- Email: [email protected]
Evaluating community care services for people with learning difficulties
Soc. Sci. Med. Vol. 44, No. 8, pp. 1255-1258, 1997 Published by Elsevier Science Ltd. Printed in Great Britain 0277-9536/97 $17.00 + 0.00
Pergamon
BOOK REVIEWS
Evaluating Community Care Services for People with Learning Difficulties, by Ken Wright, Alan Haycox and lan Leedham. Open University Press, Buckingham, U.K., 1994. 192 pp., U.K. £14.99. In the U.K. the structure and organisation of health services has over the past seven years undergone a series of changes more fundamental than any other alterations in its structure since inception in t948. The introduction of a market in healthcare and the separation of healthcare organisations into "purchasers" and "providers" have led to more detailed specification of services in terms of volume and cost. Although in the early days of the reforms considerable attention was paid to the possibility of contracting for specific outcomes this has had little practical impact on the contracting process. Against this background of organisational change a fundamental re-orientation of care for people with learning difficulties has taken place. (The authors have adopted the terminology "learning difficulties" rather than "learning disabilities" or "mental handicap".) Large scale institutional care in single function hospital communities has almost completely disappeared and been replaced with a wide mix of community provision. In this slim but very readable book the authors provide a very helpful policy orientation both in relation to events up to 1994 and in commenting on the policy prospective for the rest of the decade. The framework of evaluation chosen by the authors is not original, having been developed over a substantial period in other areas of health services. What they have done however, is to apply these principles very successfully to the very distinct area of people with learning difficulties. Sociological and economic approaches have been successfully blended to provide a highly accessible and
Managing Health Promotion: Developing Healthy Organizations and Communities, by Ina Simnet. John Wiley, Chicbester, New York, 1995. 229 pp. $14.99 (Paper). The term, "health promotion" can be used in different ways. Quite often it is taken as an umbrella term for a huge range of activities such as medical prevention, risk factor screening, health education etc. With regard to implementation, the umbrella concept is very pragmatic. It permits one to choose from a variety of intervention measures. These forms of implementation of health promotion might easily fit with existing organisational structures and policy-making processes within the public health system. However, according to the Ottawa-Charter and WHO's conceptualization of the term, health promotion particularly focuses on a socio-ecologlcal approach emphasizing the needs for organizational development, community empowerment, environmental measures and healthy public policies. The implementation of this particular approach is much more difficult. Because it aims to change the system itself and to develop a new public health, it has to consider organizational and political reluctance. It also lacks an adequate implementation infrastructure. Managing Health
readily adoptable approach to evaluation. The wide variety of dimensions considered in the development of the approach will not only be useful to those participating in or commissioning evaluative studies but also to anyone who is engaged in the implementation or development of policies in that area. The only serious drawback to the book is that having been published in 1994 it is now considerably dated in its treatment of the structures of health services in England. The abolition of Regional Health Authorities, the merging of District Health Authorities with Family Health Services Authorities and the introduction of a weighted capitation funding formula has produced a profoundly altered organisational topography. Similarly some aspects of prevention discussed in the book have now been overtaken by new developments, for example in the field of immunisation. It is however an indication of the broad based nature of this work that five pages are devoted to prevention, an area which is commonly neglected. For readers without a specific interest in learning difficulties the book will provide a useful and broad based introduction to concepts of evaluation of any community based service. For those with an involvement in learning difficulties the book will undoubtably be a valuable aid to the planning and evaluation of these services particularly where de-institutionalisation is a prominent feature. GabfieiScaHy Public Health Directorate NHS Executive Bristol BSl2 6SR U.K.
