Whatever happened to regionalization? The curious case of Nova Scotia

Abstract: The case of Nova Scotia well illustrates the complexities involved in implementing a strategy of regionalization in health care. In 1996, under the leadership of Liberal Premier John Savage, thirty‐six local hospital boards were amalgamated into four regional health boards. By 2001, however, Conservative Premier John Hamm had expanded the four regions into nine district health authorities. Both measures were justified by explicit references to cost containment and greater accountability, even though the first took numerous units and amalgamated them, while the second took the few units and multiplied them. How can this seeming contradiction be explained, and what does it say about the nature of regionalization as a policy tool for health care? The authors find that neither cost containment nor citizen engagement can explain the system of regionalization which currently informs the health care system in Nova Scotia. Rather, the present form of regionalization exists because it is useful politically in two ways: it maintains the centralization of power that existed previous to the formal decentralization of health care; and it restores the system of representation that existed prior to the implementation of regionalization. The authors conclude that, to understand how regionalization has been implemented in any given jurisdiction, one must pay close attention to the political context in which strategies of regionalization have been executed. Sommaire: Le cas de la Nouvelle‐Écosse illustre bien les complexités inhérentes à la mise en œuvre d'une stratégie de régionalisation dans les soins de santé. En 1996, sous le leadership du Premier ministre libéral John Savage, 36 conseils d'hôpitaux locaux ont fusionné pour former quatre conseils de sante régionaux. En 2001, cependant, le Premier ministre conservateur John Hamm a élargi les quatre régions pour les transformer en neuf conseils de santé de district. Ces deux mesures ont été justifiées par des références explicites à la compression des coûts et à une plus grande imputabilité, même si la première a consistéà prendre de nombreuses unités et à les fusionner, tandis que la seconde a consistéà prendre quelques rares unités et à les multiplier. Comment peut‐on expliquer cette apparente contradiction, et qu'est‐ce que cela nous dit sur la nature de la régionalisation en tant qu'outil de politique en matière de soins de santé? Les auteurs trouvent que ni la compression des coûts, ni la participation des citoyens ne peuvent expliquer le système de régionalisation qui caractérise actuellement le système de soins de santé en Nouvelle‐Écosse. Au contraire, la forme actuelle de régionalisation existe parce qu'elle est politiquement utile de deux manières: elle maintient la centralisation du pouvoir qui existait avant la décentralisation officielle des soins de santé; et elle restaure, jusqu'à un certain point, le système de représentation qui existait avant la mise en œuvre de la régionalisation. Les auteurs concluent que, pour comprendre la manière dont la régionalisation a été mise en œuvre, il faut prêter une grande attention au contexte politique dans lequel ces stratégies de régionalisation ont étéélaborées.     

SUPERVISED ACCESS

This article addresses the question of whether long-term supervised access is an appropriate solution when unsupervised access is unlikely to become possible in the future. The article assesses judicial decisions and theoretical commentary on this issue in light of the opinions and practices of service providers and in light of the best interest of the child standard. The opinions and practices of service providers were gleaned from published materials and from interviews with service providers at supervised access facilities in Vermont and New Hampshire and in Ontario, Canada. The supervised access facilities surveyed for this research were diverse in their practices and experiences but remarkably similar in their approach to long-term supervised access. Outside the scope of the research for this article was the question of whether the opinions and practices of the service providers at the facilities surveyed are representative, and this question requires further investigation .     

For Both Love and Money: Viviana Zelizer's The Purchase of Intimacy

Viviana Zelizer's recent book, The Purchase of Intimacy (2005), presents an innovative theory of how social and legal actors negotiate rights and obligations when money changes hands in intimate relationships—a perspective that could change how we understand many things, from valuations of homemaking labor to the 9/11 Victim Compensation Fund. This essay describes Zelizer's critique of the reductionist “Hostile Worlds” and “Nothing But” approaches to economic exchange in intimate relationships and then explains her more three‐dimensional approach, “Connected Lives.” While Zelizer focuses on family law, the essay goes beyond that context, extending Zelizer's approach to transfers of genetic material and concluding that her approach could point toward a more equitable resolution of disputes in and about these markets.     

Fight or flight: Integral emotions and violent intentions

The effect of proximate emotions on risk perceptions is of central importance to criminal decision‐making theory, but has been understudied. We investigate the role of two integral (situational specific) emotional responses, anger and fear, in a decision‐making context regarding the choice to commit assault. We draw on dual‐process models of information processing and appraisal theory to propose a theoretical model in which integral emotions influence decisions and behavior. Using data from an experiment embedded in a survey to a nationwide sample of adults (N = 804), we test the interrelated roles of anger, fear, and traditional rational choice considerations on the intention to commit assault. We find a strong direct association between emotions and intentions to commit assault. Additionally, anger and fear moderate the effect of cognitive deliberations on behavioral intentions and provide a lens through which to evaluate a criminogenic opportunity.     

Judges’ sentencing decisions with older offenders

Older offenders tend to be treated with more leniency in the criminal justice system. A number of studies show that older offenders are less likely to be incarcerated, and when they are incarcerated, are more likely to receive shorter sentences. However, to date, no research has directly examined why such leniency occurs. This study asked U.S. state trial court judges to reflect on their sentencing practices with older offenders and to rate the factors considered most important when sentencing this population. Responses were received from 212 judges. Only 31% of judges acknowledged treating older offenders with greater leniency. These judges also indicated that they predominantly rely on legal factors when making decisions about sentencing with older offenders rather than factors specifically associated with age. Only cognitive impairment was identified by judges as one of the five most important factors to consider when sentencing older offenders. These results are discussed in terms of judges’ awareness of how they weigh information to make legal decisions. The influence of judges’ age and attitudes about aging on sentencing decisions are also explored.     

Précis of Paul Starr's The Social Transformation of American Medicine. 1982

The following is a presentation of selected passages from The Social Transformation of American Medicine (original pages numbers enclosed in parentheses) in tandem with the names of the authors in this retrospective issue and the various themes and issues they address.     

Chapter 3: The Influence of Juveniles' Race on Police Decision-Making: An Exploratory Study

Previous studies evaluating the effects of juveniles' race on police decision-making have rendered inconclusive results. Many of these studies have suffered from methodological shortcomings. The present study utilized vignettes to describe police-juvenile encounters in order to determine police charging practices for black and white youth. The results suggest modest offense-related race effects. Black youth tend to be charged with more offenses while white youth were released more frequently. A refinement in the research methodology is indicated for further explorations of the critical issue of police bias.