Explicit rationing within the NHS quasi-market: the experience of health authority purchasers, 1996-97

This thesis analyses the findings of empirical research carried out in three case study UK health authorities in 1996-97, using repeat interviewing of senior managers. It aimed to test three competing hypotheses: i. Markets are one possible system for allocating scarce resources. The process of contract specification in a complex quasi-market is likely to make rationing more explicit than it would be in a hierarchical system ii. In the complex context of the NHS the quasi-market may fail to produce clear contracts and unambiguous allocations, because of prohibitive transaction costs, political costs and ethical costs of greater explicitness iii. Other pressures in favour of explicitness (e.g. rising expenditure, effectiveness evidence and the Patient's Charter) may be irresistible, whatever structural form the NHS takes. The complex relationship between explicit rationing, the internal market and other factors is discussed. Results suggest the quasi-market has contributed to the growth in explicit rationing, notably by decoupling purchasers and providers from their previously shared responsibility to manage resources. In other respects the market has speeded up or magnified the effect of other factors which would or could have happened anyway. Concern to control rising expenditure has led to more explicit decisions but is now rekindling interest in the value of fixed budgets for providers and implicit clinical decision-making. Factors such as the Patient's Charter have also had an independent effect on greater explicitness. Implicit rationing remains significant. The implications for health care rationing of government proposals to abolish the internal market are examined. The results suggest that explicit rationing will probably continue to grow, but with a greater emphasis on explicit criteria to guide clinicians in determining who gets treatment, rather than the exclusion of whole services. The retention of some form of commissioner provider split may also exercise continuing pressure towards explicitness

Racial Disparities in the Delivery of Health Care

This Article focuses on the role of conscious and unconscious racial bias in the delivery of care; it does not begin to address the larger issue of inadequate access to care at the outset. Improving access to health care for minorities will undoubtedly have a positive effect on these groups\u27 overall health status; however, to the extent that racial bias in the delivery of care exists apart from problems of inadequate access, the disparity in health status between whites and African Americans will no doubt continue. Part II of this Article describes racial disparities in a variety of health care contexts including the utilization of Medicare services, the selection of recipients for cadaveric organ transplantation, access to drug therapy, institutionalization for mental illness, and the representation of racial and ethnic minority groups in clinical research. Part II closes with a discussion of some of the problems inherent in measuring the degree of the disparate care problem and in isolating and evaluating the role that race plays in health care decisionmaking. Part III suggests potential solutions to the problem of disparate medical care for racial minorities, including possible constitutional and statutory remedies for past victims of disparate treatment, avenues for governmental enforcement of policies prohibiting discrimination, and other approaches for avoiding future inequalities in the delivery of medical services. This Article concludes that prospective approaches, such as education and regulatory responses to patterns of disparate care, provide the most promising avenues for addressing this troubling problem

Racial Disparities in the Delivery of Health Care

This article focuses on the role of conscious and unconscious bias in the delivery of health care. Racial disparities of a range of health care services are illustrated, including drug therapy, Medicare services, and organ transplantation. Methodological challenges to measuring such disparities are also addressed, as are sociological factors influencing disparities. Statutory and constitutional remedies are suggested to redress inequities. The author concludes, however, prospective approaches, such as regulation and education, are the most promising avenues to solving racial disparities in health care delivery

The application of process mining to care pathway analysis in the NHS

Background: Prostate cancer is the most common cancer in men in the UK and the sixth-fastest increasing cancer in males. Within England survival rates are improving, however, these are comparatively poorer than other countries. Currently, information available on outcomes of care is scant and there is an urgent need for techniques to improve healthcare systems and processes. Aims: To provide prostate cancer pathway analysis, by applying concepts of process mining and visualisation and comparing the performance metrics against the standard pathway laid out by national guidelines. Methods: A systematic review was conducted to see how process mining has been used in healthcare. Appropriate datasets for prostate cancer were identified within Imperial College Healthcare NHS Trust London. A process model was constructed by linking and transforming cohort data from six distinct database sources. The cohort dataset was filtered to include patients who had a PSA from 2010-2015, and validated by comparing the medical patient records against a Case-note audit. Process mining techniques were applied to the data to analyse performance and conformance of the prostate cancer pathway metrics to national guideline metrics. These techniques were evaluated with stakeholders to ascertain its impact on user experience. Results: Case note audit revealed 90% match against patients found in medical records. Application of process mining techniques showed massive heterogeneity as compared to the homogenous path laid out by national guidelines. This also gave insight into bottlenecks and deviations in the pathway. Evaluation with stakeholders showed that the visualisation and technology was well accepted, high quality and recommended to be used in healthcare decision making. Conclusion: Process mining is a promising technique used to give insight into complex and flexible healthcare processes. It can map the patient journey at a local level and audit it against explicit standards of good clinical practice, which will enable us to intervene at the individual and system level to improve care.Open Acces

