Contro l’ideologia islamista – Cameron insegna. Cultura e consapevolezza delle radici culturali

renalgate

Contro l’ideologia islamista.

Per l’intellettuale islamica Hirsi Ali, Cameron, che ha tenuto lunedì un discorso sull’estremismo, è l’unico leader occidentale a capire che il cuore del problema è la riforma dell’islam.

L’endorsement di Hirsi Ali al discorso di Cameron sull’islam.

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Move over teamwork: other forms of co-operative working? @pash22 @leadmedit @muirgray

Taken very broadly, there are two kinds of management or business research thinking when it comes to teams: perspectives that think teams are a decent functional way to organise workers to work effectively, and perspectives that are much more critical of the very concept of teamwork.

Instinctively, anecdotally, and from much research over the last few decades – we all know that teams often don’t work. ‘Dream teams’ of exceptional individuals can turn out to be nightmare units, groupthink and other faulty decision-making biases can make the whole less than the sum of its parts, and sometimes people end up in too many teams or don’t even know whether they’re in or out. I would argue that this is because teams are relatively artificial constructs; they are often no more than idealistic ‘boxes’ that exist unevenly only in the minds of some managers and workers.

Frequently, organisations are not like traditional sporting events or the inside of rowboats – they are much more variable, overlapping, organically changing configurations of people. Being inside a team or outside a team is not a neat shift from one state to another – teams or groupings vary continually in how ‘groupy’ or cohesive they actually are. Most management research, however, has focused on teams as neat boxes or islands that sometimes conflict a bit, but generally agree in their perceptions, have stability of membership, and have a relatively fixed relationship with their external environments. In short, it has been a romance of teams, a science of convenience, and an exercise in wishful thinking.

However, none of this is to say that teams are always doomed or flawed. With the right culture, tasks, and aligned sets of HR practices, teams can innovate and achieve highly effective working patterns. As with all social and workplace issues: it depends on the context and getting the conditions and circumstances right. However, many of these favourable initial ingredients or conditions for optimising teamwork either remain elusive or appear in an implausibly long list. It is no mean feat to ensure the selection of diverse members, extensive team-building and clear unifying goals. Teams themselves are also a moving target; in general they are changing: members come and go more often, technology encourages collaboration over almost any distance, and traditional hierarchies have become much flatter.

What I wish to say is that teams should be considered more dynamically as sitting within a broader spectrum of many cooperative working options simultaneously; as one work arrangement among many. The guiding word here being cooperation. There are multiple ‘building blocks’ of cooperation, from small-scale to large-scale, guiding how people work together, that managers can consider as part of a broader, customisable repertoire. I tend to refer to them as a ‘cooperative value chain’ or a ‘high-cooperation HR menu’. This cooperative toolkit consists of the five following components:

1) The individual. I want to be alone. Many job descriptions, rewards packages and other parts of the psychological contract bestowed via HR practices still revolve around individuals and their needs or talents. Many artists, technical problem-solvers, leaders and so on, may find they work most effectively as a demarcated, unique individual. Western, individualistic cultures may also favour personalised working this way, for at least significant portions of employees’ time, as proactivity, autonomy, and flexibility are emphasised in their roles. Single individuals are still cooperating, but in their own reflective way; they may also occupy special positions in social networks (see below) or fulfil boundary-spanning roles, where they are the individual link bridging units of cooperation that would otherwise have no way to interface.

2) The dyad. Two heads are better than one, but three’s a crowd. Some work roles explicitly involve pairs – software programmers check each other’s work, police officers patrol in pairs, and mentoring and other partnerships can occur in this way. But more exploitation of this unique two-person unit may be possible in workplaces than is currently realised. Some would argue that a dyad/couple is a small team, but I would argue it constitutes a special relationship. Two people cut a fruitful compromise, a middle ground between the egoistic isolation of working alone and the potentially biasing social pressures of a larger group.  Of course such pairs need to be carefully matched to each other and the workflow to get the most out of the pairing.

3) The classic team. The whole is greater than the sum of the parts – go team! As discussed above, in some situations, a neatly bounded, interdependent team with a clear goal may be possible. But a team charter or checklist should be carefully put in place to ensure the key conditions are right before proceeding with what is a larger, more elaborate cooperative endeavour in terms of the numbers of people involved. Social and task criteria to keep it working effectively together will need to be addressed, including a meaningful shared purpose, a differentiated mix of suitable members, clear rules or norms, wider resource-based support, and adequate coaching. Leadership, technology, lifespan, and competing teams or other boundary memberships in the wider environment will need to be addressed, in line with the other cooperative options above and below.

