Integrated systems to improve care for very high intensity users of hospital emergency department and for long-term conditions in the community.

Adult patients who are very high intensity users of hospital emergency departments (VHIU) have complex medical and psychosocial needs. Their care is often poorly coordinated and expensive. Substantial health and social resources may be available to these patients but it is ineffective for a variety of reasons. In 2009 Counties Manukau District Health Board approved a business case for a programme designed to improve the care of VHIU patients identified at Middlemore Hospital. The model of care includes medical and social review, a multidisciplinary planning approach with a designated 'navigator' and assertive follow-up, self and family management, and involvement of community based organisations, primary care and secondary care. The model has been organised around geographic localities and alongside other initiatives. An intermediate care team has been established to attend to the current presenting problems, however the main emphasis is on optimising ongoing care and reducing subsequent admissions especially by connecting patients with primary health care. This whole process could be driven by the primacy care sector in due course. The background and initial experience with implementation are described.

The professional subcultures of students entering medicine, nursing and pharmacy programmes.

This study sought to determine the attitudes, beliefs and values towards clinical work organization of students entering undergraduate medicine, nursing and pharmacy programmes in order to frame questions for a wider study. In the Faculty of Medical and Health Sciences, The University of Auckland students entering medicine, nursing and pharmacy programmes completed a questionnaire based on that used by Degeling et al. in studies of the professional subcultures working in the health system in Australia, New Zealand, England and elsewhere. Findings indicate that before students commence their education and training medical, nursing and pharmacy students as groups or sub-cultures differ in how they believe clinical work should be organized. Medical students believe that clinical work should be the responsibility of individuals in contrast to nursing students who have a collective view and believe that work should be systemized. Pharmacy students are at a mid-point in this continuum. There are many challenges for undergraduate programmes preparing graduates for modern healthcare practice where the emphasis is on systemized work and team based approaches. These include issues of professional socialization which begins before students enter programmes, selection of students, attitudinal shifts and interprofessional education.

Clinicians and the governance of hospitals: a cross-cultural perspective on relations between profession and management.

This paper explores similarities and differences in the value stances of clinicians and hospital managers in Australia, England, New Zealand and China, and provides some new insights into how we theorise about the health profession and its relations with management. The paper draws on data derived from a closed-ended questionnaire administered to 2637 hospital-based medical, nursing and managerial staff. We examine variations between the countries in the value orientations of doctors, nurses and managers by considering their assessments of issues that are the focus of reform. In particular, we examine the ways in which the Chinese findings differ from those of the other countries. Whereas the results from the Commonwealth hospitals showed a marked division between clinicians and managers about issues that can affect clinical autonomy, this was not the case in the Chinese hospitals. The concluding discussion traces these differences to a number of cultural, organisational and policy-based factors. The implications of our findings on how we conceive the relationship between professionals and organisations are then discussed, as are further lines of research.

Systemization of leadership for the systemization health care of health care: the unaddressed issue in health care reform.

The case literature strongly suggests that both in England and in Australia health care reforms have had very little impact in terms of "improved performance". It is in the context of a perceived failure in the implementation of the reforms that an interest has arisen in leadership at the level of individual clinical units (e.g an orthopaedics unit or birth unit), as the possible "fix" for bridging the promise-performance gap. Drawing upon extensive case studies that highlight the problem and context for appropriate forms of leadership, this paper argues that the appropriate discourse, in terms of leadership in health reform, needs to focus upon the issue of authorization. In making this argument, addresses the current conceptions of leadership that have been advanced in the discourse before offering some case study material that is suggestive of why attention should be focused on the issue of authorization. Illustrates how and why the processes of leading, central to implementing reform, cannot be construed as socially disembodied processes. Rather, leading and following are partial and partisan processes whose potential is circumscribed by participants' position-takings and what is authorized in the institutional settings in which they are located Argues that the "following" that clinical unit managers could command was shaped by the sub-cultures and "regulatory ideals" with which staff of each profession are involved In the interests of reform, policy players in health should not be focusing attention solely upon the performative qualities and potential leadership abilities of middle level management, but also on their own performance. They should consider how their actions affect what is authorized institutionally and which sets the scope and limits of the leadership-followership dialectic in clinical settings.

Medical Education and Curriculum Reform: Putting Reform Proposals in Context.

The purpose of this paper is to elaborate criteria by which the principles of curriculum reform can be judged. To this end, the paper presents an overview of standard critiques of medical education and examines the ways medical curriculum reforms have responded to these critiques. The paper then sets out our assessment of these curriculum reforms along three parameters: pedagogy, educational context, and knowledge status. Following on from this evaluation of recent curriculum reforms, the paper puts forward four criteria with which to gauge the adequacy medical curriculum reform. These criteria enable us to question the extent to which new curricula incorporate methods and approaches for ensuring that its substance: overcomes the traditional opposition between clinical and resource dimensions of care; emphasizes that the clinical work needs to be systematized in so far as that it feasible; promotes multi-disciplinary team work, and balances clinical autonomy with accountability to non-clinical stakeholders.

The effects of increased market competition on hospital services in Shandong and Henan Provinces.

The Chinese government began a major reform of the hospital sector in the early 1980s. The main aim was to increase productivity by phasing out prospective global budgets from the government, and encouraging between-hospital competition for the business of user-pay and insured patients. This goal was to be achieved without unreasonable prejudice to the financial sustainability of hospitals or to the fairness of access and service provision. We explored the effects of these changes by analysing data for four levels of hospital in two of the most populous provinces between 1985 and 1999. We used data envelope analysis, and found that the majority of hospitals experienced a decline in productivity. Social efficiency (measured by the level of provision of unnecessary services) also declined, especially in the largest hospitals that could easily increase the use of expensive technologies. Most hospitals increased their economic sustainability, measured as the ratio between revenue and expenditures. However, the lowest-level hospitals experienced stable or reduced sustainability due to their inability to compete with marketing by higher-level hospitals. We conclude that, although there were many benefits, the overall impact of the introduction of market forces may have been negative. An important factor was that not all aspects (such as supplier-induced demand) were adequately controlled by government agencies. We suggest ways of alleviating the most problematic elements of current arrangements.