Strategic Commissioning in the UK: Service Improvement Cycle or Just Going Round in Circles?

This article explores the drivers of the development of strategic commissioning over the last two decades, its limitations, and the implications of its rapid spread. It suggests that the differences between government departments have allowed scope for local variations, which have been exploited by local government, leaving room for more innovation than would have been possible under an entirely ‘joined-up’ government agenda. The forms taken by this new approach to strategic commissioning were consistent with continual pressure from central government to find ways of promoting externalisation of public services. Although this underlying drive was often resisted, particularly at local level, but always re-emerged. The article ends by exploring the implications of this analysis for public services in the era of fiscal austerity under the new UK Coalition government.     

Striving for a good life: The good lives model applied to released child molesters

Abstract

The good lives model (GLM) is a strengths-based approach to offender rehabilitation in which treatment aims to equip offenders with the skills and resources necessary to satisfy primary goods, or basic human values, in personally meaningful and socially acceptable ways. The aim of the present research was to explore the practical utility of the GLM with a sample of released child molesters, and investigate the relationship between primary goods attainment and overall re-entry conditions (in terms of accommodation, social support and employment). Semi-structured interviews were conducted with 16 child molesters at one, three and six months following their release from prison. As expected, participants endorsed the majority of GLM primary goods with high importance, and positive re-entry experiences were associated with increased goods attainment. Implications for clinicians, policy makers and society as a whole are discussed.     

Emergent authority and expert knowledge: Psychiatry and criminal responsibility in the UK

In the UK context, the rise of the discipline and practice of forensic psychiatry is intimately connected with the concurrent development of principles and practices relating to criminal responsibility. In this article, we seek to chart the relationship between psychiatry and the principles and practices of criminal responsibility in the UK over the early modern, modern and late modern periods. With a focus on claims about authority and expert knowledge around criminal responsibility, we suggest that these claims have been in a state of perpetual negotiation and that, as a result, claims to authority over and knowledge about criminal non-responsibility on the part of psychiatrists and psychiatry are most accurately understood as emergent and contingent. The apparent formalism of legal discourse has tended to conceal the extent to which legal policy has been preoccupied with maintaining the primacy of lay judgments in criminal processes of evaluation and adjudication. While this policy has been somewhat successful in the context of the trial – particularly the murder trial – it has been undermined by administrative procedures surrounding the trial, including those that substitute treatment for punishment without, or in spite of, a formal determination of criminal responsibility.     

Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: methodological, ethical and legal concerns

In 2007, WHO/UNAIDS recommended male circumcision as an HIV-preventive measure based on three sub-Saharan African randomised clinical trials (RCTs) into female-to-male sexual transmission. A related RCT investigated male-to-female transmission. However, the trials were compromised by inadequate equipoise; selection bias; inadequate blinding; problematic randomisation; trials stopped early with exaggerated treatment effects; and not investigating non-sexual transmission. Several questions remain unanswered. Why were the trials carried out in countries where more intact men were HIV-positive than in those where more circumcised men were HIV-positive? Why were men sampled from specific ethnic subgroups? Why were so many participants lost to follow-up? Why did men in the male circumcision groups receive additional counselling on safe sex practices? While the absolute reduction in HIV transmission associated with male circumcision across the three female-to-male trials was only about 1.3%, relative reduction was reported as 60%, but, after correction for lead-time bias, averaged 49%. In the Kenyan trial, male circumcision appears to have been associated with four new incident infections. In the Ugandan male-to-female trial, there appears to have been a 61% relative increase in HIV infection among female partners of HIV-positive circumcised men. Since male circumcision diverts resources from known preventive measures and increases risk-taking behaviours, any long-term benefit in reducing HIV transmission remains uncertain.     

Barriers to the operation of mental health legislation in Australian emergency departments: a qualitative analysis

This study aimed to describe the perceived barriers faced by emergency clinicians in utilising mental health legislation in Australian hospital emergency departments. A semi-structured interview methodology was used to assess what barriers emergency department doctors and nurses perceive in the operation of mental health legislation. Key findings from the interview data were drawn in accordance with the most commonly represented themes. A total of 36 interviews were conducted with 20 members of the Australasian College for Emergency Medicine and 16 members of the College for Emergency Nursing Australasia representing the various Australian jurisdictions. Most concerning to clinicians were the effects of access block and overcrowding on the appropriate use of mental health legislation, and the substandard medical care that mental health patients received as a result of long periods in the emergency department. Many respondents were concerned about the lack of applicability of mental health legislation to the emergency department environment, variation in legislation between States and Territories causing problems for clinicians working interstate, and a lack of knowledge and training in mental health legislation. Many felt that clarification of legislative issues around duty of care and intoxicated or violent patients was required. The authors conclude that access block has detrimental effects on emergency mental health care as it does in other areas of emergency medicine. Consideration should be given to uniform national mental health legislation to better serve the needs of people with mental health emergencies.