Contracting with General Dental Services: a mixed-methods study on factors influencing responses to contracts in English general dental practice

Background: Independent contractor status of NHS general dental practitioners (GDPs) and general medical practitioners (GMPs) has meant that both groups have commercial as well as professional identities. Their relationship with the state is governed by a NHS contract, the terms of which have been the focus of much negotiation and struggle in recent years. Previous study of dental contracting has taken a classical economics perspective, viewing practitioners’ behaviour as a fully rational search for contract loopholes. We apply institutional theory to this context for the first time, where individuals’ behaviour is understood as being influenced by wider institutional forces such as growing consumer demands, commercial pressures and challenges to medical professionalism. Practitioners hold values and beliefs, and carry out routines and practices which are consistent with the field’s institutional logics. By identifying institutional logics in the dental practice organisational field, we expose where tensions exist, helping to explain why contracting appears as a continual cycle of reform and resistance. Aims: To identify the factors which facilitate and hinder the use of contractual processes to manage and strategically develop General Dental Services, using a comparison with medical practice to highlight factors which are particular to NHS dental practice. Methods: Following a systematic review of health-care contracting theory and interviews with stakeholders, we undertook case studies of 16 dental and six medical practices. Case study data collection involved interviews, observation and documentary evidence; 120 interviews were undertaken in all. We tested and refined our findings using a questionnaire to GDPs and further interviews with commissioners. Results: We found that, for all three sets of actors (GDPs, GMPs, commissioners), multiple logics exist. These were interacting and sometimes in competition. We found an emergent logic of population health managerialism in dental practice, which is less compatible than the other dental practice logics of ownership responsibility, professional clinical values and entrepreneurialism. This was in contrast to medical practice, where we found a more ready acceptance of external accountability and notions of the delivery of ‘cost-effective’ care. Our quantitative work enabled us to refine and test our conceptualisations of dental practice logics. We identified that population health managerialism comprised both a logic of managerialism and a public goods logic, and that practitioners might be resistant to one and not the other. We also linked individual practitioners’ behaviour to wider institutional forces by showing that logics were predictive of responses to NHS dental contracts at the dental chair-side (the micro level), as well as predictive of approaches to wider contractual relationships with commissioners (the macro level) . Conclusions: Responses to contracts can be shaped by environmental forces and not just determined at the level of the individual. In NHS medical practice, goals are more closely aligned with commissioning goals than in general dental practice. The optimal contractual agreement between GDPs and commissioners, therefore, will be one which aims at the ‘satisfactory’ rather than the ‘ideal’; and a ‘successful’ NHS dental contract is likely to be one where neither party promotes its self-interest above the other. Future work on opportunism in health care should widen its focus beyond the self-interest of providers and look at the contribution of contextual factors such as the relationship between the government and professional bodies, the role of the media, and providers’ social and professional networks. Funding: The National Institute for Health Research Health Services and Delivery Research programme

Normativity and Judgement

Article (also printed in Aristotelian Society Supplementary Volume (1999)

To Arrange or Not: Marriage Trends in the South Asian American Community

The idea of the arranged marriage has always seemed exotic yet has fascinated the American public. Recent media coverage of arranged marriages is evident in popular periodicals such as the New York Times Online (August 17, 2000) and Newsweek (March 15, 1999). Foner highlights that the arranged marriage is an example of the continued impact of premigration cultural beliefs and social practices that South Asian immigrants have transported to the United States (Foner 1997, 964). She offers an interpretive synthesis by showing that [n]ew immigrant family patterns are shaped by cultural meanings and social practices that immigrants bring with them from their home countries as well as by social, economic, and cultural forces in the United States (Foner 2005, 157)

Public Artifacts, Empirical Vulnerability and Descriptive Metaphysics

Herein I argue that Amie Thomasson’s account of public artifacts is empirically vulnerable. I first identify the descriptive claims that feature in Thomasson’s argument and then outline an experimental framework in which the accuracy of those claims can be evaluated. I conclude with some brief remarks on the possible implications of my approach for Thomasson’s account, and some thoughts on whether an experimental approach to evaluating projects in descriptive metaphysics might be valuable more broadly

Reasons for post-conception human immunodeficiency virus (HIV) testing among pregnant women in Gaborone, Botswana

