A study of outcomes measures in forensic mental health

Outcomes measures, which is the measurement of effectiveness of interventions and services has been propelled onto the health service agenda since the introduction of the internal market in the 1990s. It arose as a result of the escalating cost of inpatient care, the need to identify what interventions work and in what situations, and the desire for effective information by service users enabled by the consumerist agenda introduced by Working for Patients white paper. The research reported in this thesis is an assessment of the readiness of the forensic mental health service to measure outcomes of interventions. The research examines the type, prevalence and scope of use of outcomes measures, and further seeks a consensus of views of key stakeholders on the priority areas for future development. It discusses the theoretical basis for defining health and advocates the argument that the present focus on measuring effectiveness of care is misdirected without the input of users, particularly patients in their care, drawing together the views of the many stakeholders who have an interest in the provision of care in the service. The research further draws on the theory of structuration to demonstrate the degree to which a duality of action, which is necessary for the development, and use of outcomes measures is in place within the service. Consequently, it highlights some of the hurdles that need to be surmounted before effective measurement of health gain can be developed in the field of study. It concludes by advancing the view that outcomes research can enable practitioners to better understand the relationship between the illness of the patient and the efficacy of treatment. This understanding it is argued would contribute to improving dialogue between the health care practitioner and the patient, and further providing the information necessary for moving away from untested assumptions, which are numerous in the field about the superiority of one treatment approach over another.

Service acculturation:a dyadic study of managerial and employee effects upon service firm performance

The majority of previous research into service quality and services marketing has concentrated upon the measurement of service quality outcomes, rather than the enhancement of the process by which service is delivered. In this study a conceptual model of the service acculturation process is proposed, modelling the input of service managers and employees in the delivery of service quality to customers. The conceptualisation is then empirically tested utilising a dyadic study of the New Zealand hotel industry. Results indicate that 1) a strong commitment to service is important for both managers and employees; and 2) that employees’ teamwork may have an adverse effect on perceived quality of customer service. Implications of the results and future research directions are subsequently discussed.

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.

Undermining patient and public engagement and limiting its impact:the consequences of the Health and Social Care Act 2012 on collective patient and public involvement

Patient and public involvement has been at the heart of UK health policy for more than two decades. This commitment to putting patients at the heart of the British National Health Service (NHS) has become a central principle helping to ensure equity, patient safety and effectiveness in the health system. The recent Health and Social Care Act 2012 is the most significant reform of the NHS since its foundation in 1948. More radically, this legislation undermines the principle of patient and public involvement, public accountability and returns the power for prioritisation of health services to an unaccountable medical elite. This legislation marks a sea-change in the approach to patient and public involvement in the UK and signals a shift in the commitment of the UK government to patient-centred care. © 2013 John Wiley & Sons Ltd.

Team-based working and employee well being:a cross-cultural comparison of United Kingdom and Hong Kong health services

This study examined the impact of team-based working, team structure, and job design on employee well-being (in term of job satisfaction and work stress) in staff working in healthcare organizations in Hong Kong. Cross-cultural differences in the impact of job design, team structure, and employee well-being outcomes between United Kingdom and Hong Kong were also investigated. A group of 197 staff from two Hong Kong hospitals were compared to a sample of 270 UK staff working in National Health Service organizations in the UK. Results showed that team structure and job design were significantly associated with greater employee satisfaction and lower stress for Hong Kong healthcare staff. Culture was also found to moderate the impact of team structure and job design on employee well-being. The findings suggest that although team structure and job design contribute to employee well-being, they have differential impacts across cultures. This provides insights to policy planning on building team-based organizations in the healthcare sector involving multinational collaboration.

Logics of marginalisation in health and social care reform:integration, choice, and provider-blind provision

The period 2010–2013 was a time of far-reaching structural reforms of the National Health Service in England. Of particular interest in this paper is the way in which radical critiques of the reform process were marginalised by pragmatic concerns about how to maintain the market-competition thrust of the reforms while avoiding potential fragmentation. We draw on the Essex school of political discourse theory and develop a ‘nodal’ analytical framework to argue that widespread and repeated appeals to a narrative of choice-based integrated care served to take the fragmentation ‘sting’ out of radical critiques of the pro-competition reform process. This served to marginalise alternative visions of health and social care, and to pre-empt the contestation of a key norm in the provision of health care that is closely associated with the notions of ‘any willing provider’ and ‘any qualified provider’: provider-blind provision.

