Monthly Archives: aprile 2013

Il Big Bang del NHS @Medici_Manager

Gavino Maciocco http://bit.ly/Z9NRWy

È entrata in vigore la riforma che cambia radicalmente il volto delNational Health Service inglese, un vero Big Bang per il più noto, antico e imitato modello di sistema sanitario universalistico. Cosa ne resterà di quel modello? Ben poco sostengono i più.


Il 1 aprile è entrata formalmente in vigore la legge di riforma approvata lo scorso anno (Health and Social Care Act 2012) e tenacemente voluta dal governo guidato dal premier conservatore Cameron, che la mise in cantiere immediatamente dopo aver vinto le elezioni politiche nel 2010.

Una riforma che cambia radicalmente il volto del National Health Service (NHS)[1], un vero Big Bang per il più noto, antico e imitato modello di sistema sanitario universalistico.  I principali contenuti politici della riforma sono i seguenti:

  1. L’intera infrastruttura sanitaria pubblica, dalle Strategic Health Authorities (le nostre Regioni) ai Primary Care Trusts (le nostre ASL),   è stata abolita (a partire appunto dal 1 aprile).
  2. Se sul versante del finanziamento del sistema sanitario la responsabilità  rimane (per ora…)  a carico del settore pubblico e quindi della fiscalità generale, sul versante della produzione dei servizi curativi (territoriali e ospedalieri) si va verso una diffusa privatizzazione dei servizi sanitari, guidata da logiche di mercato  molto spinte, con l’irruzione nel sistema di  grosse e potenti  compagnie multinazionali.
  3. I servizi preventivi, quei pochi che erano rimasti in capo al NHS (come il controllo delle malattie infettive e gli screening) vengono interamente trasferiti alle municipalità.

Primary Care Trusts (ripetiamo, le nostre ASL) sono sostituiti da consorzi di General Practitioners (GPs, i medici di famiglia), denominati Clinical Commissioning Groups (CCGs).  I CCGs, organizzazioni private a pieno titolo, rappresentano il vero perno del sistema. Saranno complessivamente 211 in tutta l’Inghilterra e saranno i destinatari di 65 miliardi di sterline di fondi pubblici (quasi il 70% dei 95 miliardi di sterline dell’intero budget sanitario nazionale).

Tale cambiamento”, si legge in un articolo di Lancet, “mina uno dei meccanismi chiave attraverso cui il NHS riesce a garantire un pieno ventaglio di servizi indipendentemente dal luogo di residenza dell’assistito. I Primary Care Trusts sono responsabili per l’intera popolazione in una definita area geografica, non solo per i pazienti che sono iscritti in un determinato servizio. Questa responsabilità basata sulla popolazione consente una valutazione a lungo termine dei bisogni, la pianificazione e la committenza dei servizi per rispondere a quei bisogni, e la rendicontazione pubblica dell’uso delle risorse per quella popolazione. La proposta del governo abbandona il principio basato sulla popolazione; la committenza che sarà esercitata dai futuri consorzi dei medici di famiglia riguarderà solo gli assistiti iscritti con i medici di quel determinato consorzio all’interno di confini geografici amorfi e indefiniti. Verrà così meno la possibilità di programmare un’adeguata distribuzione geografica dei servizi per le comunità e le popolazioni locali”[2].

Con i fondi assegnati i CCGs finanzieranno le attività dei GPs e i servizi che verranno offerti ai loro pazienti da parte dei vari provider – pubblici e privati – a cui vengono commissionate le prestazioni: dalle cure domiciliari, all’assistenza specialistica e ospedaliera.  Ciò ha immediatamente sollevato la questione del loro potenziale conflitto d’interessi: GPs prescrittori di prestazioni erogate da provider privati, con possibili interessi a comune con GPs.  “Metà dei GPs nei CCGs  hanno legami finanziari con i provider privati”, sostiene il BMJ[3]. “Il fatto che i GPs abbiano interessi esterni può influenzare le loro decisioni nella scelta dei provider e può mettere a rischio il rapporto di fiducia con i loro pazienti, perché questi  possono diffidare del motivo per cui sono stati inviati per un determinato trattamento”: così si esprime Clare Gerada, Presidente del Royal College of GPs, che aggiunge: “Ciò inoltre può danneggiare anche il NHS perché avere molti differenti provider può aumentare i costi e frammentare l’assistenza, a tutto danno dei pazienti”[4].

Le cose potrebbero ulteriormente complicarsi se – come la legge prevede – i CCGs appaltassero l’attività di committenza a agenzie private, per le quali  gli interessi commerciali nella scelta del provider sarebbero ancora più evidenti.

Altro elemento critico è la perdita del livello nazionale di definizione dei livelli essenziali di assistenza, assegnato prima della riforma al Ministero della salute, che stabiliva le prestazioni che le strutture pubbliche erano tenute a tenute a garantire uniformemente  in tutto il territorio e anche i livelli di partecipazione alla spesa, per alcune limitate categorie di prestazioni. Con la riforma sarà ciascun CCG a stabilire quali prestazioni saranno garantite ai pazienti e anche i livelli di partecipazione alla spesa.

Ad aggravare la situazione ci sono anche i tagli apportati dal governo Cameron al budget della sanità (meno 20 miliardi di sterline entro il 2015) e ad altri settori del welfare, che si ripercuotono negativamente sull’assistenza sanitaria.  Scrive sul Guardian Simon Atkins, medico di famiglia: “Un crescente numero di persone affolla i nostri ambulatori a causa delle politiche del governo.  Questo infatti ha tagliato in maniera spropositata i servizi per i poveri, gli anziani e i disabili e ogni giorno vedo persone che sono in grande difficoltà a causa di ciò. Ad esempio, a causa dei tagli, è stato chiuso nel nostro quartiere un Centro Diurno che dava supporto e possibilità di compagnia a tante persone”[5].