The first steps between Portugal and the Russian-speaking target market in medical tourism

O objetivo deste estudo de caso é abordar os primeiros passos para criar um turismo médico em Portugal, especificamente como iniciar uma abordagem para promover ofertas de serviços médicos conjuntas num mercado-alvo de língua russa. O projeto "Turismo médico em Portugal", promovido pela associação privada sem fins lucrativos Health Cluster Portugal, embora apresente genericamente formas de concretizar a estratégia de marca e um plano de ação no desenvolvimento de um cluster de turismo médico em Portugal não o faz para o mercado de língua russa. O desenvolvimento e o sucesso futuro do estudo aqui apresentado podem contribuir para o desenvolvimento do mercado de serviços médicos no país. A investigação consiste em: revisão da literatura considerada relevante para descrições de turismo médico, fatores de tomada de decisão e modelos de negócios; análise de informação secundária para abordar os "pull factors" referentes a Portugal assim como os determinantes no desenvolvimento do projeto "turismo médico em Portugal e as motivações dos turistas médicos de língua russa em viagens médicas; análise e discussão da informação resultante de entrevistas semiestruturadas sobre os "push factors" de pacientes de língua russa em viagens médicas bem como sobre os pontos fortes e fracos de Portugal na atração de turismo médico; recomendações sobre a atração de turistas médicos de língua russa e a criação de um ambiente amigável local durante o tratamento. O estudo concluiu dando indicações sobre o próximo passo para a construção de um cluster de turismo de saúde forte, competitivo, orientado para o cliente e bem organizado, com pacotes atraentes de turismo médico para turistas médicos e parceiros fornecedores do serviço. A análise de quais tratamentos são os mais populares entre os turistas médicos de diferentes países de língua russa não é o objetivo do estudo.The main objective of the case study is the first steps to create medical tourism in Portugal, namely a medical tourism cluster with actors to promote the joint medical offers in a Russianspeaking target market. The project "Medical tourism in Portugal", promoted by the private non-profit association Health Cluster Portugal, starts a way of embodying branding strategy and a plan of action in the development of a medical tourism cluster in Portugal. The development and future success of the project can influence the development of the medical services market and the economic development of the country. The research structure consists of the following parts: literature review for descriptions of medical tourism, decision-making factors and business models; Portugal pull factors and development of the project "Medical tourism on Portugal" with using secondary data; motivations of Russian-speaking medical tourists in medical trips with using secondary data; results from semi-structured interviews of the push factors of Russian-speaking patients in medical trips and Portugal's strengths and weaknesses in the pull factors in medical tourism are discussed; recommendations on attracting Russian-speaking medical tourists and creating a like-home environment during the treatment for them. The study concluded by pointing out what must be the next step to a vigorous effort to construct strong, competitive, customer-oriented and well-organized health tourism cluster, with attractive medical tourism packages for medical tourists and patient’s providers. Analyse of which treatments are the most popular among medical tourists from different Russian-speaking countries is not the study’s aim

Improving the healthcare service quality in Chinese Public Class-A Hospitals: from frontline healthcare professional's perspectives