Promotion: Developing Healthy Organizations and Communities shows how to bridge the gap between the predominant pragmatic but unspecific implementation of health promotion as an umbrella term and a more particular concept of health promotion as organizational development. Therefore, this book might be useful in overcoming some of the reluctance to implement organizational change. The author of this work served within the British public health system as health promotion manager and consultant for many years. Her approach is well informed, pragmatic and never fails to refer to the actual needs of the system, especially National Health Service reforms in U.K. The development of health-promoting organizations, intersectoral collaboration and health alliances are identified as directly related to actual government policies. The U.K. government strategy for improving the health of the population build on the concept of health gains is one example. She points out that in the past National Health Service has normally been more concerned with "outputs (provision of services)" than with the achievement of better "outcomes (improved health of the population)," and the implementation of the new strategy needs to shift the organizational perspective. The development of health-
1255
Pergamon
BOOK REVIEWS
Evaluating Community Care Services for People with Learning Difficulties, by Ken Wright, Alan Haycox and lan Leedham. Open University Press, Buckingham, U.K., 1994. 192 pp., U.K. £14.99. In the U.K. the structure and organisation of health services has over the past seven years undergone a series of changes more fundamental than any other alterations in its structure since inception in t948. The introduction of a market in healthcare and the separation of healthcare organisations into "purchasers" and "providers" have led to more detailed specification of services in terms of volume and cost. Although in the early days of the reforms considerable attention was paid to the possibility of contracting for specific outcomes this has had little practical impact on the contracting process. Against this background of organisational change a fundamental re-orientation of care for people with learning difficulties has taken place. (The authors have adopted the terminology "learning difficulties" rather than "learning disabilities" or "mental handicap".) Large scale institutional care in single function hospital communities has almost completely disappeared and been replaced with a wide mix of community provision. In this slim but very readable book the authors provide a very helpful policy orientation both in relation to events up to 1994 and in commenting on the policy prospective for the rest of the decade. The framework of evaluation chosen by the authors is not original, having been developed over a substantial period in other areas of health services. What they have done however, is to apply these principles very successfully to the very distinct area of people with learning difficulties. Sociological and economic approaches have been successfully blended to provide a highly accessible and
Managing Health Promotion: Developing Healthy Organizations and Communities, by Ina Simnet. John Wiley, Chicbester, New York, 1995. 229 pp. $14.99 (Paper). The term, "health promotion" can be used in different ways. Quite often it is taken as an umbrella term for a huge range of activities such as medical prevention, risk factor screening, health education etc. With regard to implementation, the umbrella concept is very pragmatic. It permits one to choose from a variety of intervention measures. These forms of implementation of health promotion might easily fit with existing organisational structures and policy-making processes within the public health system. However, according to the Ottawa-Charter and WHO's conceptualization of the term, health promotion particularly focuses on a socio-ecologlcal approach emphasizing the needs for organizational development, community empowerment, environmental measures and healthy public policies. The implementation of this particular approach is much more difficult. Because it aims to change the system itself and to develop a new public health, it has to consider organizational and political reluctance. It also lacks an adequate implementation infrastructure. Managing Health
readily adoptable approach to evaluation. The wide variety of dimensions considered in the development of the approach will not only be useful to those participating in or commissioning evaluative studies but also to anyone who is engaged in the implementation or development of policies in that area. The only serious drawback to the book is that having been published in 1994 it is now considerably dated in its treatment of the structures of health services in England. The abolition of Regional Health Authorities, the merging of District Health Authorities with Family Health Services Authorities and the introduction of a weighted capitation funding formula has produced a profoundly altered organisational topography. Similarly some aspects of prevention discussed in the book have now been overtaken by new developments, for example in the field of immunisation. It is however an indication of the broad based nature of this work that five pages are devoted to prevention, an area which is commonly neglected. For readers without a specific interest in learning difficulties the book will provide a useful and broad based introduction to concepts of evaluation of any community based service. For those with an involvement in learning difficulties the book will undoubtably be a valuable aid to the planning and evaluation of these services particularly where de-institutionalisation is a prominent feature. GabfieiScaHy Public Health Directorate NHS Executive Bristol BSl2 6SR U.K.
Promotion: Developing Healthy Organizations and Communities shows how to bridge the gap between the predominant pragmatic but unspecific implementation of health promotion as an umbrella term and a more particular concept of health promotion as organizational development. Therefore, this book might be useful in overcoming some of the reluctance to implement organizational change. The author of this work served within the British public health system as health promotion manager and consultant for many years. Her approach is well informed, pragmatic and never fails to refer to the actual needs of the system, especially National Health Service reforms in U.K. The development of health-promoting organizations, intersectoral collaboration and health alliances are identified as directly related to actual government policies. The U.K. government strategy for improving the health of the population build on the concept of health gains is one example. She points out that in the past National Health Service has normally been more concerned with "outputs (provision of services)" than with the achievement of better "outcomes (improved health of the population)," and the implementation of the new strategy needs to shift the organizational perspective. The development of health-
1255