Ciò che sta succedendo – sostiene Lucy Reynold della  London School of Hygiene and Tropical Medicine – è un vero mutamento genetico del NHS, anche se il governo cerca di minimizzare la portata del cambiamento sostenendo che non ci sarà differenza tra servizi erogati da provider pubblici e privati.  In realtà “nel settore pubblico i medici cercano di avere finanziamenti adeguati per rispondere in maniera adeguata ai bisogni dei loro pazienti. L’obiettivo è la cura e i soldi sono un mezzo per raggiungerlo. Quando invece ti trovi nel settore privato – afferma la Reynold – la compagnia si pone l’obiettivo di fare soldi, la priorità è quella di  distribuire i dividendi ai soci”.  Reynold prevede che la competizione tra provider  pubblici e privati, tutta basata sui prezzi, alla fine sarà vinta da quest’ultimi, con conseguenze irreversibili. “E ogni volta che il settore privato riuscirà a sottrarre un contratto  al settore pubblico, ciò provocherà la scomparsa di quel servizio perché verranno meno le risorse per pagare i salari dei dipendenti”[6].

Che la riforma rappresenti l’inizio della fine del NHS  è anche opinione di David Hunter, professore di politica sanitaria all’Università di  Durham, il cui punto di vista è così riassunto:  “quando la sanità è dominata dal mercato  dobbiamo aspettarci: a) una riduzione della qualità delle cure; b) un aumento dei costi; c) il trasferimento di  finanziamenti pubblici in profitti privati; d) la riduzione della libertà di scelta; e) la perdita di  controllo democratico e di public accountability nel campo dell’assistenza sanitaria”[7].

Bibliografia

  1. Dossier NHS su SaluteInternazionale
  2. Whitehead M, Hanratty B, Popay J. NHS reform: untried remedies for misdiagnosed problems? Lancet 2010; 376:1373-5.
  3. Limb A, Half of GPs on clinical commissioning groups have financial links with private providers, BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e2431
  4. Campbell D. The Guardian, 27.03.2012
  5. Atkins S. The Guardian, 08.01.2013
  6. Reynold L. The future of NHS – Irreversible privatization? BMJ 2013;346:f1848 doi: 10.1136/bmj.f1848
  7. Hunter D. Will 1 April  mark  the beginning  of the end of England’s NHS? Yes, BMJ 2013;346:f1951 doi: 10.1136/bmj.f1951

Building European reference networks in health care. Exploring concepts and national practices in the European Union @Medici_Manager

Under the European Directive on the application of patients’ rights in cross-border health care, the development of European reference networks was promoted as one of the prime areas for cross-border cooperation among Member States. These networks are meant to improve access to and provision of high-quality specialized health care to those patients who need it, and to act as focal points for medical training and research, information dissemination and evaluation, especially for rare diseases.

The idea of pooling resources in this way parallels moves to concentrate specialized health care services driven by financial constraints, workforce shortages and growing attention to quality and safety.

This book examines the ways in which reference networks have developed in European countries, for what kind of medical conditions or interventions, the motivations behind their establishment, the regulatory and administrative processes involved, and the financial arrangements needed. This study outlines the key policy implications and challenges of developing the concept of reference networks at national and European levels, and will assist policy-makers, health professionals, administrators and others involved in implementing the Directive.

http://bit.ly/14giEYc

Statement by Professor Malcolm Grant, Chairman of the NHS Commissioning Board @Medici_Manager @NHSCB

28 February, 2013

The Chair of the NHS Commissioning Board, Professor Malcolm Grant, today (Thursday) made the following statement at the organisation’s public board meeting held in Manchester.

He said:

“I want to make a statement about the Chief Executive. We stand at the moment poised at the commencement of one of the great momentous changes in the NHS. We will see the abolition of 161 statutory bodies and the creation of 211 new clinical commissioning groups.

“But this isn’t just a structural change. This is about a change in culture, it’s about a devolution, it’s about unleashing the power of commissioning – perhaps for the first time in the history of the NHS. It’s a complex, a hugely complex institution. The NHS treats in the order of 1 million people a day. There is no other organisation on earth with that reach and with that complexity, and with that function of being a remarkable, not just healthcare organisation but social support organisation that goes to the very heart of British society.

“The wakeup call that the Francis report has given us has drawn attention to numerous failings within the NHS – not just within Mid Staffs, but of a system which has from time to time focused upon the wrong things and has had dire consequences for those who have been unfortunate enough to be adversely affected by it.

“There has been a search amongst many people who suffer a sense of dismay and shock from the events that have been disclosed by Francis’s report – a search for accountability and in particular a focus upon the work of David Nicholson who through much of that period was a senior executive in Strategic Health Authorities. Indeed he held, because of the turmoil of reorganisation of that day, he held no fewer than seven jobs in six years within the NHS – culminating in his appointment in 2006 to be the Chief Executive of the NHS.

“David’s current formal position is that until 1 April he is employed 50% by the Government as Chief Executive of the NHS, and 50% by us, the Commissioning Board. With effect from 1 April his employment transfers 100% to the Commissioning Board. I have been deeply worried by speculation in the media about his future. Over the recent weeks I have reflected on several occasions with David about what has been said in the press. I have discussed it personally with each of the Directors of the Commissioning Board and I have discussed it collectively with the Non-Executive Directors of the Board.

“We have come to a clear view that David Nicholson is the Chief Executive of the Board. He is the person who we wish very strongly to lead a strong Executive Team on the Board. He is the person whose command of the detail of the NHS and his commitment and his passion to its future, we believe to be fundamental to the success of the Board. This is not, as it were, a statement of vulnerability but a statement of strength. We look David to you, to provide us with the leadership as we take through this exceptionally challenging set of changes. Thank you.”

http://bit.ly/YNyyBF

3 different blogging styles for your hospital or health care organization @Medici_Manager @Dermdoc

Find one that fits your voice the best. By Kelly Merrick | Posted: February 28, 2013 http://bit.ly/YAet2s

Kelly Merrick is the social media mentor at Hive Strategies. You can check out the Hive Strategies blog here.

When you decide to start a health care-related blog, there are a lot of elements to consider. You have to determine how much time you can devote to managing a blog, what your comment policy will be, and some strategies for how to gain followers.

But there is something else you should consider, something that I think is perhaps more important than all of the above items: What purpose you want your blog to serve.

I read a lot of health care blogs, and for the most part, all of the blogs have a specific type, which features the strength of the writer. So, as you are preparing to start your own blog, I want you to consider what you want your blog to accomplish.

Do you want to educate your readers by giving them information about topics such as immunizations and the latest health research? Or do you want to tug on their heartstrings by telling stories? Or do you want to weave your own personal life experiences into your blog? This is a crucial step to take because it will ultimately decide why your readers return for more.

