Students Management Role And Public Service Responsibility

Students Management Role And Public Service Responsibility

“Appreciating the centrality of meeting service user needs, and the essentiality of the widest possible community participation, how best can we measure quality (i.e. efficiency, effectiveness, access, safety, person-centeredness, access) of service delivery according to the health and social needs of the public in our particular locality?”


Many European countries have witnessed an increasing need to for community participation in individual and collective situations of decision making on health policy in the recent past of two decades of governance of health systems. Involving the community is believed to extend choice and improve decisions as it widens the range of expertise available, views and experience hence there is a more likelihood that policy decisions will be more acceptable and will make people take responsibility for community and individual health decisions. It has been found that the trend of health and health systems has numerous variables that emphasize on the need to ensure community participation in policy making in all levels (Brown, I.(2000).

The association between health service providers and users of health services is going through a major transformation. Social and economic changes have been linked to this transformation by most writers. An increase in consumerism is linked to growth of market based societies as it produces more expectations in the area of limited resources (Abercrombie 1994; Mechanic 1998; Mays 2000). Coverage of healthcare scandals by the media leads to decreasing levels of public trust. An example is when there is an exposure to the public by the media cases like lack of appropriate screening of blood products as was a case in Bristol cardiac surgeons in the UK and in France in the 1980s. Greater explicitness about the way health care is rationed or resourced have also been noted (Davies 1999).

A lot of governments have introduced a health policy that enhances the crucial nature of involving users in making decisions. This form of health policy varies in different countries but common features can be noted. Numerous European countries have created policies for protecting the rights of patients (e.g. Finland) but in other countries these laws or rights have not been enforced by any legislation (e.g. the UK Patient’s Charter). Several other states have done national consultation on health priorities for example New Zealand and UK and others have involved the community in the local health organizations (e.g. UK, New Zealand and Israel) (Calnan 1995, 1998). Not many countries have made the involvement of the community in decision making on health issues a legal requirement a part from the UK (Health and Social Care Act 2001).

User involvement is a complicated venture but this study will try to examine the areas of influence in the community participation in health care decision making process. The study will examine evidence on whether user perspectives are any different from those of the managers and professionals of health and the effect of these perspectives. The objectives and aims of involvement of the user and the merits of taking strategic overview in integrating involvement in the health care organizations is considered in this study. Involvement of users in making choices on care and treatment and reasons it is taken to be crucial for them to make better and informed decisions is also studied.

The involvement of users in service improvement e.g. service planning, clinical research and evaluation is considered to be also an important factor. Quality management is discussed in order to curb the tendency of collecting user’s views regardless of the implications of practice in producing results in services.

Involvement of the local communities or the public is crucial in identifying better approaches as they have a more clear conceptual foundation than any other approaches. This practice is advocated by the WHO.

Why involve users?

Service users and health professionals have different interests concerning involvement of users. Rudolf Klein argues that in instances of scarce resources, different groups will differ on how the resources will be utilized. It has been proved that service users and health professionals differ on the important indicators of quality care. Wensing and colleagues (1996) further notes that general practitioners focused on the importance of answering patients’ needs, on the other hand the patients wanted to be taken seriously and be listened. The patients considered their involvement in decision making important whereas general practitioners argued that the patients’ ability to influence should not be taken too far.

An argument against involvement of patients in decision making is that this type of decisions cannot be founded on only technical information but also beliefs and values. Thus, the ones involved in the decision making should weigh options differently. Such instances may make two doctors disagree on the best treatment to give to a patient. In a study by Rakow (2001), it was realized that doctors treating children with congenital heart disease differed on the preference of management for the same patient. It was decided that time preferences of the patient or their parents in cases where they act as their decision makers are the aspects that should be considered.

Another argument supporting patient involvement in decision making about care and treatment is that it creates a better health outcome. Informed patients have from previous studies shown to be more compliant to treatment and have better outcomes (Kaplan et al. 1989). Much of these studies was from North America and might not be appropriate to health care systems that are funded by the public.

All the above arguments have their consequences. One being that: different types of users and health professional have different interests and values. This shows that there is need for a distinction between current, potential and occasional users, representatives and user advocates, ad carers.

