others involved in service delivery as 'street-level bureaucrats' because their high degree of discretionary rule-making power enabled them to effectively make policy as well as implement it. The article considers the relationship between education reform and the NPM and focuses on the increased emphasis on skills-based teaching and changes in management and leadership in schools. The literature and survey of teachers demonstrate that discretion in the workplace has been eroded to such an extent due to a high degree of central regulation and local accountability as to question the applicability of Lipsky's model. The findings are based on the literature and a small survey undertaken by the author. © 2007 BELMAS.

Evaluating local strategic partnerships:theory and practice of change

Local Strategic Partnerships (LSPs) are a major recent innovation in English local governance. As the 'partnership of partnerships' in a locality, the ability of the LSP to provide an arena for community leadership and joined up service delivery is vital to the Local Government Modernisation Agenda. Drawing on material from the national evaluation of LSPs, this paper assesses their progress. A theory of change (ToC) approach was adopted in the evaluation, and the paper shows how this approach was developed and utilised. The main findings from the evaluation are then presented and discussed. In conclusion, the article draws some wider conclusions both about the strengths and weaknesses of the ToC approach and about LSPs themselves.

Patient involvement in primary care mental health:a focus group study

Background: Patient involvement in health care is a strong political driver in the NHS. However in spite of policy prominence, there has been only limited previous work exploring patient involvement for people with serious mental illness. Aim: To describe the views on, potential for, and types of patient involvement in primary care from the perspectives of primary care health professionals and patients with serious mental illness. Design of study: Qualitative study consisting of six patient, six health professional and six combined focus groups between May 2002 and January 2003. Setting: Six primary care trusts in the West Midlands, England. Method: Forty-five patients with serious mental illness, 39 GPs, and eight practice nurses participated in a series of 18 focus groups. All focus groups were audiotaped and fully transcribed. Nvivo was used to manage data more effectively. Results: Most patients felt that only other people with lived experience of mental illness could understand what they were going through. This experience could be used to help others navigate the health- and social-care systems, give advice about medication, and offer support at times of crisis. Many patients also saw paid employment within primary care as a way of addressing issues of poverty and social exclusion. Health professionals were, however, more reluctant to see patients as partners, be it in the consultation or in service delivery. Conclusions: Meaningful change in patient involvement requires commitment and belief from primary care practitioners that the views and experiences of people with serious mental illness are valid and valuable.

Motivations for servitization:the impact of product complexity

Purpose – The purpose of this paper is to identify the commonalities and differences in manufacturers’ motivations to servitise. Design/methodology/approach – UK study based on interviews with 40 managers in 25 companies in 12 sectors. Using the concept of product complexity, sectors were grouped using the Complex Products and Systems (CoPS) typology: non-complex products, complex products and systems. Findings – Motivations to servitise were categorised as competitive, demand based (i.e. derived from the customer) or economic. Motivations to servitise vary according to product complexity, although cost savings and improved service quality appear important demand-based motivations for all manufacturers. Non-complex product manufacturers also focus on services to help product differentiation. For CoPS manufacturers, both risk reduction and developing a new revenue stream were important motivations. For uniquely complex product manufacturers, stabilising revenue and increased profitability were strong motivations. For uniquely systems manufacturers, customers sought business transformation, whilst new service business models were also identified. Research limitations/implications – Using the CoPS typology, this study delineates motivations to servitise by sector. The findings show varying motivations to servitise as product complexity increases, although some motivational commonality existed across all groups. Manufacturers may have products of differing complexity within their portfolio. To overcome this limitation the unit of analysis was the strategic business unit. Practical implications – Managers can reflect on and benchmark their motivation for, and opportunities from, servitisation, by considering product complexity. Originality/value – The first study to categorise servitisation motivations by product complexity. Identifying that some customers of systems manufacturers seek business transformation through outsourcing.

Investigation of PHY, MAC and APP layers for adaptive and cross-layer optimization in IEEE802.11 WLAN

Due to huge popularity of portable terminals based on Wireless LANs and increasing demand for multimedia services from these terminals, the earlier structures and protocols are insufficient to cover the requirements of emerging networks and communications. Most research in this field is tailored to find more efficient ways to optimize the quality of wireless LAN regarding the requirements of multimedia services. Our work is to investigate the effects of modulation modes at the physical layer, retry limits at the MAC layer and packet sizes at the application layer over the quality of media packet transmission. Interrelation among these parameters to extract a cross-layer idea will be discussed as well. We will show how these parameters from different layers jointly contribute to the performance of service delivery by the network. The results obtained could form a basis to suggest independent optimization in each layer (an adaptive approach) or optimization of a set of parameters from different layers (a cross-layer approach). Our simulation model is implemented in the NS-2 simulator. Throughput and delay (latency) of packet transmission are the quantities of our assessments. © 2010 IEEE.