Educational

An educational blog is one that is practical. It covers topics that are useful to the audience and helps them make decisions for themselves. An educational blog is great for many reasons, and is a good choice if you are the type of health care provider who keeps up on the latest medical research and has a strong desire to share practical applications with a larger audience.

A great example of an educational blog is one by Registered Nurse Linda Scherf. Scherf manages her hospital’s Birthing Center blog in McMinnville, Oregon, and covers topics from car seat safety to how to obtain your baby’s birth certificate to breast-feeding advice.

Narrative

A narrative blog is a powerful one, especially if you are the type of person who is a storyteller. When done correctly, a narrative blog pulls readers in and captivates them through a story that revolves about anything from a tense moment in the ER or a special encounter with a patient.

A narrative blog is an extremely powerful blog because you are using your personal experiences to drive the content. But be careful with a narrative format because it has the risks of running long and revealing protected patient information.

The blog One Case at a Time by anesthesia resident Felicity is one of the best narrative blogs I have read. She is a talented writer and has the ability to pull me into every one of her posts with dramatic and tense stories about her experiences with patients and colleagues.

Personal

A personal blog is one that might be educational and narrative, but pulls largely on personal opinions and stories to make a point. A personal blog is one that is powerful because it gives you insight into who the blogger is, and can be full of personal thoughts, fears and hopes.

If you are a health care provider who has the desire to give information through personal experiences, and if you are comfortable giving out details from your professional and person life, this type of blog can really help you connect with your audience.

I suggest following the blog Reflections of a Grady Doc, written by Dr. Kimberly Manning, if you are considering a blog that draws mostly from personal experiences. Her blog also combines a narrative element, which makes her blog even more engaging.

Although I encourage you to decide if you want your blog to be largely educational, narrative or personal, a good blog will incorporate all three. But by choosing a specific type of blog, you give yourself some boundaries and guidelines to follow, which can be extremely helpful when you are deciding what to write about on any given day. It also will attract a certain type of reader, so you’ll want to be aware of what you want your blog to accomplish.

If you are writing to a specific audience, educational might be your blog type. But if you are writing to a larger audience who may not be in your area, a narrative blog may fit you. And if you want to connect with your reader, wherever they may be, a personal blog is an effective way to accomplish that.

But no matter what type of blog you choose to write, keep in mind what your strengths are as a writer, because you’ll want to make sure you can sustain your blog and enjoy it at the same time.

Helping patients to die well @Medici_Manager @giovanimedici @specializzandi

Fiona Godleeeditor, BMJ @fgodlee

There is more than one way to die well, say Katherine Sleeman and Emily Collis in their article on caring for dying patients (doi:10.1136/bmj.f2174). The trouble is that far too many people die badly. Whatever your definition of a good death, dying in hospital when you would prefer to die at home, or dying in pain, distress, isolation, or uncertainty will not be part of it. Yet, as the authors explain, over half of all deaths (in the UK at least) occur in hospital, many patients die with unmet needs, and more than half of complaints referred to the Healthcare Commission are about the care of dying people. All of this is despite the growing recognition of the need for good end of life care. And of course the risk of dying badly matters not only to the person who is dying but to their relatives and friends. The authors quote Cicely Saunders, founder of the hospice movement: “how we die remains in the memory of those who live on.”

But there is good news. While modern medicine often seems to actively promote bad end of life care, doctors can do a great deal to help patients achieve a good death. Early identification of the dying phase, good communication with patients and relatives, sensible prescribing, effective management of physical symptoms, and understanding of the patient’s social, psychological, and spiritual needs must all play their part.

Sleeman and Collis have targeted their advice towards doctors in training. But clinicians at all levels of experience will benefit from reading their article. Senior doctors will, in any case, want to model the highest professionalism and humanity when dealing with dying patients. Knowing that younger doctors will be taking their cues from you provides an additional incentive.

The article usefully tackles some of the misconceptions that have dogged the Liverpool care pathway in recent months. The pathway is a framework, not a treatment, so doesn’t need formal consent, but the decision to start someone on it should be made by a multidisciplinary team and should be discussed with the patient where appropriate and always with the relatives. While on the pathway, patients should be supported to eat and drink; and if the patient’s condition improves, the pathway can be stopped.

Essential to good end of life care is the ability to recognise that a person is dying. Sadly, this is a prognostic skill that doctors are “notoriously poor at,” say the authors. But do patients need to know that they are terminally ill in order to receive good care? The same authors take part in our Head to Head debate this week, arguing that patients should be told, since this knowledge is necessary for informed decisions (doi:10.1136/bmj.f2589). But Leslie Blackwell argues against what she calls “prognostic disclosure” (doi:10.1136/bmj.f2560). This is, she says, “a failed model for medical decision making that creates more suffering than it relieves,” and “for most people the apparent choice between comfort and prolongation of life is a false one.” I’m not convinced, but I would like to hear your views.

Cite this as: BMJ 2013;346:f2656

 

 

 

Stati disuniti d’Europa

Keynes blog

HornGustav Horn, presidente dell’Institut für Makroökonomie und Konjunkturforschung della  Hans-Böckler-Stiftung (vicino ai sindacati), sulla progressista Die Zeit propone una riflessione sul meccanismo profondamente sbagliato alla base della moneta unica: la concorrenza fra stati [da Voci dalla Germania].

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50 Most Influential Physician Executives – 2013 (text list) RT @drsilenzi

Andrea Silenzi, MD, MPH

Read more: 50 Most Influential Physician Executives – 2013 (text list) | Modern Healthcare http://www.modernhealthcare.com/article/20130420/INFO/130419962#ixzz2RAprmEFz
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Do You Have Executive Presence? @Medici_Manager @LDRLB @drsilenzi

David Burkus —  March 15, 2013 http://ldrlb.co/2013/03/do-you-have-executive-presence/

We all know what it takes to succeed as a leader: hard work, intelligence, determination, luck. While those may be important, it turns out that they may not even approach the impact of one other key dimension: executive presence. In a recent study conducted by Sylvia Ann Hewlett and a team of researchers at the Center for Talent Innovation, the senior leaders surveyed listed executive presence – being perceived as leadership material – as the essential factor in determining who gets ahead in an organization.