The other consequence is the balance to be observed when users are given the chance to make decisions. Mechanisms and methods that should be used in involving and listening to users is another issue that emerges. There is no doubt that the results will be different in all cases the decisions takes place at either macro level of the health system, macro level of the health system or at the meso level of the health organisation.

Managers involved in social care and health organisations should clearly understand how important user, patient and community involvement in decision making is. They should note and understand the arguments for and against the involvement. Difficulties that may occur in these processes should be tackled appropriately.

Developing a Conceptual Framework

In assessing the participation in a health programme, the use of indicators in any programme to tell us on the level of participation can be suggested. The participation can be said to become narrower, broader or unchanged. Development of the indicator of community participation depends on a clear understanding of the phrases ‘participation’ and ‘community’.

Definition of the terms

Community has had two meanings in the literature of health/development (Midgley). The first meaning which is often used in health literature defines community in geographical terms: a group of people living together in the same defined area where they share basic values and organisation.

The other meaning defines community to be a group of people sharing the same basic interests. These interests differ or change from time to time as the actual members of that community change.

The third definition which is important to health professionals concerns target populations or ‘at risk’ groups, it is rooted in the epidemiological view of the community. In trying to achieve equity, efficiency and effectiveness, there needs to be identified groups of people to ensure that resources are allocated properly. In seeking a realistic definition therefore it is important to account for heath concerns.

Participation has a wide range of meanings. Three characteristics appear to be common in all these definitions. First, participation must be active, mere receiving of services does not count to be participation. Second, participation involves choice; the right and responsibility to make choices hence implicitly or explicitly have power over decisions affecting their lives. Third, choice must have the possibility of being effective.

Community participation thereby can be defined by all aspect that takes into account geographic, common interests and epidemiological meanings with features of the described participation. Community participation is a social process where specific groups having shared needs living in a defined geographic area that actively pursue identification of their needs, participate in decision making and who establish mechanisms in meeting their needs. Community participation focuses on improving individual’s health and health care by fostering effective decisions that force the shift in resources to achieve equity.

Choice refers to the individual decisions about treatment options, care packages or insurers. Mostly, choice applies to decisions at the individual level for example in selecting health insurance or health and care providers. Choice sometimes influences the degree and nature of service chosen. It is obvious that the governance of health should encourage different service options and also give chance to alternative providers. It is essential that in exercising choice people are equipped with the information and ability to make a selection from a wide range of alternatives. In making choice one requires well informed individuals who have been provided with the relevant ideas concerning service options. Due to this development of choice for a long time now has experienced expansion in social marketing on health and consumer information. Advertising in consumer magazines has increased whist health service quality information is being given on the internet.

Voice in this case is the collective patient and public views on health policy concerns or individually evaluating services. Voice mechanisms advocate for public views and collective patient health policy concerns. It does not necessarily mean however that the decision makers on health policy have to adhere to these concerns when deciding. The health systems in Europe take public and patient views on policies of health into account in several ways. Health service providers, regulatory agencies and health insurers use surveys of the public, focus groups, experience of the patients and opinions to collect the views of the consumers on current attitudes.

Representation in health systems is the formal role in health systems governance, such as membership of governing boards and committees. Patients and members of the public have roles in the boards of insurers, health regulators or health service providers.

User or community participation in choices about treatment and care

Two main arguments have been raised on the importance of involving users in treatment choices. The first argument relates to the ethical principle of autonomy in which individuals have a right in exercising control in decisions that affect their lives. This has caused many states to enact legislations that support the clinical duty in obtaining informed consent for participation in research and treatment. If the users believe that there has been an abuse of their rights to make informed choices by health professionals, a court redress can be sought. There is a variance however in the legal standards and procedures of different countries. Users of health care systems in the UK can pursue a case for negligence if they feel that they have been given insufficient information or battery if they consider that they have been touched without consent. Standards in the UK are changing but they are still weak as compared to other countries and also what counts as reasonable or sufficient information often has precedence (Doyal 2001).

The other argument is that involvement decisions and better information leads to improved health outcomes. A bulk of evidence has been collected from the US since not a lot of study in different areas has been done. Research on this area has been done well by Kaplan and colleagues. They carried out series of studies where patients with chronic conditions were either given only basic information or on the other hand given education on options available in their treatment and helped to ask questions during the consultation. It was clear that patients who had received support and coaching had significantly better health results using measures e.g. blood pressure or sugar levels and were more involved in the consultation (Kaplan et al. 1989). Users highly value information and lack of it or poor information may lead to dissatisfaction from the patient (McIver 1993).