4) The multi-team system. Teams don’t exist in a vacuum, but in a ‘team of teams’.Beyond single teams, research is increasingly considering multi-team systems (MTSs) or ‘teams of teams’. Army, Navy, and Air Force; or Police, Ambulance, Fire would be obvious examples, but of course most organisations contain multiple groups, divisions, functions, layers etc. with potential for forming and/or recognising MTSs. One commanding team might lead several subsidiary teams, or teams with specific goals might come together to achieve a higher goal. As with single teams, structures need to be made crystal clear and cooperative flows and linkages choreographed and monitored carefully. People may need to be cross-trained, or to attend multiple team events, but without taking on too much workload. The relationship between the immediate goals of one team and the higher goals of the set of teams need to be clarified, as well as prioritised in various scenarios.

5) The social network. The wisdom of crowds. In a sense here we come full circle as individual employees occupy distinctive positions within collaborative networks, but in an increasingly interconnected world with more permeable communication boundaries, anyone can be meaningfully connected with up to 150 others at any one time. We enter the realm of crowd-sourcing, flash mobs, consortia, and other self-organising forms of social movement or widespread cooperative organisation. The boundaries of entire businesses and sectors may be transcended, co-operators may never meet or be totally aware of each other, and finished products may be complex mosaic or snowball outputs, difficult to link directly back to the inputs and processes of diverse contributors. Yet impressive tasks and economies of scale can be achieved, sometimes on goodwill and intrinsic motivation alone.

In conclusion, HR practitioners should try to take advantage of mapping this broader array of cooperative building blocks simultaneously. Rather than simply asking ‘to team or not to team?’ they should consider offering employees a greater range of performance opportunities via these other cooperative value chain options, enabling them to work more naturalistically and fully unlock their talents.

http://www.hrzone.com/feature/people/move-over-teamwork-what-about-all-other-forms-co-operative-working/141116

“Per App sanitarie prevedere l’obbligo di supervisione del medico”

Andrea Silenzi, MD, MPH

Da prevedere obbligo supervisione del medico per App a scopi medici. No a video visite e riduzione relazione interpersonale. Per le applicazioni a scopi medici (diagnostici, terapeutici, assistenziali) per il Consiglio Nazionale Bio-Medico “dovrebbe esserci un obbligo di supervisione del medico (informazione al momento di scaricare la app/condizione per scaricare app)”.

Leggi tutto su QuotidianoSanità

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General Practice after the election

A Better NHS

General Practice after the election. (First published on the LMC Newsletter)

In 2008, Professor Don Berwick wrote in the British Medical Journal,

Reinvest in general practice and primary care—These, not hospital care, are the soul of a proper, community oriented, health preserving care system. General practice is the jewel in the crown of the NHS. Save it. Build it.

His advice was ignored. The NHS has an unprecedented funding-gap of this governement’s own making and it has no credible plan to fill it. General Practice is in a parlous state one in three training posts and one in six vacancies unfilled while older GPs are retiring early and younger ones are emigrating or choosing to work part-time. The loss of MPIG could force dozens of practices to close. The consequence is that the remaining GPs cannot cope. Something has to give.

What GPs want, according to the recent BMA…

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How to do a SWOT

thinkpurpose

In the most strategic of rooms in my building, I found an agenda on a flipchart. It is not exceptional, it is typical. This probably happens in your building. This is how decisions are made….


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*the photo is real
**the words totes stolen from the brilliant W1a and 2012 .