The study surveyed 18 focus groups, 4,000 college-degreed professionals, 50 personal interviews and 268 senior-level executives and concluded that leadership positions are most often given to those who look the part. Attributes like hard work and past performance are important, but the study’s biggest finding was that executive presence is a requirement for top leadership positions.

But what exactly is executive presence?

Hewlett and her team also sought to deconstruct executive presence by defining the three components that help a leader look the part:

Communication. Excellent speaking skills, active listening and assertiveness are required skills for leaders. In addition to interpersonal communication, leaders need the ability to read an audience or situation and craft the appropriate response. Perhaps that’s why 28 percent of senior executives agreed that communication predicts your leadership potential.

Appearance. Looking polished and well put together was found to be an important element of presence. While only 5 percent of senior leaders considered it to be a key factor, every leader surveyed recognized appearance for its potential to derail high potential talent.

Gravitas. Leaders with executive presence must project confidence. In high-pressure situations, members look to their leader for confident, decisive action. Keeping ones poise under stress is vital for those in senior leadership, which is why two-thirds of the leaders surveyed agreed that gravitas was the core characteristic of executive presence.

The study’s findings also have some interesting implications for developing women and multicultural professionals into senior leaders. While the traditional explanations like work/life balance or a lack of available high-level sponsors were seen as reasons for the talent gap among these potential leaders, the survey also found that the impact of executive presence may play a role as well. Women and multicultural professionals felt they were held to a stricter standard and tended to feel a higher intrinsic tension between remaining true to oneself and assimilating with the dominant organizational culture, according to the study. Over 80 percent of women and people of color said they were unclear as to how to act on feedback about their own executive presence. In addition, 56 percent of people of color felt they were held to a stricter code of executive presence than the average organizational member.

In addition to analyzing the talent development factors and deconstructing the fuzzy concept of executive presence, Hewlett and her team have provided a method for analyzing executives for leadership development. By better understanding executive presence as a leadership competency, HR professionals and senior leaders can work more effectively develop future leaders, remove unnecessary barriers on women and multicultural professionals and make sure they are tapping into the potential of their most promising talent. On an individual level, potential leaders should examine this study’s implications for their own development.

Ask yourself: how well are you demonstrating poise under pressure? Is your appearance polished and put together? Can you effectively read an audience and communicate your ideas?

Alla ricerca dell’informazione di qualità @Medici_Manager

La buona informazione è la migliore medicina. “La disponibilità di informazioni affidabili e validate – considera Carlo Favaretti – può generare valore aggiunto solo se questa disponibilità viene ‘catturata’ da tutti coloro che, nella pratica quotidiana, devono combinare al meglio le risorse disponibili con i bisogni e le domande dei cittadini”. Ben venga quindi una guida come La ricerca documentale, rivolta a tutte le figure professionali sanitarie, su come trovare nel mare magnum web-based l’informazione di cui si ha bisogno in una prospettiva evidence-based oriented.

La presentazione di Carlo Favaretti go

Acquista il libro a soli 12 € go

Guida minima ai sistemi elettorali @Medici_Manager @wricciardi

Visto che tra poco si ricomincerà a parlarne, meglio arrivare preparati: come funzionano le cose in cinque paesi europei

Uno dei dibattiti più frequenti nella politica italiana è quello sulla legge elettorale. È così da circa trent’anni, ma in concreto dal 1946 al 1993 – i primi cinquant’anni della storia italiana – si è votato sempre con lo stesso sistema (poi vedremo quale). Dopo le ultime elezioni politiche, il tema è ritornato di attualità: subito dopo i risultati, si è cominciato a parlare di una nuova legge elettorale che sia in grado di garantire “la governabilità”: ovvero una solida maggioranza per i partiti vincitori delle elezioni alla Camera e al Senato.

L’Italia oggi ha una legge elettorale complicata, proporzionale con liste bloccate e vari sbarramenti nonché alcune correzioni maggioritarie, su tutte il grosso premio di maggioranza alla Camera. È stata definita Porcellum, a parole non la vuole nessuno, in pratica ci abbiamo già eletto tre parlamenti: chi volesse approfondire come funziona può leggere qui. Negli altri paesi e nella storia recente ci sono sistemi diversi, che esporremo con qualche esempio e con qualche distinzione iniziale, per arrivare preparati al prossimo, prevedibile dibattito. Un’unica premessa. I sistemi elettorali sono moltissimi e non ne esiste uno perfetto: ciascuno privilegia un aspetto piuttosto che un altro (la rappresentanza territoriale; la durata dei governi; la tutela delle minoranze) e la scelta tra l’uno e l’altro è una scelta delicata e senza garanzia di successo.

Iniziamo dalle basi
Il sistema elettorale è il modo con cui i voti espressi dagli elettori si traducono in rappresentanza parlamentare: cioè nel numero di parlamentari assegnati a ogni partito o coalizione politica. Cominciamo con la distinzione principale, quella tra sistema maggioritario e sistema proporzionale. Nella mappa qui sotto sono rappresentati i vari sistemi elettorali del mondo: in rosso i sistemi maggioritari, in blu quelli proporzionali.

Quello più semplice da riassumere è il proporzionale: in questo caso, la percentuale di parlamentari coincide più o meno con il numero di voti ricevuti alle elezioni. In Italia, tra il 1946 e il 1993, si è votato con un sistema proporzionale “puro” (tranne che nel 1953), che oggi è in vigore in alcuni paesi come Israele (ne abbiamo parlato più estesamente qui), Albania, Turchia e Brasile. L’attuale Porcellum è un sistema proporzionale corretto, perché di base assegna i parlamentari in base ai voti che hanno ricevuto, ma assegna anche un premio di maggioranza, cioè un numero fisso di parlamentari, alla coalizione che ottiene anche un solo voto più degli altri (la cosa complicata è che, in Italia, il premio alla Camera è nazionale, mentre al Senato si assegna regione per regione).

A questo punto introduciamo un altro elemento essenziale, e cioè i collegi o circoscrizioni elettorali. Queste sono le aree territoriali in cui viene diviso il paese ai fini della rappresentanza in parlamento: nei casi in cui per ogni area si elegga un solo parlamentare si parla di solito dicollegio, mentre se ne vengono eletti più di uno si parla di circoscrizione. La cosa più semplice è che ci sia una sola circoscrizione elettorale grande come tutto il paese (come in Israele); all’estremo c’è un numero di collegi uguale al numero dei parlamentari, come per le elezioni dei deputati in Regno Unito.