The theory advocating for improvement of information to patients is considered to be more straightforward than the other theory for participation in decisions concerning decisions on treatment. Numerous authors have stated that the degree to which users or the community would want to be involved varies depending on various factors e.g. if it is an emergency situation or chronic condition. Younger and more educated individuals have shown a greater need for involvement in treatment decisions than people who are older people (Coulter 1997; Charles et al. 1997).

The major theories developed against provision of better information to patients and offering them more chances to be involved in decisions concerning treatment and care are the difficulties experienced and the resource implications involved. One of the difficulties is relaying complex information concerning risks and benefits of courses of action to be taken.

How organisational change initiatives, through a substantially effective and appropriate application of national policy and guidelines have provided enhanced scope for effectiveness in various countries

Patients in Europe are likely to become more demanding customers of health services over the next two decades. This will be influenced by the mass media about health, the interactive digital television and the service options of health available. The demand for high personalized services based on their particular choices and requirements. Such new developments offer challenges to the governance of systems of health in the EU.

Decision makers from different countries were brought together by the Ninth Futures Forum held by WHO in Amsterdam, The Netherlands on 10–11th October 2005. There was brought different interests and system perspectives to the issue of governance of health systems and community participation.

Switzerland for a long time now has been applying a high participatory approach, as numerous votes happen on many policy issues on both the federal and cantonal levels. It is believed that this has enhanced a better balance of focus on policies relating to public and clinical matters.

Slovenia`s Ministry of Health has been making efforts toward public communication and incorporating dialogue in making decisions since independence. Mechanisms in this country need to be further enhanced for better and quality health services.

Germany, with its system highly decentralized to the regional level is of need to determine the extent to which participation of the community or the public is done in the European countries and if their systems have observed any difference in results. Whether if public participation complicates or eases decision making is also a major issue.

Israel is going through a major issue of intervening to cover its citizens with a compulsory health insurance scheme. Because this is a major concern which affects the health benefits of the people, it could be crucial to open this issue to public participation for more acceptance and effectiveness of the administration of the matter. Attempts have been made to form a citizen’s parliament at district levels. This kind of forum is hoped to give insights to countries facing the same problem.

In Norway, particular concerns to engage marginal groups of people in more participatory decision-making.

Finland‘s many policy decisions are made at the local level. There is developed interest for them to learn from different states on the best ways to engage individuals of the community in policy making.

Malta is trying to learn how other countries have fully engaged their citizens in health policy decisions for it to draft efficient policies for its system.

In Belgium citizen’s participation is relatively new. Its patient’s rights have been developed recently. In other industries it has been successful in offering client-oriented services

Netherland’s Ministry of Health, Welfare and Sport regards citizens and patients as partners of health policy making. Its recent reform in health insurance has enhanced choice in the insurers benefit packages and choice at the individual level. Collectively the complicated issues are determining the governance decisions which need participation of the public and the ones which will not.

In the UK, its government is working towards increasing choice of health care providers to offer its residents a more concrete voice on policies concerning health policy. Social inequality in health remains to be a major concern. Well off and wealthy individuals are more likely to make use of these channels of choice and voice.

Public participation in Iceland has drastically increased in the past 10-15 years. There has been a strengthened a participatory approach in governance of health systems due to patient movement. Boards of health centres and hospitals constituted representatives from the local communities and also representatives of hospital staff.

Portugal has promoted participation of the public through developing a national health strategy via public consultations.

These cases of different countries’ application of national policy and guidelines may offer relevant examples to other countries wanting to involve the public in consultation on health policies. The rights of patients however may require more attention in days to come.

Reasons for Partnerships and Joint Working Initiatives between Health and Social Services

The purpose of health and social services is primarily addressing the needs of those who employ them. But there exist deterrents and traditional boundaries that often prove to be a major obstacle. Vulnerable older persons and children ailing from mental disabilities are amongst those who suffer most as a result of the failures brought about by the current system. There isn’t a simple solution to address the failings of the system. However, it is essential and of great importance that the groups and trusts responsible for the provision of social services and those mandated to provide health services to come together and work towards the realisation of shared objectives (Department of Health, 1998).

