Listening to local voices: adapting rapid appraisal to assess health and social needs in general practice

OBJECTIVES

To explore the use of rapid appraisal in defining the health and social needs of a community and to formulate joint action plans between the residents and service providers.

DESIGN

Collection of data by an extended primary care team from three sources: existing documents about the neighbourhood, interviews with a range of informants, and direct observations to build a profile of the community.

SETTING

Council estate of 670 homes in Edinburgh.

MAIN OUTCOME MEASURES

Perceived problems of the community and suggestions for change.

RESULTS

The interviews and focus groups identified six priorities for change, many of which were not health related. These changes have been or are being implemented.

CONCLUSIONS

An expanded primary care team can use rapid appraisal as a first step in identifying and meeting local health needs. It facilitates a multidisciplinary approach and complements quantitative methods of assessing need.

Access to health care. A conceptual framework and its relevance to health care planning

Despite some serious past efforts to clarify its multiple dimensions and meanings, access to health care has remained a rather elusive concept, hampering the work of health care policymakers and professionals as they endeavor to effect meaningful health care reform. This article provides perhaps the most detailed clarification of the access concept, especially the crucial linkages among the various access dimensions, and presents a comprehensive conceptual framework for evaluation and planning activities as they relate to people's access to health care services. The proposed conceptual model recognizes access as the outcome of a process involving the interplay between the characteristics of the health care service system and of potential users in a specified area, and moderated by health care related public policy and planning efforts. An elaborate typology of access, incorporating four pairs of access dimensions, is also derived. This atomization of the concept allows us to focus on specific aspects of the access to health care problem, and to develop precise outcome indicators of health system performance for evaluative purposes. Further, it enables the access concept and its pertinent dimensions to be put into proper perspective when assessing the health care access situation in a specific national or regional context. The relevance of the proposed access model and the typology to health care planning in general, and to spatial planning of health care service systems in particular, is also discussed.

The market reform of the New Zealand health care system searching for the Holy Grail in the Antipodes

Everywhere there is a recognition that the delivery of health care is ineffective and inefficient and that these unpleasant outcomes are a product of the perverse incentives inherent in all health care systems. In New Zealand the Government documented the defects of the health care system and has introduced radical competitive market reforms, with a purchaser-provider split, in the belief that these will improve the system's performance. The nature of these reforms, centred on the purchaser-provider divide, is similar to changes introduced in the Netherlands, the UK, Sweden, Israel and Russia. The reforms which have been introduced in New Zealand are evaluated in terms of the eight major problems its Government sought to eradicate. It is shown that instead of mitigating these problems the reforms may worsen them, with the system becoming fragmented and less equitable. The move away from a single (tax) source of funds (i.e. the single pipe) may make cost control more difficult. The Government is seeking to address the issue of information generation to facilitate market trading but it is not clear how effectiveness and efficiency data will be produced in adequate volume and quality, let alone how it will be used to change producers behaviour. Many of the problems identified by the New Zealand Government are significant and in need of resolution. However whilst the political imperative may require immediate action, the economic case for these reforms is quite poor. Incremental change, with careful evaluation, would 'inform' policy change with knowledge of the attributes of competing management mechanisms and reward systems. Instead there is the too familiar combination of political assertions and an unwillingness to measure the impact of change, behaviours which may create the causes for the advocacy of the next 'redisorganisation' of the health care system.

Purchasing for all: an alternative to fundholding

OBJECTIVE

To evaluate general practitioner participation in a district health authority's purchasing work.

DESIGN

Questionnaire study of 131 Hackney general practitioners and 33 senior health service managers; review of the minutes of 28 meetings of the Hackney General Practitioners' Forum and the contract between City and Hackney Health Authority and the St Bartholomew's NHS Trust.

SETTING

Hackney General Practitioners' Forum.

MAIN OUTCOME MEASURES

General practitioners' and managers' perceptions of how representative and effective the general practitioners' forum is; proportion of new quality targets and service developments contributed by general practitioners; main issues discussed by the forum and impact on district health authority policy.

RESULTS

99 (76%) general practitioners and 27 (82%) managers responded. Both groups perceived the forum as representative. 92% (24/26) of the managers thought the forum was effective but only 74% (70/95) of general practitioners did so, largely because some doubted that the forum was listened to 75% (103/138) of quality targets and 55% (16/29) of service developments planned in the 1993-4 contract were contributed by general practitioners. They also lobbied successfully for more resources for urology and community mental health services.

CONCLUSIONS

Input into commissioning via a general practitioners' forum can be both representative and effective. General practitioners need to work closely to achieve a consensus and those involved need administrative support. The relation between general practice and public health medicine needs to be strengthened.

The purchaser-driven reformation in health care: alternative approaches to leveling our cathedrals

Slowly mounting interest in the provider community in delivery system reform badly underestimates the extent to which major reconfiguration is already being engineered by aggressive purchasers. The once widely held view that provider-sponsored integrated firms represent the ideal health care system is being challenged by purchasers who are crafting, through short- and long-term selective contracting, provider networks that offer many of the same advantages ascribed to integrated firms. Three alternative approaches to restructuring delivery systems are examined and appraised in terms of how each may or may not be able to satisfy purchaser demands. The relentless pursuit of better cost management will have profound consequences for health care providers and their managers. Major redeployment of resources will occur as the industry converts from a hospital-centered to a continuum of care-centered management philosophy.

The role of CQI in the strategic planning process

This article describes the strategic planning process used to define the health care needs of a region and to prepare Henry Ford Health System (HFHS) to meet the needs of the 21st century. It presents key applications of continuous quality improvement in the development and implementation of the strategic plans for HFHS; explains how HFHS adapted the Deming/Shewhart cycle of continuous improvement for the purpose of improving its planning process; and delineates how the strategic planning, financial planning, and quality planning processes have been integrated.

Reform demands strategic action at the regional level

Those who understand the primary forces driving reform are in a better position to survive the transformation underway. To succeed, organizations must use this knowledge and act strategically at the regional level.