In a highly competitive market, healthcare service improvement is important to satisfy people’s increasing need for care and to maintain the sustainability of hospitals' competitive advantages. Although Public Class-A hospitals are the top hospitals in China, existing problems exert negative influences on service quality. This research aims to contribute to the improvement of Chinese Public Class-A hospitals by investigating the perspectives of healthcare professionals regarding service improvement. Using a qualitative approach, 16 professionals working for several Public Class-A hospitals were interviewed and expressed their views on the existing service quality, the factors influencing this service and made suggestions about how to improve it. The results of content analysis revealed that professionals view Chinese Public Class-A hospitals as having good medical ability, advanced equipment and reliable curative effect. The price of treatment is considered high but acceptable. According to professionals, the main problems were poor service attitude, lack of emotional support, communication problems, long waiting times, environmental problems, and administrative problems. The identified barriers to high-quality service delivery include professional pressure and burnout, patient factors, remuneration and promotion perspectives. Overall, more people-centered services were suggested, meaning that healthcare professionals should improve their service consciousness and humane care, while the whole society should give humane care to healthcare professionals as well. Other suggestions involved enhancing the hierarchical medical system, strengthening doctor-patient communication, optimizing the treatment processes, improving hospital environment and publicity, and dispensing health education. In short, addressing these themes can contribute to improve the service of Chinese Public Class-A hospitals.Num mercado altamente competitivo, a melhoria da qualidade dos serviços de saúde é importante para satisfazer as crescentes necessidades de cuidados da população e para a sustentabilidade das vantagens competitivas dos hospitais. Os hospitais públicos de Classe-A ocupam os lugares cimeiros na China, e os problemas neles existentes influenciam negativamente a qualidade do serviço que prestam. Este estudo tem por objetivo contribuir para a melhoria destes hospitais investigando as perspetivas dos profissionais sobre a melhoria do serviço. Com base numa abordagem qualitativa, 16 profissionais que trabalham em diversos hospitais públicos de Classe-A foram entrevistados e expressaram os seus pontos de vista sobre o nível de qualidade de serviço existente, os fatores que afetam este serviço e as sugestões para o melhorar. Os resultados da análise de conteúdo revelam que os profissionais vêm os hospitais chineses de Classe-A como tendo elevada capacidade médica, equipamento avançado e uma reposta curativa eficaz. O preço dos serviços é considerado relativamente elevado, mas aceitável. Segundo os profissionais, os principais problemas existentes nestes hospitais referem-se à existência de fraca atitude de serviço, falta de suporte emocional, problemas de comunicação, longas listas de espera, problemas ambientais e problemas administrativos. As barreiras à prestação de cuidados de maior qualidade identificadas pelos profissionais reportam-se à pressão e ao burnout dos profissionais, a fatores relacionados com os doentes, à remuneração e às perspetivas de promoção. Em geral, os profissionais sugerem um serviço mais centrado nas pessoas, ou seja, os profissionais deverão acentuar a prestação de cuidados mais conscienciosos e humanos, enquanto a sociedade deverá cuidar de forma também mais humana dos profissionais de saúde. Outras sugestões focam-se na melhoria do sistema hierárquico de saúde, no fortalecimento da comunicação ente o médico e o doente, na optimização dos processos terapêuticos, na melhoria do ambiente hospitalar e na prática de educação em saúde. Em suma, lidar com estes temas pode contribuir para a melhoria do serviço prestado pelos hospitais chineses de Classe-A

Expressive Minimalism and Fuzzy Signals: The Judiciary and the Role of Law

The proper role of courts engenders significant debate. Yet, what seems better settled is the principle that courts are the place at which the common law is developed. Its genesis and modifications evolve out of the juridical process and when that process becomes encumbered or deferred to the legislature the role of the judiciary is called into question. This essay makes the case that expressive minimalism too often governs the common law judicial approach to biotechnology. The cases visited in this domain test our capacity to understand whether life is appropriately described as being beyond the definition of property, as well as the disputed assumptions about life being commodifiable, patentable, destroyable, and conscriptable. There are also the circumstances that demand secondary or third party response depending on judicial expression, including what to do when life is stolen, misappropriated or fraudulently acquired. Goodwin argues that rather than motivating legislative action, or imbuing the bench with greater wisdom or information, expressive minimalism in the context of biotechnology will likely send fuzzy signals. Fuzzy signals will not be clear messages to the legislature. To the contrary, fuzzy signals, like those transmitted across cell phones and televisions, discombobulate messages, distort pictures, and ultimately, are difficult to read

Expressive Minimalism and Fuzzy Signals: The Judiciary and the Role of Law

The proper role of courts engenders significant debate. Yet, what seems better settled is the principle that courts are the place at which the common law is developed. Its genesis and modifications evolve out of the juridical process and when that process becomes encumbered or deferred to the legislature the role of the judiciary is called into question. This essay makes the case that expressive minimalism too often governs the common law judicial approach to biotechnology. The cases visited in this domain test our capacity to understand whether life is appropriately described as being beyond the definition of property, as well as the disputed assumptions about life being commodifiable, patentable, destroyable, and conscriptable. There are also the circumstances that demand secondary or third party response depending on judicial expression, including what to do when life is stolen, misappropriated or fraudulently acquired. Goodwin argues that rather than motivating legislative action, or imbuing the bench with greater wisdom or information, expressive minimalism in the context of biotechnology will likely send fuzzy signals. Fuzzy signals will not be clear messages to the legislature. To the contrary, fuzzy signals, like those transmitted across cell phones and televisions, discombobulate messages, distort pictures, and ultimately, are difficult to read