Reasons for Joint Investment Plans

The various health and social care institutions should employ joint investment plans to address the improvement of services that are provided for the vulnerable persons in the society. The joint investment plans should be informed by the respective needs and the objectives that are jointly shared with regard to the vulnerable persons. The joint investments plans constitutes an integral part of the health improvement plan and is paramount in the informing of the strategic framework and the arrangements and subsequent measures that are to be taken by the local authorities.

Joint investment plans are meant to improve people’s ability to be independent as a result of the improvement in the coordination of the local services.

Improve working relations between different agencies as a result of greater transparency with regard to the current and future spending occasioned by service development and the improvement of the health and social services provisions.

Joint investment plans will facilitate the acknowledgement of all the issues pertaining to the quality of service and concerns of the effectiveness and similarly inform the strategic objectives and the priorities on service development.

Joint investment plans will also facilitate the production of information paramount for the restructuring of service provision from the health and social care institutions.

The joint ventures will also aid in the preparation and improvement of the strategies employed in the respective health and social care institutions.

Commissioning of Services

The commissioning of services brings much emphasis on health and social care institutions partnering to address the manner in which services are obtained. The commissioning of services also ensures that the health and the social care services are made accessible and closer to the people they are meant to serve, bringing together both the initial care and health services for the community. Consequently, the commissioning of services by the health and social care institutions allows for the partners to try out other approaches to facilitate better provision of services.

Joint commissioning of services serves as a body that coordinates and is responsible for the impacts of health concerns on the prevalence of crime and poverty and also the instances of unemployment.

Joint commissioning of services also facilitates the identification of key aspects and themes in the course of the development of the respective social care plans.

It also prioritizes the concerns of the most vulnerable groups in the society that have suffered more due to the inadequacy of the current structures.

The joint commissioning of services also servers to identify the funds that are to be committed for the services that is to be done jointly.

The purpose of the collaborations between the health and social service institutions in the planning of services locally is to facilitate efficiency in the manner in which the social needs and the health care needs are undertaken. The health and social care institutions can also enter into partnerships with stakeholders from other sectors such as housing and general practitioners. Such partnerships will facilitate the allocation of care managers from the various health and social care institutions to provide services that meet the needs of the individuals. The partnerships also allow for the separation of service management roles from those of care management roles Department of Health, 1998). General practitioners will be closely involved in the development of community care and agreements with the authorities involved in housing to facilitate the development of houses strategies such as house shelters and the building of houses that meet the specific needs of the respective individuals. The successes of the partnerships are however informed by a distinct commitment of funds by the respective collaborators that are committed to the undertaking. The funding can include contributions taken directly from the institutions involved and can also include funding taken from the respective health authorities. The above joint arrangements will facilitate the integration of services and the delivery of more competent services that informed by the needs of the individual users.

How Patient Choice, Information and Patient Representation can be used, and measured, to improve the quality of service.

The ability to measure is paramount to facilitate the improvement of quality. Measurement allows for the definition of the mandate of the respective health institutions as well as those of the social care institutions and subsequently compare and contrast them to what they have realized in their original targets prompting the identification of opportunities for improvement (Brant, 1992). The quality of services in the health and social care institutions are informed mostly by inspections that are carried out on a regular basis, surveys that seek to gauge the satisfaction levels of the public, assessments that are facilitated by third parties and the use of statistical pointers a majority of which have not been authenticated. Health services and patient social care that centred on the patient are essential to the quality of healthcare services, the delivery of the health care services and ensure that the healthcare and social care services are informed by the specific needs of the patients. The absence of an approach that is meant to collect relevant information regarding the patients and that of their experience in the respective health and social care institutions is responsible for the limited and narrowed perspective in the efforts that target to improve the quality of the health and social care services (Jenkinson, Coulter & Bruster, 2002).

