Social science & medicine
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Social science & medicine · Nov 2013
Discretion or discretions? Delineating professional discretion: the case of English medical practice.
There has much debate about the extent to which professional discretion has been challenged by recent organisational changes such as through the new forms of governance associated with the introduction of the principles of the New Public Management (NPM) into health systems and other public sector services. What appears to be missing from these debates is a detailed analysis of the concept of professional discretion itself. This paper attempts to fill this gap by delineating the key concepts of professional discretion evident in the literature and exploring their significance in an empirical study of the influence of the 2004 new general medical services contract (nGMS) and the introduction of the Quality and Outcomes Framework (QOF), a prescriptive pay-for-performance system designed to standardise the quality of care provision in general medical practice in the United Kingdom. ⋯ A multi-dimensional conception of discretion was used to explore how GP discretion might have been influenced by contractual changes and in particular, QOF. The findings suggest that through a complex interplay of factors, a post-QOF reduction in GP discretion was identifiable, highlighting different potential sources of constraint such as in the social, organisational and economic dimensions of discretion. The evidence also suggested the emergence of a new form of organisational medical professionalism within general practice characterised by standardisation, bureaucracy and performance management.
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Social science & medicine · Nov 2013
Subsidized childcare and child development in Colombia: effects of Hogares Comunitarios de Bienestar as a function of timing and length of exposure.
Rigorous evidence regarding the impact of early care and education on children's development comes primarily from high-income nations. A few studies from Latin America and the Caribbean have identified benefits of conditional cash transfer and home visiting programs on children's development. However, there is still controversy around the impact and cost-effectiveness of childcare approaches. ⋯ No significant gains were found for nutritional status. The estimated benefit-cost ratio ranged from 1.0 to 2.7, depending upon varying discount rates. Findings lend support for a potentially effective strategy to promote the development of low-income children in Colombia and other developing nations.
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Social science & medicine · Nov 2013
Intelligent policy making? Key actors' perspectives on the development and implementation of an early years' initiative in Scotland's public health arena.
Increased political enthusiasm for evidence-based policy and action has re-ignited interest in the use of evidence within political and practitioner networks. Theories of evidence-based policy making and practice are being re-considered in an attempt to better understand the processes through which knowledge translation occurs. Understanding how policy develops, and practice results, has the potential to facilitate effective evidence use. ⋯ The importance of context was underscored, in terms of the need to align with prevailing political ideology and in the facilitative strength of networks within the relatively small public health community in Scotland. Respondents' perceptions support several existing theoretical models of translation, however no single theory offered a comprehensive framework covering all aspects of the complex processes reported. Childsmile's use of best available evidence and on-going contribution to knowledge suggest that the programme is an example of intelligent policy making with international relevance.