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A "managed competition" model was introduced in the Canadian province of Ontario as part of the government's reform of home care. With this model, it was assumed that competitive forces would encourage quality while driving down costs. While such reforms often achieve cost controls by constraining the incomes and practices of health-care workers, there has been relatively little analysis of the extent to which self-governing health-care professionals, particularly those outside of medicine and nursing, may experience a decline in their ability to control the content and context of their professional work. In this article, the authors analyse the results of thirty-six in-depth interviews with representatives of Community Care Access Centres (CCACs), the organizations that purchase and coordinate the delivery of homecare services, and rehabilitation provider agencies to examine the impact of Ontario's managed competition reform on rehabilitation professionals. Findings suggest that the impact of the reform varied across the economic, political, and clinical dimensions of professional autonomy and that, despite a general loss of autonomy under the managed competition model, market forces also served to mitigate the loss of autonomy, thus contributing to a remarkable resilience of professional autonomy. Un modele de << concurrence dirigee >> a ete introduit recemment dans la province canadienne de l'Ontario dans le cadre de la reforme gouvernementale des soins a domicile. Avec ce modele, il etait presume que les forces de la concurrence encourageraient la qualite tout en faisant baisser les couts. Alors que de telles reformes parviennent souvent a maitriser les couts en reduisant les revenus et les pratiques des travailleurs de la sante, il y a eu relativement peu d'analyses de faites sur la mesure dans laquelle les professionnels de la sante autonomes, particulierement ceux qui exercent en dehors de la medecine et de la profession infirmiere, connaissent une perte de controle sur le contenu et le contexte de leur travail professionnel. Dans le present article, les auteurs analysent les resultats de trente-six entrevues en profondeur menees aupres de representants des Centres d'acces aux soins communautaires (CASC), organismes qui achetent et coordonnent la prestation des services de soins a domicile, et organismes de prestation de soins de readaptation, afin d'examiner les consequences de la reforme de la concurrence dirigee de l'Ontario sur les professionnels de la readaptation. Les resultats laissent entendre que l'effet de la reforme a varie en fonction des dimensions economiques, politiques et cliniques de l'autonomie professionnelle et que, malgre une perte d'autonomie generale liee au modele de concurrence dirigee, les forces du marche ont egalement permis d'attenuer la perte d'autonomie, contribuant ainsi a la remarquable resilience dont font preuve ces professionnels en la matiere., Public and political concerns about the sustainability of national health-care systems have stimulated governments in countries around the world to experiment with reforms that introduce some degree of competitive market [...]

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2005.08.042 Byline: Glen E. Randall (a), A. Paul Williams (b) Keywords: Neo-liberalism; Health care reform; Health policy; CCAC; Canada; Competition; Rehabilitation services Abstract: The rise of neo-liberalism, which suggests that only markets can deliver maximum economic efficiency, has been a driving force behind the trend towards using market-based solutions to correct health care problems. However, the broad application of market-based reforms has tended to assume the presence of fully functioning markets. When there are barriers to markets functioning effectively, such as the absence of adequate competition, recourse to market-based solutions can be expected to produce less than satisfactory, if not paradoxical results. One such case is rehabilitation homecare in Ontario, Canada. In 1996, a 'managed competition' model was introduced as part of a province-wide reform of home care in an attempt to encourage high quality at competitive prices. However, in the case of rehabilitation home care services, significant obstacles to achieving effective competition existed. Notably, there were few private provider agencies to bid on contracts due to the low volume and specialized nature of services. There were also structural barriers such as the presence of unionized employees and obstacles to the entry of new providers. This paper evaluates the impact of Ontario's managed competition reform on community-based rehabilitation services. It draws on data obtained through 49 in-depth key informant interviews and a telephone survey of home care coordinating agencies and private rehabilitation provider agencies. Instead of reducing costs and improving quality, as the political rhetoric promised, the analysis suggests that providing rehabilitation homecare services under managed competition resulted in higher per-visit costs and reduced access to services. These findings support the contention that there are limits to market-based reforms. Author Affiliation: (a) DeGroote School of Business, McMaster University, 1280 Main Street West, MDG-229, Hamilton, Ont., Canada L8S 4M4 (b) Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, 12 Queen's Park Crescent West, Toronto, Ont., Canada M5S 1A8