I sistemi maggioritari sono di diversi tipi. La cosa importante da notare è che “maggioritario” non ha alcun collegamento con la maggioranza in Parlamento. Significa invece che il principio del sistema è che chi prende anche solo un voto in più ottiene l’elezione (non la maggioranza!). Detta così è molto vaga, ma si spiega con un caso molto concreto (e frequente). Il maggioritario più frequente è quello dei collegi uninominali: in ogni collegio si elegge un solo parlamentare con un principio maggioritario. Vediamo ora le leggi elettorali di diversi paesi, che daranno l’occasione di spiegare qualche altro dato importante e qualche particolare in più dei diversi sistemi.

Germania
Per eleggere il Bundestag (almeno 598 seggi, ma il numero esatto è variabile) si utilizza un sistema piuttosto complicato. 299 sono eletti in collegi uninominali, a turno unico: il che vuol dire che chi prende un voto più degli altri viene eletto, il cosiddetto first-past-the-post (FPTP). Gli altri, almeno 299, sono eletti tra i partiti che hanno ottenuto almeno il 5 per cento dei voti a livello nazionale o almeno 3 parlamentari nei collegi uninominali, attraverso il sistema proporzionale. Quindi, in concreto, i tedeschi votano con due schede diverse: una per il loro rappresentante locale e una con le liste partitiche (per la parte proporzionale).

Francia
Il sistema elettorale francese per l’elezione dell’Assemblea Nazionale (577 membri) è un maggioritario in collegi uninominali a doppio turno. Dunque, la Francia è divisa in 577 collegi che eleggono un solo parlamentare. Veniamo alla cosa più importante e cioè il maggioritario a doppio turno: per essere eletti bisogna ottenere il 50 per cento + 1 dei voti nel collegio e anche un quarto dei voti degli aventi diritto.

Se nessun candidato ottiene la maggioranza assoluta si tiene un ballottaggio una settimana dopo il primo turno tra tutti i candidati che hanno ottenuto più del 12,5 per cento degli aventi diritto al voto: il che, vista la crescente astensione alle legislative, circa il 47 per cento nel 2012, significa percentuali di voti molto più alte. Di fatto, la stragrande maggioranza dei collegi va al ballottaggio e quasi sempre ci sono solo due contendenti. Per essere eletti al secondo turno basta prendere un voto in più dei contendenti.

Regno Unito
I 650 membri della Camera dei Comuni del Regno Unito sono eletti con il sistema del collegio uninominale a turno unico (i membri della Camera dei Lord, caso molto raro, sono invece nominati e non eletti, oppure ereditano il seggio). Chi prende più voti in ogni collegio viene eletto, senza nessuna quantità minima di voti richiesti; i collegi hanno una popolazione media di circa 60 mila persone. Sistemi come quello britannico sono usati anche in molte altre elezioni tra cui quella del Lok Sabha, la camera bassa del parlamento indiano e per l’elezione del Congresso degli Stati Uniti.

Spagna
I 350 membri del Congresso dei Deputati sono eletti con un sistema proporzionale, ma con un’importante correzione a livello provinciale. Infatti, ciascuna delle 50 province spagnole deve avere necessariamente almeno due deputati e quindi la divisione proporzionale dei voti si effettua solo su 250 parlamentari. La soglia di sbarramento è al 3 per cento. La legge elettorale ha subito solo leggere modifiche dal 1977, l’anno del ritorno del paese alla democrazia: la sua conseguenza principale è che le aree meno popolate della Spagna sono sovrarappresentate.

Grecia
La Grecia ha un sistema elettorale piuttosto simile a quello italiano: quindi, straordinariamente complicato. L’aspetto più importante è che c’è un premio di maggioranza di 50 parlamentari (il Parlamento greco ha una camera sola, che ha 300 membri) per il partito che ottiene più voti degli altri. Per il resto, come in Italia, il sistema è proporzionale: gli altri 250 seggi sono distribuiti con diverse complicazioni tra i partiti che superano la soglia di sbarramento del 3 per cento.

Foto: JUNG YEON-JE/AFP/Getty Images

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Hospitals begin to recognize social media’s potential to improve patient experience @Medici_manager @Dermdoc

“In Canada in health care we’re at a point where most hospitals accept the role of social media for branding and communication, but only the lead adopters are using it for patient engagement and for clinical use.” – Ann Fuller, public relations director,   Children’s Hospital of Eastern Ontario (CHEO)

Call up the website home page for any large Canadian hospital and you’ll likely spot the familiar icons that link to the institution’s facebook, Twitter and YouTube accounts.

Hospitals are inherently conservative institutions and, as such, have been relative latecomers to adopt social media, which are broadly defined as digital channels that can facilitate timely, collaborative and interactive communication.

As they enter the social media fray, hospitals face a host of challenges and decisions. These range from basic upkeep—nothing is more frustrating to a potential user than a neglected or stale-dated facebook or Twitter account—to deciding how interactive to be with patients, and what staff should be trained and involved in social media use.

From marketing to improved care

Not all hospitals haven entered the fray—for example, smaller hospitals may not be able to afford the expertise and time involved in establishing a social media presence—and among those that have, how they use social media varies significantly.

Many still use the channels for marketing and old-style public relations communication—for example posting news releases—while some larger hospitals are more active, have thousands of followers, and can track and address patient concerns.

But the potential of using social media to improve patient care and patient experience is only beginning to be realized, according to health care digital communication leaders.

That’s not surprising because it’s only been a few years since hospitals began to take social media seriously; the Ontario Hospital Association hosted its fourth Social Media in Health Care conferencejust last month; the first was Jan 21, 2010.

Social media policies can allay concerns about risk

The issue of privacy and risk dominated discussions about social media several years ago, but that concern has begun to be addressed as hospitals formulate and adopt social media policies (seeCHEO policy, for example) that spell out ground rules for use.

An emerging debate contrasts the approach of hospitals that use a single channel “firehose” social media approach—institutions that have just one facebook and one Twitter account for all communication—and those that have multiple social media channels.