The Patient Perspective as a Mechanism to Measure Health Care Performance

Approaches meant to measure the satisfaction of patients are not as adequate and efficient. This is informed by the fact there isn’t enough evidence and proof with regard to the tools that are employed to measure the levels of satisfaction of the individual patients. On the other hand, the analysis of the experiences of the customers as the measuring of their expectations provides a better platform to inform the betterment of the health and social care services (Goodrich & Cornwell, 2008). An institute in Europe known as the Picker Institute determined that patients were either informed by their expectations as taxpayers or were informed by their expectations as users of the respective health and social services. The Institute is credited with the production of a number of survey tools that are now essential and form the basis of numerous surveys with regard to the experiences of patients in the respective health and social care institutions worldwide. The Picker apparatus addresses eight dimensions of care that are essential to the respective patients. These include: the information coupled by education, how care is coordinated, the levels of physical comfort, the emotional support of the patients, the respect accorded to preferences of the respective patients, how involved are the friends and family, the transition and continuity of the health services and the impression that the health and social care inspires by and large (Department of Health/NHS Finance Performance & Operations, 2008). The experiences of the individual patients are informed by the human and factors based on organization at the different levels of care. This information can be sourced by employing methodologies such as the use of surveys, use of narrative techniques or by seeking out feedback from the respective patients. The use of surveys can be employed at a national level, state or focus on the individual provider of the care. It is paramount that the sample sizes are appropriate for national surveys to inform on the means to improve the delivery of the care at the provider level. Narrative methods entail the acquiring of information through conducting interviews on patients regarding specific health care and social care incidents after visiting the institution. They include methods such as the journey of patients, tracer methodologies and critical incidents. The measures that investigate the experiences of the patients are used to inform the improvement in the provisions of health care services from the health care and social care institutions to the patients. Drivers that facilitate the achievement of these include: pay only when satisfied by the performance, accreditations by relevant authorities and redesign programs meant for clinical service. The application of such drivers and measures goes a long way increase competition amongst the health and social care providers (McKeon, 1997). Systems and measures that address patient feedback and the various approaches that facilitate engagements from the community are of great importance. However, they are not capable of replacing the various systems that facilitate the collection of information on the ground with regard to their experiences in the health care and social care institutions (Coulter, 2005).

The uses of Patient Experience Measures

The primary reason for the patient experience measures is to add-on the clinical outcome measures, process outcomes and the measures that address the cost incurred as a result of safe and quality care and not replace them (Brant, 1992). Among the reasons for examining the experiences of patients are:

It serves as an external measure of accountability for the health and social care institutions

It enhances the choices of the respective patients

It serves to improve on quality of the care in the care institutions

It also measures how the care institutions perform

Information regarding the experiences of the respective patients can be analysed by employing a number of formats. Organizations can be audited based on the policies and the procedures of the respective organizations, external accreditation can also be employed to determine best practices and also the information regarding the experience of the patient can be examined by identifying the incidents that had considerable impact on the respective patients. The use of surveys on the experiences of patients to audit the institutions of care yields low ratings compared to when the traditional auditing tools are employed. One possible reason for the differences could be that surveys on the experiences of the patients check whether the policies of the care institutions have been enacted compared to the traditional auditing methodologies that examine whether such policy exist in the care institutions. The use of similar questions to compare the respective care institutions would facilitate the availing of information that would aid the enhancing of patient choice. The experiences of the patients constitute the United Kingdom’s framework on the quality of the care and outcomes (QOF). The United Kingdom also initiated a scheme that pays care institutions based on there performances which are obtained from the quality and outcomes framework (QOF) indicators (Department of Health/NHS Finance Performance & Operations, 2008). Points on the experiences of the patients are obtained from the national trust survey. The patient’s experiences results obtained from the questions in the survey are used by the patients to aid them in choosing of a provider. It is however important to note that the use of mechanisms that provide feedback from the patients are not of any relevance to the improvement of the quality of care from the care institutions unless they are integrated to the system and there should be mechanisms put in place use that information.

The Information Available for Use by Patients

Patients in Australia have little access to information that would assist them in the informing of the care institutions and practitioners that they likely to choose. Some of the resources available to them include links via Healthinsite to the respective jurisdiction of the patients, telephone directories, the use of public libraries, a number of consumer groups and institutions that identify care institutions that are accredited such as the AGPAL (The Australian Council on Healthcare Standards, 2009). This is however not the case in the United Kingdom where through the choice of NHS, patients are flooded by information on the care institutions in their country. Some of th

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