Thabo Mbeki and the AIDS 'jury'.

This paper examines the debate regarding efforts by the South African government to control the spread of HIV infections, with particular reference to events surrounding the 13th International AIDS conference. We posit that the reaction of the medical, pharmaceutical, and media sectors to the stance by the President Mbeki on HIV control amounts to an over-simplification of a very complex issue. Empathy and sincere partnership are required to address South Africa's worsening AIDS situation.

Mediating the cultural boundaries between medicine, nursing and management--the central challenge in hospital reform.

This paper documents the resilience of medical and nursing profession-based subcultures and the extent of the differences between them. Against this background, we assess the capacity and willingness of medical and nursing managers to promote changes that will extend the accountability of clinicians and engender more evidence-based, financially driven and output-oriented approaches to service delivery.

A cross-national study of differences in the identities of nursing in England and Australia and how this has affected nurses' capacity to respond to hospital reform.

This paper examines similarities and differences in the identity of nursing in England and Australia. In doing this we examine how in each country nursing has developed different ideologies and strategies. Our analysis draws on data derived from a cross-national study of hospital staff in England and Australia. We demonstrate how differences in the occupational identity of nursing in each country are registered in their values, attitudes and beliefs. We suggest that these differences reflect the interplay of factors such as the strategic stances of nursing professional and industrial organisations and how nurses in each country have positioned themselves in responding to recent changes in health policy.

Reconsidering clinical accountability. An examination of some dilemmas inherent in efforts to bolster clinician accountability.

The paper critically appraises current efforts to bolster the accountability of clinicians. The paper opens with an examination of the values, meaning and rules which underpin different accountability systems. Against this background we canvass conceptual, practical and ethical issues which need to be addressed if efforts to extend the accountability of clinicians are to meet with success.

A comparison of the impact of hospital reform on medical subcultures in some Australian and New Zealand hospitals.

This article examines similarities and differences in the way that hospital staff in Australia and New Zealand are evaluating efforts to improve quality, clinical effectiveness and service integration, and to strengthen clinical accountability. We draw on data from a cross-national study of hospital staff in Australia and New Zealand. The results highlight the way in which respondents' views about reform are influenced by the interplay of two factors: the impact of respondents' occupational backgrounds (our findings point to differences in the profession-based subcultures of medicine, nursing and general management and the way that these are reflected in respondents' assessments of particular aspects of reform); and the way that the impact of professional subcultures may be mitigated by differences between the systems in which respondents were located, including differences between the programs of reform that have been pursued in each country. The implications of these findings are discussed.

Severity variations within DRGs: measurement of hospital effects by use of data on significant secondary diagnoses and procedures.

The Diagnosis Related Group classification has provided an excellent basis for enhancing the equity of resource allocation between public acute hospitals. However, it underestimates the higher levels of severity and consequent costliness of referral hospitals. This paper describes a practical way of measuring within-DRG variations in severity, which can be used to increase the precision of casemix-based funding. It involves the regression of length of stay against the numbers of significant diagnoses and procedures, and bence the prediction of additional justified costs. An example is given of its application to data from South Australian public hospitals.

Attitudes and knowledge about case mix reform among hospital staff in Australia.

This paper reports some of the findings of a national survey of staff in acute care hospitals about their knowledge of case mix and their attitudes towards it. Our findings suggest that, despite the range and scope of activities that have been pursued under the Australian Casemix Development Program (ACDP), knowledge of case mix among acute care hospital staff remains patchy. The evidence also shows that significant aspects of the DRG classification system and the uses to which it can be put are not accepted by many hospital staff, particularly medical staff. The paper concludes with a discussion of what some of these findings imply for future activity on case mix reform.

Health planning as context-dependent language play.

The concept of planning as context-dependent language play is proposed as a heuristic device to overcome shortcomings which are traced to the planner centered, means-end and prescriptive orientations of much of the existing literature on health planning. The model proposed suggests that planning should be analysed not simply in terms of the capacities and/or responsibilities that it claims to assign to planners, but also in the way that different planning discourses are mobilized, for strategic effect, by a range of other players in front-stage and back-stage settings. Within this conception, a planning exercise comes to be seen as an episode in dramas which have been running for extended periods of time. What distinguishes planning episodes from others in these dramas, is not simply the entry of players designated as planners, but also the discourses that both planners and other players mobilize as they attempt to structure and contest their relationships with one another. The implications of what this conception of planning holds for future research are then discussed.

Structural impediments to TQM in Australian health care.

The culture of quality called for by total quality management (TQM) has much to recommend it. Australian experience, however, suggests that it is not something that can easily be added to the profession-based structures and cultures prevailing in most Australian hospitals. Implementing TQM is not just a matter of advocating it. The institutional transformation implied by TQM requires additional action on multiple fronts, both internal and external to the hospital.

Unrecognised structural implications of casemix management.

This paper takes issue with some conceptual and hence practical shortcomings which underlie current attempts to use casemix methodologies in bringing medical clinicians within the writ of management. The reform programme is grounded in an instrumental conception of organisation which construes the conduct and structuring of relationships in a hospital as being the product of its alleged purposive character and its formal design features. Accordingly, it is assumed that improving hospital efficiency and effectiveness requires no more than recasting formal authority structures and introducing information systems which will extend management's capacity to surveil and control the performance of clinical work. The paper argues that this conception of hospital organisation and what is required to achieve reform, ignores institutional pre-requisites which underpin management in industrial and commercial settings and denies evidence about a range of factors inherent in the prevailing organisation of medicine which militate against efforts to extend the writ of management over hospital-based medical work.

Constituting management requires more than creating hierarchy and providing information.

Current efforts to realign authority relationships within hospitals are important, but not sufficient. The rules which underpin the autonomy of medicine and those which are required for constituting management in clinical settings are not 'things' which can be decreed in and out of existence either by altering the lines on a hospital organisation chart, or by improving hospital information systems and allocating managerial responsibility to some clinicians. Accordingly, the ultimate success of the current hospital reform program will depend on the willingness of players in health policy circles to broaden their reform agenda to encompass issues which go well beyond factors internal to the organisation of hospitals. Included here are initiatives in areas such as hospital casemix funding and budgeting; clinical protocols; establishing linkages between the managerial and clinical roles of clinician managers; and recasting the employment of hospital medical staff.

The organisational change implications of casemix-based hospital management.

The 1970s and 80s have witnessed increasing concern about the efficiency and effectiveness of hospitals as core units of the health care system. In recent times, the solutions offered for improving hospitals have centred on the promotion of a more output and finance-driven approach to hospital-based service provision, strengthening managerial authority and more recently, incorporating clinicians into the day-to-day management of hospitals. The purpose of this paper is to examine the background to these developments, how they are being made manifest within hospitals and to foreshadow their implications for the work of clinician-managers.