Journal of Health Services Research & Policy

This article examines how health professionals guide parental acquisition of knowledge and development of expertise following diagnosis of Type 1 diabetes in a young child.

Fifty-five consultations from two outpatient paediatric diabetes clinics, one in the UK and one in the US, were audio recorded, transcribed and analysed; eight exemplar extracts are presented here. Participants were parents, whose child younger than 6 years of age had been diagnosed with diabetes within the previous 14 months, and health professionals, who were experienced doctors, nurses, dieticians and social workers.

Over the first year following diagnosis, experienced health professionals use four strategies to enable parental self-management of their child's diabetes. Clinicians begin by setting expectations to define the shared responsibilities for the management of the child's disease. Next, they introduce two concepts, trial and error, to help parents respond to variations in blood glucose values and pattern recognition, to help parents refine therapy. As parents gain confidence, clinicians encourage independent pro-active management. Together, these four strategies form a framework to enable development of parental expertise.

This framework addresses the needs of parents and guides their socialization as they assume the role of an expert health care provider for their child. If incorporated into clinical guidelines and health professional training programmes, the framework could facilitate improved self-management of diabetes and perhaps of other chronic diseases.

To elucidate the association between health care spending and the quality of care in ischaemic stroke patients in Kyoto prefecture, Japan.

Municipalities in Kyoto were categorized into quartiles based on age–sex adjusted spending for ischaemic stroke admissions. We used logistic regression models to analyse if patients from lower spending municipalities were less likely to obtain high-quality care. The sample consisted of patients admitted to hospitals in Kyoto prefecture due to ischaemic stroke between February 2009 and March 2010. Quality measures included process indicators such as diagnostic tests, recommended medications, and rehabilitation services; and outcome measures of in-hospital mortality and 30-day mortality rates.

Mean health care spending per patient ranged from 9749 US dollars (USD) to USD 14,303 from the lowest to highest municipalities. Patients from municipalities in the lowest spending quartile were significantly associated with poorer performance in the majority of the process indicators but had similar mortality rates to patients from high-spending municipalities.

Spending was found to be unevenly associated with the quality of care provided and may be indicative of an insufficient provision of resources and specialist expertise in the lower spending municipalities. Further efforts must be made to improve the quality of care in lower spending regions in Japan.

In an effort to reduce costs and respond to climate change, health care providers (Trusts) in England have started to change how they purchase goods and services. Many factors, both internal and external, affect the supply chain. Our aim was to identify those factors, so as to maintain future supply and business continuity in health and social care.

Qualitative interviews with 20 senior managers from private and public sector health service providers and social care providers in south west England. Interviews were recorded, transcribed and thematically analysed.

There were four areas of concern: contradictions with government legislation which caused confusion about how best to deliver sustainable solutions; procurement was unclear and created multiple approaches to purchasing bulk items at low cost; internal organizational systems needed to be reconsidered to embed sustainability; and embedding sustainability requires a review of organizational systems. There are examples of sustainability solutions throughout the National Health Service (NHS) but the response continues to be patchy. More research is needed into why some Trusts and some staff do not recognize the benefits of a core approach or find the systems unable to respond.

The NHS is one of the major purchasers of goods and services in England and is therefore in an excellent position to encourage sustainable resource management, manufacturing, use and disposal.

To identify the management populations of acute hospitals, and to consider how the composition of this critical but criticized group affects managerial capacity.

A multi-method study of six acute trusts, involving 1200 managers in setup interviews, focus groups and a survey. Interviews with senior managers identified the key middle management groups in their trusts. The workforce information offices at two trusts estimated the management numbers from their databases. The findings were compared with the NHS Information Centre data on the number of ‘managers and senior managers’ across the service.

The management population of an acute trust includes ‘pure plays’, whose roles are mainly managerial, and ‘hybrids’, whose roles combine managerial and clinical duties. Together, pure plays and hybrids comprise around 30% of staff in an acute trust, and even this may be an underestimate. Hybrid managers typically outnumber pure plays by four to one. NHS Information Centre data indicate that only 3% of all NHS employees are ‘managers and senior managers’.

In a climate of cost reductions and radical change, acute trusts have challenging management agendas. Policy to ‘cut management’, if focused on pure plays, increases the managerial burden on hybrids, diluting their clinical focus, and potentially jeopardizing the change agenda along with quality and safety of patient care. To strengthen management capacity, acute trust leadership and management development programmes must target the full ‘hybrids and pure plays’ population, and particularly hybrids who comprise the majority.

To review the evidence on environmental sustainability in health and social care, describe what the implications of sustainability might be for service models and policy, and explore the connection between environmental and financial sustainability.

Literature review of 78 published articles and qualitative analysis of 28 semi-structured interviews.

Provision of health and social care has a substantial impact on the environment, and opportunities exist at a number of levels to deliver services in a more sustainable way. While there is some scope to improve efficiency at the operational level, significant improvements in sustainability may require a more fundamental transformation in service models, for example, with a stronger emphasis on prevention. The current policy framework in England is perceived to create a number of barriers that discourage professionals from redesigning services in ways which could promote both environmental and financial sustainability.

Increasingly, health and social care will need to be delivered in ways that are not only financially sustainable, but environmentally sustainable too. Close conceptual connections exist with improving productivity – focusing on cost-effectiveness, value and prevention of avoidable activity could enhance sustainability from both an environmental and a financial perspective. Priorities for health care organisations could include prevention, exploring the opportunities presented by new technologies, and improving medicines management and prescribing practices. Policy-makers need to explore what changes are needed to create a more enabling environment, as well as how existing policies can be delivered in the most sustainable way.