M.Cur. (Midwifery and Neonatal Nursing Care)Free voluntary counselling and testing (VeT) for Human Immunodeficiency Virus (HIV) by the international community and many African states is the entry point into HIV and Acquired Immunodeficiency Syndrome (AIDS) prevention, care, treatment and support. It is therefore worrisome that despite the Botswana government' multiple HIV preventative strategies, of the 56% Batswana who tested for HIV in 2008, only 34% know their status (National AIDS Coordinating Agency, Central Statistics Office & Ministry of Health, 2009:4). Among those who were tested, women outnumbered men, but even these women only had their HIV-status tested when they were already pregnant or when one of their children was suspected to have contracted AIDS, an observation that Hamblin and Reid (1991:4) has made years ago. Ethical standards were followed to conduct a study, the purpose of which was to explore and describe the reasons why women in Gaborone only volunteered to go for vcr of HIV when they were already pregnant, instead ofdoing so before they conceived. An exploratory, descriptive, qualitative and contextual design was used. Participants who met the sampling criteria were interviewed and data was audio-taped before transcription and analysis. An independent coder was involved to confirm the themes and sub-themes before relevant literature was searched. Strategies of trustworthiness were adhered to in the study (Lincoln & Guba, 1985:289-331). Findings revealed that the most significant reason for participants not testing for HIV prior to pregnancy was fear of consequences of an HIV-positive result, such as stigma and discrimination against them by their partners, families and communities should they test HIV-positive, Another reason was the socio-cultural beliefs, norms and values expressed in different forms. However, once they fell pregnant, they had themselves tested because their fear of losing their babies to HIV overruled their fear ofbeing ostracised by anybody else. Based on the findings, guidelines were formulated to assist midwives and HIV and AIDS counsellors to facilitate uptake of vcr of HIV prior to pregnancy among childbearing women and men from as young as +-15 years. Conclusions were drawn and recommendations made concerning midwifery practice, education and possible further research on this topic on a larger scale

Toxic Corporate Culture: Assessing Organizational Processes of Deviancy

There is widespread recognition that organizational culture matters in corporations involved in systemic crime and wrongdoing. However, we know far less about how to assess and alter toxic elements within a corporate culture. The present paper draws on management science, anthropology, sociology of law, criminology, and social psychology to explain what organizational culture is and how it can sustain illegal and harmful corporate behavior. Through analyzing the corporate cultures at BP, Volkswagen, and Wells Fargo, this paper demonstrates that organizational toxicity does not just exist when corporate norms are directly opposed to legal norms, but also when: (a) it condones, neutralizes, or enables rule breaking; (b) it disables and obstructs compliance; and (c) actual practices contrast expressed compliant values. The paper concludes that detoxing corporate culture requires more than changing leadership or incentive structures. In particular, it requires addressing the structures, values, and practices that enable violations and obstruct compliance within an organization, as well as moving away from a singular focus on liability management (i.e., assigning blame and punishment) to an approach that prioritizes promoting transparency, honesty, and a responsibility to initiate and sustain actual cultural change

Complexity of distances: Theory of generalized analytic equivalence relations

We generalize the notion of analytic/Borel equivalence relations, orbit equivalence relations, and Borel reductions between them to their continuous and quantitative counterparts: analytic/Borel pseudometrics, orbit pseudometrics, and Borel reductions between them. We motivate these concepts on examples and we set some basic general theory. We illustrate the new notion of reduction by showing that the Gromov-Hausdorff distance maintains the same complexity if it is defined on the class of all Polish metric spaces, spaces bounded from below, from above, and from both below and above. Then we show that $E_1$ is not reducible to equivalences induced by orbit pseudometrics, generalizing the seminal result of Kechris and Louveau. We answer in negative a question of Ben-Yaacov, Doucha, Nies, and Tsankov on whether balls in the Gromov-Hausdorff and Kadets distances are Borel. In appendix, we provide new methods using games showing that the distance-zero classes in certain pseudometrics are Borel, extending the results of Ben Yaacov, Doucha, Nies, and Tsankov. There is a complementary paper of the authors where reductions between the most common pseudometrics from functional analysis and metric geometry are provided.Comment: Based on the feedback we received, we decided to split the original version into two parts. The new version is now the first part of this spli