Development and psychometric evaluation of a new team effectiveness scale for all types of community adult mental health teams:a mixed-methods approach

Defining 'effectiveness' in the context of community mental health teams (CMHTs) has become increasingly difficult under the current pattern of provision required in National Health Service mental health services in England. The aim of this study was to establish the characteristics of multi-professional team working effectiveness in adult CMHTs to develop a new measure of CMHT effectiveness. The study was conducted between May and November 2010 and comprised two stages. Stage 1 used a formative evaluative approach based on the Productivity Measurement and Enhancement System to develop the scale with multiple stakeholder groups over a series of qualitative workshops held in various locations across England. Stage 2 analysed responses from a cross-sectional survey of 1500 members in 135 CMHTs from 11 Mental Health Trusts in England to determine the scale's psychometric properties. Based on an analysis of its structural validity and reliability, the resultant 20-item scale demonstrated good psychometric properties and captured one overall latent factor of CMHT effectiveness comprising seven dimensions: improved service user well-being, creative problem-solving, continuous care, inter-team working, respect between professionals, engagement with carers and therapeutic relationships with service users. The scale will be of significant value to CMHTs and healthcare commissioners both nationally and internationally for monitoring, evaluating and improving team functioning in practice.

Giving whistleblowers greater protection:improving quality of care

This year, an independent review of whisleblowing in the NHS made recommendations as to how whistleblowers could be given greater protection. The review, chaired by Sir Robert Francis, intended to improve the quality of patient care and safety in the health service. But with many practitioners remaining unregulated, there are unanswered questions as to how reports of mistakes can be properly investigated and the necessary action taken against incompetent or negligent practitioners. Amanda Casey, Chair of the Registration Council for Clinical Physiologists, makes the case for regulation of professionals whose work poses potential risks to patients and can place healthcare managers in an invidious position.

Hospital accounting and the history of health-care rationing

Focussing on the period from 1948 to 1997, this paper examines the history of rationing in the British National Health Service (NHS), with special reference to the role of hospital accounting in this context. The paper suggests that concerns regarding rationing first emerged in the 1960s and 1970s in response to the application of economic theories to the health services, and that rationing only became an issue of wider concern when the NHS increasingly came to resemble economic models of health services in the early 1990s. The paper moreover argues that, unlike in the USA, hospital accounting did not play a significant role in allocating or withholding health resources in Britain. Rudimentary information systems as well as resistance from medical professionals are identified as significant factors in this context.

Accounting and the 'insoluble' problem of health care costs

Health service accounting reforms are frequently promoted, explained or justified with reference to ageing populations, expensive medical technologies and their purported implications for the cost of health care. Drawing on Foucault’s genealogical method, we examine the emergence of concerns regarding health expenditure in the wake of the creation of the British National Health Service in 1948, and their relationship with health service accounting practices. We argue that concerns regarding the cost of health care are historically contingent rather than inescapable consequences of demographic and technological change, and that health service accounting practices are both constitutive and reflective of such concerns. We conclude by relating our analysis to current attempts to control costs and increase efficiency in the health services.

GPs' perspectives on managing the NHS Health Check in primary care:a qualitative evaluation of implementation in one area of England

OBJECTIVES: To evaluate the implementation of the National Health Service (NHS) Health Check programme in one area of England from the perspective of general practitioners (GPs). DESIGN: A qualitative exploratory study was conducted with GPs and other healthcare professionals involved in delivering the NHS Health Check and with patients. This paper reports the experience of GPs and focuses on the management of the Heath Check programme in primary care. SETTING: Primary care surgeries in the Heart of Birmingham region (now under the auspices of the Birmingham Cross City Clinical Commissioning Group) were invited to take part in the larger scale evaluation. This study focuses on a subset of those surgeries whose GPs were willing to participate. PARTICIPANTS: 9 GPs from different practices volunteered. GPs served an ethnically diverse region with areas of socioeconomic deprivation. Ethnicities of participant GPs included South Asian, South Asian British, white, black British and Chinese. METHODS: Individual semistructured interviews were conducted with GPs face to face or via telephone. Thematic analysis was used to analyse verbatim transcripts. RESULTS: Themes were generated which represent GPs' experiences of managing the NHS Health Check: primary care as a commercial enterprise; 'buy in' to concordance in preventive healthcare; following protocol and support provision. These themes represent the key issues raised by GPs. They reveal variability in the implementation of NHS Health Checks. GPs also need support in allocating resources to the Health Check including training on how to conduct checks in a concordant (or collaborative) way. CONCLUSIONS: The variability observed in this small-scale evaluation corroborates existing findings suggesting a need for more standardisation. Further large-scale research is needed to determine how that could be achieved. Work needs to be done to further develop a concordant approach to lifestyle advice which involves tailored individual goal setting rather than a paternalistic advice-giving model.