To Ed Bennett, who manages web operations at the University of Maryland Medical System, the progression from hosting single to multiple speciality channels—from addressing patient concerns at a broad level, to also addressing narrower concerns of specific patient groups—is a natural evolution.

Social media: this is where the public is talking about you

Part of his job is to monitor all online mentions of his medical centre and decide which ones are appropriate to respond to, and who should respond. “This is where conversations are moving, where they’re [the public] is talking about you, and if you don’t participate, you are cut off from the discussion.”

A lot of concerns are about services such as parking, or long waits in the ER, or how to get test results, he notes. “If you are able to resolve these, or just respond in a polite way, you can turn a negative into a positive.”

Craig Thompson, director of digital communications at Women’s College Hospital in Toronto, says  the  “low hanging fruit”  that  social media can address involves better communication about issues that frequently frustrate patients, such as hospital access and how to prepare for procedures.  Beyond that, opportunities to use social media to improve patient experience “present themselves at different times, every organization has to find its own solutions.”

Social media such as facebook also present the opportunity to create “extensions of real life face-to-face patient support groups,” says Bennett. The Maryland University Medical System sponsors four or five of such groups, including for transplant and for trauma patients; participants have to be invited to join (the groups are closed) and the groups are moderated by a health care professional.

“Still, we explain that nothing on the Internet is 100% closed and warn people not to put out any information that wouldn’t be comfortable with the world seeing,” he says.

The multiple channel approach

Michelle Hamilton-Page is the manager of social media at CAMH (the Centre for Addiction and Mental Health in Toronto), which has a multiple channel model approach to social media (see, for example, its foundation-associated endstigma facebook page).

Hamilton-Page’s position is based in education, rather than communications, and she spends much of her time helping groups within CAMH think through whether social media can help them meet their objectives and, if so, how to go about it.

A similar approach is taken at St. Michael’s Hospital in Toronto, notes digital media manager Anthony Lucic. “People think of social media as mass communication, but it can be really focused and targeted. Sometimes, it’s about just wanting to talk with a core group of peers. Our approach is very grassroots, we sit down with people to find out who they want to engage, and what networks they could use.”

Children’s Hospitals have been early adopters of social media

Children’s Hospitals, like CHEO in Ottawa and the SickKids (the Hospital for Sick Children) in Toronto, are among the most advanced in terms of using social media. That’s partly because the patients, and their parents, are younger—and members of age cohorts that are relatively more comfortable using social media.

“Our patients, and their parents, have different expectations” compared to adult hospitals, says Ann Fuller, public relations director at CHEO. “New generations are used to sharing more and have different expectations of privacy than my mother did.”

And Fuller notes some doctors are saying it is time to relook at the idea that that physicians should not interact through social media with patients, point to “niche applications” where, for example, a clinician could be on facebook with a group of young patients with diabetes.

recent research study at CHEO into patients’ use of facebook underscored its importance to teenagers with long-term and chronic illnesses and noted that only a few disclosed any personal health information on their facebook pages.

It concluded that that the need for social-network-based communication between patients and healthcare providers—now forbidden by some institutions—will increase and that “age-appropriate privacy-awareness education” should be strengthened.

Calls for more education, literacy 

Better education about social media is something that Sivan Keren Young, manager of digital communications at Sunnybrook Health Sciences Centre, thinks is essential. “Everyone is using social media, but no one gets any social media literacy training, there’s nothing in schools, and that can cause mistakes, people can unintentionally do the wrong thing.”

Interestingly, it was disappointment about the level of public uptake for H1N1 vaccination was the inspiration for the first major Canadian examination of how health care institutions could use social media to understand and improve the patient experience.

“For us, the light bulb went on” when the Toronto-based Health Strategy Innovation Cell went online to find out what was being said in patient websites and chat rooms about the H1N1 vaccine, says Cathy Fooks, president of The Change Foundation , which co-authored a report on using social media to improve health care and worked with two health care organizations to explore the potential of social media.

What the investigators discovered was a whole series of anti-vaccination conversations about concerns about the vaccine—concerns that were inhibiting people from getting vaccination. “Public Health had no idea—none of that concern had turned up in their formal communication channels,” Fooks noted.

The foundation went on to co-author with the Innovation Cell a seminal report on using social media to improve health care and a report based on work with two health care organizations exploring the potential of using social media.

According to Bennett, those who are still sceptical about social media should stop thinking of it as brand new and different: “It’s still people talking to each other.”

Vaccines and Autism: CDC Study Says No Connection @Medici_Manager @WRicciardi

Frank DeStefano, MD, MPH http://bit.ly/13g2KgW

New CDC Study of Vaccine Doses and Autism

Concerns about childhood vaccinations and the risk for autism persist for many parents and some members of the public. A new CDC study published in the Journal of Pediatrics [1]addressed a current concern about the relationship between autism spectrum disorder (ASD) and vaccination, which centers on the number of vaccines and vaccine antigens given to infants and children, according to the recommended childhood immunization schedule.

The study evaluated the association between the level of immunologic stimuli received from vaccines during the first 2 years of life and the development of ASD. The findings showed that neither the number of antigens from vaccines received on a single day of vaccination, nor the total number of antigens received during the first 2 years of life, is related to the development of autism.

About This CDC Study

This study is the first of its kind to evaluate the issue of “too many vaccines too soon” and the development of ASD. The study was conducted in 3 managed care organizations (MCOs), involving 256 children with ASD and 752 control children matched by birth year, sex, and MCO. In addition to ASD, researchers evaluated autistic disorder and ASD with regression and found no relationship with the number of vaccine antigens received in either of these categories.

Study data were obtained from immunization registries and medical records. The data used in this study had been collected and analyzed previously.[2] Children eligible for the study were born between January 1, 1994, and December 31, 1999, and were 6-13 years old at the time of data collection.

Each child’s total vaccine antigen exposure was determined by adding the number of different antigens in all vaccines that each child received in 1 day, as well as all vaccine antigens each child received up to 2 years of age. The number of vaccines and number of vaccine doses administered according to type of vaccine are shown in the Table.