Abstract Background Integrating the best available evidence into program standards is essential if system-wide improvements in the delivery of community-based mental health services are to be achieved. Since the beginning of the Assertive Community Treatment (ACT) program movement, program standards have included a role for the community. In particular, ACT program standards have sought to ensure that members of the local community are involved in governance and that former clients participate in service delivery as "Peer Support Specialists". This paper reports on the extent to which ACT program standards related to community participation have been implemented and identifies barriers to full compliance. Methods Qualitative and quantitative data were collected through a telephone survey of ACT Program Coordinators in Ontario, Canada, using a census sample of the existing 66 ACT programs. A thematic approach to content analysis was used to analyze respondents' qualitative comments. Quantitative data were analyzed using SPSS 16.0 and included means, frequencies, independent t-tests and Pearson Correlations. Results An 85% response rate was achieved. Of the 33 program standards, the two that received the lowest perceived compliance ratings were the two standards directly concerning community participation. Specifically, the standard to have a functioning Community Advisory Body and the standard requiring the inclusion of a Peer Support Specialist. The three major themes that emerged from the survey data with respect to the barriers to fully implementing the Community Advisory Body were: external issues; standard related issues; and, organizational/structural related issues. The three major themes concerning barriers to implementing the Peer Support Specialist role were: human resource related issues; organizational/structural related issues; and, standard related issues. Conclusions The reasons for low compliance of ACT programs with community participation standards are complex and are tied to structural and human resources barriers (both internal and external to the ACT programs) as well as to the requirements of the standards themselves. In order for improvements to the mental health system to be achieved there is a need to identify and address these barriers. Failure to do so will result in less than optimal client, family and economic efficiency outcomes.

The use of Internet-enabled technology (information and communication technology such as smartphone applications) may enrich information exchange among providers and, consequently, improve health care delivery. The purpose of this systematic review was to gain a greater understanding of the role that Internetenabled technology plays in enhancing communication among physicians. Studies were identified through a search in three electronic platforms: the Association for Computing Machinery Digital Library, ProQuest, and Web of Science. The search identified 5140 articles; of these, 21 met all inclusion criteria. In general, physicians were satisfied with Internet-enabled technology, but consensus was lacking regarding whether Internet-enabled technology improved efficiency or made a difference to clinical decision-making. Internetenabled technology can play an important role in enhancing communication among physicians, but the extent of that benefit is influenced by (1) the impact of Internet-enabled technology on existing work practices, (2) the availability of adequate resources, and (3) the nature of institutional elements, such as privacy legislation. [ABSTRACT FROM AUTHOR]

Background: Differences in care philosophies may influence transitions from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS). Aims: To review literature about CAMHS and AMHS care philosophies and their influence on transitions. Method: MEDLINE, PsycINFO, Embase and CINAHL databases were searched electronically using keywords related to transitions, youth and mental disorders. Content relating to philosophies of care was searched manually. Descriptive themes were extracted and the analysis suggested four hypotheses of how care philosophies influence transitions. Results: Of the 1897 identified articles, 12 met eligibility criteria. Findings reveal consistent differences in care philosophies between CAMHS (developmental approach, involving families and nurturing) and AMHS (clinical/diagnosis-focus, emphasis on client autonomy and individual responsibility). Conclusions: Better understanding of philosophical differences and collaborative planning and service delivery may foster shared approaches in CAMHS and AMHS to better meet the needs of transitioning youth. [ABSTRACT FROM AUTHOR]