Managerial work roles of health care executives in the changing environment of academic medical centers

The current U.S. health care system faces numerous environmental challenges. To compete and survive, health care organizations are developing strategies to lower costs and increase efficiency and quality. All of these strategies require rapid and precise decision making by top level managers. The purpose of this study is to determine the relationship between the environment, made up of unfavorable market conditions and limited resources, and the work roles of top level managers, specifically in the settings of academic medical centers. Managerial work roles are based on the ten work roles developed by Henry Mintzberg, in his book, The Nature of Managerial Work (1973). ^ This research utilized an integrated conceptual framework made up of systems theory in conjunction with role, attribution and contingency theories to illustrate that four most frequently performed Mintzberg's work roles are affected by the two environment dimensions. The study sample consisted of 108 chief executive officers in academic medical centers throughout the United States. The methods included qualitative methods in the form of key informants and case studies and quantitative in the form of a survey questionnaire. Research analysis involved descriptive statistics, reliability tests, correlation, principal component and multivariate analyses. ^ Results indicated that under the market condition of increased revenue based on capitation, the work roles increased. In addition, under the environment dimension of limited resources, the work roles increased when uncompensated care increased while Medicare and non-government funding decreased. ^ Based on these results, a typology of health care managers in academic medical centers was created. Managers could be typed as a strategy-formulator, relationship-builder or task delegator. Therefore, managers who ascertained their types would be able to use this knowledge to build their strengths and develop their weaknesses. Furthermore, organizations could use the typology to identify appropriate roles and responsibilities of managers for their specific needs. Consequently, this research is a valuable tool for understanding health care managerial behaviors that lead to improved decision making. At the same time, this could enhance satisfaction and performance and enable organizations to gain the competitive edge . ^

Making Life More Satisfying for Hospitality Managers

Because of the considerable amount of time that hospitality managers spend at work, the relationship between life satisfaction and job satisfaction is of particular interest. Dissonance may result when the role at work conflicts with the role at home of with the family. Food service managers indicate that the top inter-role conflicts area is that work time takes up time that they would like to spend with family and others; that they are too tired to do some of the things they would like to do after work; and that the job makes it difficult to be the kind of friend, spouse, or parent that they would like to be.

Use of public oral health services by the adult population: a multilevel analysis

Background It is important to assess context to explain inequalities in oral health, particularly with regard to the type of service used; thus, this study aimed to identify the social determinants of public dental service use by adults and to assess whether, beyond the level individual, existing inequalities are also expressed in the context in which individuals are embedded. Methods A multilevel analysis with three levels of aggregation of variables was performed. The individual variables were derived from the database of the SB Minas Gerais project—a survey of oral health status of the population of Minas Gerais, a state of the Brazilian Southeast region. The variable at the neighborhood level came from the Census of 2010. The variables at the municipal level were obtained from available public databases relating to oral health services. At the municipal level, the Human Development Index (HDI) variable was chosen to represent quality of life in the municipalities. Results In the final model, the following individual variables were associated with greater use of public dental services: lower income (PR = 1.98, 95% CI = 1.53; 2.58), higher number of residents at home (PR = 1.37, 95% CI = 1.11; 1.68) and higher number of teeth requiring treatment (PR = 1.49, 95% CI = 1.20; 1.84). With regard to context variables, a poorer infrastructure (PR = 0.62, 95% CI = 0.40; 0.96) leads to a lower use of public services. Conclusion The use of public services is associated with family income, how this income is divided in households, the need for treatment presented by the individual and the organization of the existing oral health service infrastructure in the municipality.

The impact of income and social status on population health: a scenario based simulation for nursing students

The development of critical thinking and communication skills is an essential part of Baccalaureate and Practical Nursing education. Scenario-based simulation, a form of experiential learning, directly engages students in the learning process. This teaching learning method has been shown to increase students’ understanding of the influence of their personal beliefs and values when working with clients and to improve therapeutic communication and critical thinking skills. Students in both the BN (Collaborative) and PN Programs at the Centre for Nursing Studies demonstrate a strong theoretical understanding of the impact of income and social status on population health but often experience difficulty applying this knowledge to the clinical situations involving clients and families. The purpose of the project was to develop a scenario-based simulation activity to provide nursing students with first-hand experiences of the impact of income and social status on health service accessibility. A literature review and stakeholder consultations were conducted to inform the project. The findings of these initiatives and Kolb’s Experiential Learning Theory were used to guide all aspects of the project. This report is an account of how the income and social status simulation and its accompanying materials were developed. This project provided an excellent learning opportunity that demonstrated the use of advanced nursing competencies.