Table. Antigens in Vaccines and Total Doses Administered by Vaccine Type

Vaccine Type Antigens per Dose Dosesa
Diphtheria toxoid/tetanus-diphtheria (DT/TD) 2 14
Diphtheria-tetanus-pertussis (DTP) 3002 235
DTP – Haemophilus influenzae type B (Hib) 3004 1659
Diphtheria-tetanus-acellular pertussis (DTaP) 4b 1165
DTaP 5b 789
DTaP 6b 492
DTaPHepatitis B 6b 3
Influenza 10 95
Hib 2 2123
Hepatitis A 4 22
Hepatitis B 1 3085
HepatitisB-Hib 3 215
Measles, mumps, rubella (MMR) 24 1093
Measles 10 2
Meningococcusc 2 285
Mumps 9 1
Pneumococcusd 8 698
Polio 15 3385
Rabies 5 1
Rotaviruse 14 57
Rubella 5 2
Typhoid 3000 4
Varicella 69 917
Yellow fever 11 1
aTotal vaccine doses administered in the study population from birth to 2 years of age
bNumber of antigens in DTaP vaccines varied by manufacturer
cMeningococcal C conjugate vaccine administered as part of a clinical trial at 1 MCO
dPneumococcal conjugate (7-valent) vaccine; some doses administered in a clinical trial at 1 MCO
eRotaShield® (no longer marketed)

The number of vaccine antigens has decreased in recent years although the number of recommended vaccines has increased. The routine immunization schedule in 2013 contains more vaccines than the schedule of the late 1990s. The maximum number of vaccine antigens that a child would be exposed to today by 2 years of age is 315, compared with several thousand in the late 1990s. This is the result of changes in vaccines that allow them to more precisely stimulate the immune system. For example, the older whole-cell pertussis vaccine induced the production of approximately 3000 different antibodies, whereas the newer acellular pertussis vaccines (such as DTaP) stimulate the production of 6 or fewer different antibodies.

This study strengthens the conclusion of a 2004 comprehensive review by the Institute of Medicine of the scientific evidence that favored a rejection of the causal association between certain vaccines types and autism.[3]

Knowledge, Attitudes, and Beliefs About Vaccines and Autism

Some parents are concerned that there is a link between vaccines (such as MMR) or certain vaccine ingredients (such as thimerosal) and autism. However, several large and reliable studies of MMR vaccine have been done in the United States and other countries.[3,4] None has found a link between autism and MMR vaccination. Furthermore, research[2] does not show a link between thimerosal in vaccines and autism. Although thimerosal was taken out of childhood vaccines in 2001, autism rates have continued to climb.

Although scientific evidence shows that vaccines do not cause autism, a 2012 HealthStyles survey showed that slightly more than 15% of parents are concerned that they do (LaVail K, Fisher A, CDC; unpublished data). Data from the survey found that 22.8% of parents are concerned that children receive too many vaccines at a single doctor’s visit, and 22.8% of parents are concerned that children receive too many vaccines by the age of 2 years. The vaccines, they believe, can cause learning disabilities, such as autism. In another recent survey,[5] more than 1 in 10 parents of young children refuse or delay vaccinations in the belief that delaying vaccines is safer than giving vaccines according to the CDC-recommended immunization schedule. Children do not receive any known benefits from delaying vaccines. Delaying vaccines puts children at risk of becoming ill with vaccine-preventable diseases.

What Clinicians Can Do

CDC research with parents about their vaccine attitudes and vaccination behaviors has found that most US parents believe that vaccines are important, and they vaccinate their children. In fact, coverage for most of the routine childhood vaccines remains at or exceeds 90% in children aged 19-35 months. CDC and other agencies and organizations continue to conduct research to learn more about the causes of autism.

Healthcare professionals are the main determinants of parents’ decisions about whether to vaccinate their children. This study provides evidence that clinicians can use to reassure parents that the number of vaccines received early in life is not associated with the development of autism. Clinicians can help parents to learn the signs of ASD and act early so that action can be taken to help their children reach their full potential. Online resources, tools, and educational materials for clinicians to use to communicate with parents and caregivers are found at the end of this article.

Web Resources

CDC. Developmental Milestones

CDC. Autism Spectrum Disorders. Screening and Diagnosis for Healthcare Providers

American Academy of Pediatrics. Community Pediatrics. Act Early on Developmental Concerns: Partnering with Early Intervention

Frank DeStefano, MD, MPH, is Director of the Immunization Safety Office of the Centers for Disease Control and Prevention (CDC). He is a graduate of Cornell University and the University of Pittsburgh School of Medicine. He received training in public health and preventive medicine in the Epidemic Intelligence Service and preventive medicine residency at CDC. He obtained a Masters of Public Health degree at Johns Hopkins University School of Hygiene and Public Health. He has had extensive epidemiologic research experience at CDC, the National Institutes of Health, and at non-governmental research organizations. His areas of research have included immunizations, autism and other developmental disabilities, reproductive health, veterans’ health, diabetes, cardiovascular diseases, and other chronic diseases. Dr. DeStefano is an author on over 150 publications in leading scientific and medical journals. For the past 16 years Dr. DeStefano has had a focus on vaccine safety.

Un partito dei medici

Girolamo Sirchia

In Inghilterra si è costituito un nuovo partito politico chiamato National Health Action (NHA) composto da medici che vogliono difendere il Servizio Sanitario Nazionale dagli attacchi della politica e del profitto.

(BMJ 2012;345:e7731)

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Never Too Young to Lead @Medici_Manager @muirgray

The young people in your company are ready to lead. Here’s how to prepare them for the responsibility. http://bit.ly/X57bD8

Never too young to lead
“We expect to lead and be led. In the absence of orders I will take charge, lead my teammates, and accomplish the mission. I lead by example in all situations.” — Navy SEAL Creed

My first combat mission with my Navy SEAL platoon was to secure a hydroelectric power plant in Northern Iraq. My role on this mission was to guide the helicopter pilots over the landing zone and manage the fast rope insertion for our assault team. At the time, I thought this was a lot of responsibility for a new guy. What I figured out after we nailed our landing, and after many other successful missions, is that age has very little to do with leadership ability.

The SEAL Teams are a relatively flat organization. Everyone goes through the same grueling training, and everyone is trained to lead regardless of age or rank. In the business world, emergent leadership is about team members taking the initiative to accept more responsibility and perform work outside of their general roles. If we, as leaders, encourage and promote this type of drive, our young team members will be ready to rise within the organization, and our companies will be better off for it.