Background: Organ transplantation has become an effective means to extend lives; however, a major obstacle is the lack of availability of cadaveric organs. India has one of the lowest cadaver organ donation rates in the world. If India could increase the donor rate, the demand for many organs could be met. Evidence from high-income countries suggests that an organ donor registry can be a valuable tool for increasing donor rates. The purpose of this study is to determine whether the implementation of an organ donor registry is a feasible and appropriate policy option to enhance cadaver organ donation rates in a lower-income country.Methods: This qualitative policy analysis employs semi-structured interviews with physicians, transplant coordinators, and representatives of organ donation advocacy groups in Mumbai. Interviews were designed to better understand current organ donation procedures and explore key informants' perceptions about Indian government health priorities and the likelihood of an organ donor registry in Mumbai. The 3-i framework (ideas, interests, and institutions) is used to examine how government decisions surrounding organ donation policies are shaped.Results: Findings indicate that organ donation in India is a complex issue due to low public awareness, misperceptions of religious doctrines, the need for family consent, and a nation-wide focus on disease control. Key informants cite social, political, and infrastructural barriers to the implementation of an organ donor registry, including widely held myths about organ donation, competing health priorities, and limited hospital infrastructure.Conclusions: At present, both the central government and Maharashtra state government struggle to balance international pressures to improve overall population health with the desire to also enhance individual health. Implementing an organ donor registry in Mumbai is not a feasible or appropriate policy option in India's current political and social environment, as the barriers, identified through the 3-i framework lens, may be too difficult to overcome. Despite the evidence supporting the use of donor registries as a means to enhance organ donation rates, it is clear that context is critical and that it is not always practical to apply evidence-based policy solutions from high-income countries to lower-income settings. [ABSTRACT FROM AUTHOR]

Background: The use of information and communication technology (ICT) has tremendous potential to enhance communication among physicians, leading to improvements in service delivery. However, the protection of health information in digital/electronic format is an ongoing concern., Objective: The purpose of this study was to examine guidance for the protection of health information when using ICT from all 10 of Canada's provincial regulatory colleges for physicians and to discuss the potential policy and service delivery implications., Method: A search of the regulatory college websites was conducted, followed by a document analysis (content and thematic)., Results: The college website search identified 522 documents; 12 of these documents (from 8 of the 10 colleges) met the study criteria. These documents were notable for the considerable variation in the scope and detail of guidance provided across the colleges., Conclusion: While the federal-provincial division of powers in Canada enables different jurisdictional approaches to health service delivery and, thus, opportunities for policy learning, this governing structure may also contribute to a lack of incentive for collaboration, leading to an absence of standardised guidance for health information protection when using ICT. This, in turn, may result in unequal and inequitable protection of health information across the provinces. Therefore, a macro-level approach to policy development in this area may hold the greatest promise for enhancing the protection of health information and doing so in a more standardised manner in countries with federal systems of governance.

This study describes instructions for after-hours care offered by family physicians' offices when patients telephone the practice. Randomly selected (n=1,680) Ontario family physicians and general practitioners were telephoned after hours from October 2007 to February 2008.Instructions among the 1,102 eligible offices suggested emergency services (58.6%; 646/1,102), the toll-free, nurse-staffed Telephone Health Advisory Service (THAS) with on-call physician back-up (45.0%; 496/1,102), the practice's own after-hours clinic (27.9%; 307/1,102), an on-call physician (8.0%; 88/1,102) or a walk-in clinic (6.9%; 76/1,102). Some messages (13.9%; 153/1,102) provided no instructions. Physicians in a reformed model with obligations to provide some after-hours care were more likely to advise an after-hours clinic (32.0%; 285/891) than other physicians (10.4%; 22/211) (p<0.001).Many family physician telephone messages in Ontario suggest emergency services only or do not provide any instructions. Only slightly more than half suggest use of the government-funded THAS. Patients may be unaware of many after-hours care options.