Health‐care reform and the dimensions of professional autonomy

Abstract: A “managed competition” model was introduced in the Canadian province of Ontario as part of the government's reform of home care. With this model, it was assumed that competitive forces would encourage quality while driving down costs. While such reforms often achieve cost controls by constraining the incomes and practices of health‐care workers, there has been relatively little analysis of the extent to which self‐governing health‐care professionals, particularly those outside of medicine and nursing, may experience a decline in their ability to control the content and context of their professional work. In this article, the authors analyse the results of thirty‐six in‐depth interviews with representatives of Community Care Access Centres (CCACs), the organizations that purchase and coordinate the delivery of home‐care services, and rehabilitation provider agencies to examine the impact of Ontario's managed competition reform on rehabilitation professionals. Findings suggest that the impact of the reform varied across the economic, political, and clinical dimensions of professional autonomy and that, despite a general loss of autonomy under the managed competition model, market forces also served to mitigate the loss of autonomy, thus contributing to a remarkable resilience of professional autonomy. Sommaire: Un modèle de « concurrence dirigée » a été introduit récemment dans la province canadienne de l'Ontario dans le cadre de la réforme gouvernementale des soins à domicile. Avec ce modèle, il était présumé que les forces de la concurrence encourageraient la qualité tout en faisant baisser les coûts. Alors que de telles réformes parviennent souvent à maîtriser les coûts en réduisant les revenus et les pratiques des travailleurs de la santé, il y a eu relativement peu d'analyses de faites sur la mesure dans laquelle les professionnels de la santé autonomes, particulièrement ceux qui exercent en dehors de la médecine et de la profession infirmière, connaissent une perte de contrôle sur le contenu et le contexte de leur travail professionnel. Dans le présent article, les auteurs analysent les résultats de trente‐six entrevues en profondeur menées auprès de représentants des Centres d'accès aux soins communautaires (CASC), organismes qui achètent et coordonnent la prestation des services de soins à domicile, et organismes de prestation de soins de réadaptation, afin d'examiner les conséquences de la réforme de la concurrence dirigée de l'Ontario sur les professionnels de la réadaptation. Les résultats laissent entendre que l'effet de la réforme a varié en fonction des dimensions économiques, politiques et cliniques de l'autonomie professionnelle et que, malgré une perte d'autonomie générale liée au modèle de concurrence dirigée, les forces du marché ont également permis d'atténuer la perte d'autonomie, contribuant ainsi à la remarquable résilience dont font preuve ces professionnels en la matiére.     

A PRACTITIONER'S PERSPECTIVE ON UNIFIED FAMILY COURTS: CASE STUDIES

As a summary of simple examples demonstrating practical advantages of a family court, this article relates a few experiences from the perspective of a family law attorney who practices regularly in the Fulton County Family Division in Atlanta.     

COMMUNICATION STRATEGIES ON SOCIAL CORPORATE RESPONSIBILITY: THE ROLE OF FREEDOM OF EXPRESSION

The political and the economic spheres increasingly overlap. Consumption is viewed not only as an economic act, but also as an act of political and moral significance. Due to the blurring of the commercial and the political spheres, consumers use their purchasing power as a carrot and a stick for corporations to comply with corporate social responsibility (CSR) standards. As a consequence, corporate communication strategies tend to highlight commitment to CSR standards, portraying companies as “good corporate citizens.” Conversely, other stakeholders expose unethical business practices so as to induce corporate change. Both sides tend to invoke freedom of expression with a view to opposing limitations on their communication strategies. Taking two well-known examples as a starting point, the present article explores the role of freedom of expression as a means to incite corporate actors to both adopt and comply with CSR standards from a comparative perspective. Using an economic framework, it argues that non-commercial expression critical of corporate practices deserves a higher level of protection than corporate communication strategies.     

Gender and Race Differences in Delinquent Careers

Abstract Studies of delinquent careers have often tracked only male offenders, and have almost always failed to explore the interaction of race and gender in delinquency. This study tracks a cohort of youth whose first referral to juvenile court was in 1980, and explores the role played by both race and gender in official delinquent careers. Findings reveal that both race and gender play a significant role in official delinquency. Looking first at female delinquency, this research finds that white and nonwhite females do not differ significantly in the types of offenses they commit. Moreover, if girls are “chronic” delinquents, their offenses are most often trivial rather than serious. With males, racial differences emerge in both seriousness and chronic nature of delinquency. Nonwhite males in this cohort are more likely to be referred for personal offenses and less likely to be referred for public order and victimless offenses. Nonwhite males are also significantly more likely to become recidivists, and to have more seriously delinquent careers. This article discusses the implications of these findings, particularly with reference to the “convergence theory” of delinquency, which suggests that race plays a stronger role than gender in female delinquency. Finally, the article considers the policy implications of the current range of definitions of “chronic” delinquency.     

Familial functioning as a support system for adolescents' postdetention success

Youths transitioning out of detention are particularly in need of support systems that can divert them from recidivism. This article examines the relationship between incarcerated youths' sense of their families' functioning and their perceived likelihood for postdetention success. Despite the control of background variables, results reveal that delinquents who indicated stronger familial functioning also reported a greater likelihood of future success. Although interventions that focus on improving the supportive capacity of families have shown great promise, treatment drop-out rates remain high. To explore incarcerated youths' view of family focused interventions, respondents rated the potential utility of family and nonfamily focused intervention options. A majority of respondents reported that family focused interventions would be helpful. A group of respondents, overrepresented by adolescents with low family functioning, reported that this type of intervention would not be helpful. These results are discussed in terms of their impact on offering family focused interventions for juveniles.     

The consequences of error: Recidivism prediction and civil-libertarian ratios

The utility of recidivistic prediction is limited by the false positive problem: predictions of failure (recidivism) that do not occur. False negatives (predicted successes but observed failures) are also worrisome, and together both types of error can be formally evaluated by what Blumstein, Farrington, and Moitra call the civil-libertarian ratio: the ratio of the subjective cost of a false positive to a false negative. Choice of a recidivistic criterion and selection of a proportion of offenders for criminal justice intervention have implications for the evaluation of the disutility or subjective cost associated with various civil-libertarian ratios. Logistic regression models of four recidivistic criteria are evaluated to demonstrate how base rate (observed failure rate) and selection ratio (proportion selected to fail) affect the disutility associated with a range of civil-libertarian ratios. Use of civil-libertarian ratios by criminal justice policy makers is demonstrated. Predictive utility is relatively difficult to achieve for rare recidivistic events if the decisions involve severe deprivation of liberty (incarceration decisions). Predictive utility is easier to achieve for more common forms of recidivism or in decision contexts where there is less concern for false positives, such as for “intermediate sanctions.”