Here are four ways we can prepare our young people for leadership:

  • Showcase their talent. Don’t hide your young leaders. Show them to the world. Let them be the face of your company. Encourage them to contribute to the company blog or industry publications, take training courses, speak at conferences and trade shows, and collaborate on ways to improve company systems and offerings.
  • Manage them, not their work. If you have the right people in the right jobs, don’t micromanage their efforts. Set boundaries and then back off. Allow them to be innovative and develop systems, processes, and methodologies that will get the job done. Doing this will not only result in a more confident team and better retention, but will give your team members a sense of ownership that they wouldn’t get by simply following orders.
  • Let them fail.  While providing guidance and leadership, we must also allow for failure. Encourage your young leaders to take calculated risks when appropriate. When things don’t go as planned, use that as a coaching opportunity to help them understand how to succeed in the future. Any successful entrepreneur knows that they have gained the most wisdom through their mistakes.
  • Link their effort to tangible results. Real leaders want to know exactly how their role affects the growth of the company. As you develop leaders, give them goals and milestones to hit so they understand the roadmap for success. Ensure that they know exactly how their efforts and results drive the company forward. As they develop in leadership roles, they will know how they got there and where they need to go next.

Let’s encourage our young team members and provide them the resources for success. If we can build our emerging leadership teams from loyal employees who started at the bottom, then our companies will be stronger and have a more loyal foundation for growth.

Navy SEAL combat veteran Brent Gleeson is the co-founder and CMO at Internet Marketing Inc., No. 185 on the 2012 Inc. 500. His leadership approach is inspired by the unrivaled SEAL training and the Navy SEAL Creed. @brentgleeson

The Leader’s Checklist @Medici_Manager @muirgray

By Michael Useem http://onforb.es/ZDrtpP

Effective leadership can be mastered, and at the core of that learning, in my view, should be a Leader’s Checklist, a complete set of vital leadership principles that provide a clear map for navigating through virtually any leadership moment.

From my development work with hundreds of managers and executives in leadership programs in Asia, Europe, North America, and South America, from research interviews with many managers in the United States and abroad, and from witnessing managers facing a range of critical moments, I have concluded that their thinking and experience tend to point to a core of just 15 mission-critical leadership principles that vary surprisingly little among companies or countries.

I have also become convinced that with leadership, as with much else, brevity is the soul of wit. Albert Einstein once described the calling of modern physics as an effort to make the physical universe as simple as possible—but not simpler. The Leader’s Checklist is likewise at its best when it is as bare-bones as possible—but not more so.  Here, distilled from an array of sources, is that set of core principles:

1. Articulate a vision: Formulate a clear and persuasive vision and communicate it to all members of the enterprise.

2. Think and act strategically: Set forth a pragmatic strategy for achieving that vision both short- and long-term, and ensure that it is widely understood; consider all the players, and anticipate reactions and resistance before they are manifest.

3. Honor the room: Frequently express your confidence in and support for those who work with and for you.

4. Take charge: Embrace a bias for action, for taking responsibility even if it is not formally delegated, particularly if you are well positioned to make a difference.

5. Act decisively: Make good and timely decisions, and ensure that they are executed.

6. Communicate persuasively: Communicate in ways that people will not forget; simplicity and clarity of expression help, as do elements ranging from personal actions to grand events.

7. Motivate the troops: Appreciate the distinctive intentions that people bring, and then build on those diverse motives to draw the best from each.

8. Embrace the front lines: Delegate authority except for strategic decisions, and stay close to those most directly engaged with the work of the enterprise.

9. Build leadership in others: Develop leadership throughout the organization.

10. Manage relations: Build enduring personal ties with those who look to you, and work to harness the feelings and passions of the workplace.

11. Identify personal implications: Help everybody appreciate the impact that the vision and strategy are likely to have on their own work and future with the firm.

12. Convey your character: Through gesture, commentary, and accounts, ensure that others appreciate that you are a person of integrity.

13. Dampen over-optimism: Counter the hubris of success, focus attention on latent threats and unresolved problems, and protect against the tendency for managers to engage in unwarranted risk.

14. Build a diverse top team: Leaders need to take final responsibility, but leadership is also a team sport best played with an able roster of those collectively capable of resolving all the key challenges.

15. Place common interest first. In setting strategy, communicating vision, and reaching decisions, common purpose comes first, personal self-interest last.

To illustrate just one of the principles, consider the last, placing common mission ahead of personal interest, especially when its seems least natural to do so. This precept is expressed in our oft-used phrases of “servant” or “selfless” leadership, and it is well captured in a U.S. Marine Corps dictum: “The officer eats last.” In business, Jim Collins makes it one of his defining qualities for those who lead their companies “from good to great.”

The fifteenth principle could also be heard in the White House on November 16, 2010, when President Barack Obama presented the Medal of Honor to Army Staff Sergeant Salvatore A. Giunta. During the sergeant’s second combat tour in Afghanistan, his team had been ambushed by a well-armed insurgent group. Giunta had raced forward under fire at great risk to himself to render aid to the wounded and to rescue an injured G.I. being dragged away by insurgents. The United States cited Giunta for his “unwavering courage, selflessness, and decisive leadership while under extreme enemy fire” and for his “extraordinary heroism and selflessness above and beyond the call of duty.” When the president detailed this selfless act of leadership during the White House ceremony—with Giunta’s wife and parents and the survivors of his unit present and the Medal of Honor recipient himself standing at the president’s side—the East Room, according to a reporter, “was so silent you could hear a rustle from across the room.”

This article is adapted from the just-published e-book The Leader’s Checklist,by Michael Useem, which is available from e-book sellers includingAmazonBarnes&Noble.com, and Apple iBookstore.

Michael Useem is director of the Center for Leadership and Change Management, and William and Jacalyn Egan professor of management, at the Wharton School of the University of Pennsylvania. He is the author ofThe Leadership Moment, Investor Capitalism, andThe Go Point, among other books. His articles have appeared in Fortune, Harvard Business Review, The New York Times, The Wall Street Journal, and elsewhere, and he has presented programs and seminars on leadership development at American ExpressCitigroup,Coca-ColaGoldman SachsGoogle, Johnson & Johnson, Microsoft, the Department of Justice, the U.S. Military Academy, and many other companies and organizations. Follow him on Facebook and Twitter.