The politics of management in health care: a British perspective

This paper discusses the contribution of organizational political perspectives to a better appreciation of policy implementation problems in health care. The context is the efforts of successive British governments to accord a higher priority to community health and long-stay services. The limited success of these policies owes much to continuing medical control of the philosophy of the organization and agenda, in spite of government responsibility for funding and providing health services. More effective policy implementation depends on a recognition of the "naturalness" of organizational politics, rather than treating them as constraints in an otherwise rational, managerial system.     

Health care policy: lessons from the past and issues of the future

Liberal distributional values, the increasingly powerful capacity of medicine to provide more and better care, and concern about the health hazards of an industrial society fueled the vast expansion of the health care sector during the last 20 years. That growth was facilitated by a growing economy. The current health policy debate at one level reexamines the distributional bases of entitlement programs, and at another seeks alternative resource allocation mechanisms to reduce the cost of health care. This article has two themes. First, distributional and allocational policies are shown to be intrinsically related, so that the health policy debate is fundamentally a clash between liberal and libertarian values. Second, the inexorable social forces driving the health care system are shown to be the aging of the population and the rapid expansion of technology. The resulting dynamics imply the further growth of the health sector, now in the environment of a sluggish economy. Future policies will have to struggle with how to ration scarce health resources and how to reorient the health care sector to the problems of the aged.     

Industrial rationalization of a cottage industry: multi-institutional hospital systems

The environment facing hospitals, generally supportive until the 1970s, may now be characterized as complex, turbulent, and constrained. In response to such environmental conditions, hospitals have adopted new strategies and structures. The strategies, described as corporate rationalization, have led away from the traditional structure of freestanding, autonomous hospitals and toward the formation of multi-institutional systems. These systems are designed to provide sufficient strength to cope with the environment, to acquire scarce and valued resources, to allow organizational stability, to achieve organizational purpose, to enable growth and/or survival, and to enhance market position. The impact of multi-hospital systems is viewed in two major areas: acquisition, retention, and utilization of economic and human resources, and organizational, political, and social factors.     

Slim just left town: decisionmaking on an intensive care unit

The title of this paper comes from an incident that occurred while I was participating in morning rounds on the pediatric and surgical intensive care unit of a large, midwest tertiary care center. The patient under discussion was an eight-week-old girl who had been born without kidneys, and who had been cared for on the unit for seven weeks. In the previous week, the baby's condition had gone steadily downhill, as she experienced on medical catastrophe after another. One of the nurses asked the staff doctor who was leading rounds that morning, "What are the baby's chances?" The physician replied, "Her chances are slim." To which one of the young residents immediately answered, "Slim just left town."     

Genetic markers in human bone: I. Deoxyribonucleic acid (DNA) analysis.

Deoxyribonucleic acid (DNA) was isolated from a number of spongy and compact human bone tissue specimens, and the yield was estimated on a "per milligram of starting tissue" basis. DNA was, in addition, isolated from a number of corresponding blood and bone tissue specimens. Spectrophotofluorometry and ethidium bromide visualization on minigels were used to estimate the quantity and degree of degradation of DNA. The DNA from several blood-bone pairs is shown to give concordant restriction fragment length polymorphism (RFLP) typing results by two different typing protocols with five different single-locus probes. DNA from several additional blood-bone pairs is shown to give concordant results for human leucocyte antigen (HLA)-DQ alpha phenotypes following polymerase chain reaction (PCR) amplification and hybridization to specific allele-specific oligonucleotide (ASO) probes, and for the variable numbers of tandem repeats (VNTR) length polymorphisms 3' to the human apolipoprotein B (APOB) gene following PCR amplification with specific primers and analysis of the products by electrophoresis and ethidium bromide visualization.     

Pitfalls in the diagnosis of drug smuggler's abdomen

Narcotics "body packing" can be detected in abdominal X-rays by the ring shadow caused by air trapped in the packs. In a series of 82 cases admitted for abdominal X-ray in Helsinki, Finland, in 1982 through 1988, we encountered 9 (11.0%) true positives, 3 (3.6%) false positives, and 1 (1.2%) false negative. The false positives were due to the constipation often associated with the narcotics abuse. The false negative X-ray diagnosis was attributable to an inexperienced radiologist. False negatives may also be associated with packets containing marijuana, packs with few wrappings, aluminum-foil coated packs, and machine-packed narcotics. Searching for trapped air in radiographs, repeated X-raying by an experienced radiologist, use of computed tomography, or combined urinary drug screening may be applied to diminish false findings and to avoid unnecessary arrest for the purpose of fecal screening over several days.