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Il movimento fisico è indispensabile per la salute fisica e mentale

Girolamo Sirchia

Il WHO (Organizzazione Mondiale della Sanità) definisce come “insufficiente” l’attività fisica moderata di 150 minuti la settimana o meno per i soggetti adulti. E’ a queste persone che bisogna rivolgersi in particolare perché aumentino anche di poco la loro attività fisica, ricordando loro che il movimento promuove la salute fisica e mentale a tutte le età e previene malattie croniche e disabilità. Le persone totalmente inattive sono circa il 25% della popolazione e queste presentano i rischi maggiori in termini di mortalità globale, diabete di tipo 2 e alcuni tipi di tumore. In un gruppo di 252.925 adulti statunitensi è stato osservato che un’attività fisica moderata anche modesta (1 ora la settimana o meno) riduce del 15% il rischio di mortalità da ogni causa, e valori analoghi si sono ottenuti anche per la mortalità da tumore o da incidenti cardiovascolari in altre popolazioni. E’ l’inattività totale quindi il vero rischio…

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The Courage And Triumph Of The Patient @Medici_Manager @acpatient @leadmedit @pash22

Leah Binder Contributor

Improving the “patient experience” is a trending topic in health policy circles these days, the subject of many new conferences and journal articles. Providers puzzle over this. How can they improve patient “compliance” and “adherence” to doctor’s orders? What are the techniques to educate patients on “self-management”? How can we better coordinate the various services offered to each patient so the patient doesn’t fall through the cracks?

It is gratifying to see this emphasis on patients. Yet many providers still do not grasp that improving patient experience requires something more than studying the issue and implementing a few new policies. It requires nothing short of a paradigm shift in the way they think about their role in the patient’s life and the fundamentals of their practice.

The best example of providers misunderstanding the depth of this issue is how the influential provider-governed Beryl Institute defines the patient experience: “the sum of all interactions, shaped by an organization’s culture that influence patient perceptions across the continuum of care.” In other words, Beryl believes that the patient experience is the patient’s reaction to what providers do.

Trust me, that is not how patients view their own experience.

“Momma had her last radiation treatment today,” a young woman I’ll call Karen posted on Facebook last June. “Can’t even explain the amount of strength and courage that crazy lady has shown and I couldn’t be more proud to call her my Mom.”

Patients and their families see their experiences as Karen did, as the act of summoning every last reserve of strength and courage to endure each minute, one day at a time. Patients don’t see themselves as mere recipients of services. Patients and their families don’t talk about self-management or compliance or adherence. They find themselves in an epic story of survival and adventure. They are the reluctant heroes of that personal drama, Odysseus setting forth on the ultimate journey. Some patients are ready and some aren’t, but every patient is forced to try their best, since the road is before them.

One of the country’s leading thinkers on the patient experience is Dave deBronkart, who miraculously survived Stage 4 kidney cancer. His mantra (and the title of the book he coauthored): “Let Patients Help.” DeBronkart advises providers to recognize patients as journeymen, not baggage, in the quest toward recovery. He speaks to provider groups throughout the world, and gave one of the most popular TED talks ever, all with an eye toward reframing the way the health care system engages patients and insisting that patients are part of the cure, not passive recipients of care. He says that patient knowledge and wisdom and willingness to research are a wealth of untapped resources.

Most of us know someone like Karen, Karen’s mom or Dave, who stood up and squarely faced the worst news imaginable. Though doctors work with patients every day, there is something very different about being on the other side of the fence, as deBronkart’s co-author Dr. Danny Sands movingly recounts in his blog about suffering life-threatening seizures.

Providers can nurture, coach, mentor, guide and be humble enough to realize they have only a small – though critical – role to play in the larger life story of the human beings they call patients. Providers succeed when they recognize they aren’t treating a disease or filling an empty vessel with “services,” but coaching a complex person with a destiny and a legacy who, for better or worse, is the hero of her own life.

I’m sad to report that Karen’s “crazy lady” mother, Susan, 52, died from breast cancer a few days ago. Susan was beloved throughout her rural Maine community, an exceptional teacher, community volunteer, mother. She had a very special gift with children, many of whom are traveling from far and wide to come to the funeral of this woman they revered.

“I believed a miracle would happen and she would beat this beast,” said Susan’s dear friend Kathleen, “She fought the most courageous fight I’ve ever witnessed. Heaven is so lucky to have this new angel.”

In my opinion, Susan did win, though not the way we all hoped for. But a life well-lived is the ultimate triumph. “To have been given 22 years with you was such a blessing.” Karen wrote in an open letter the day her mother died. “I promise with all my heart to be the fun loving, positive and slightly wacky person you’ve taught me to be. Thank you for all the amazing memories Momma Bear.”

Susan’s a winner and so are the many excellent physicians and nurses who cared for her through her battle with cancer. As the famous doctor Patch Adams once said, “You treat a disease, you win, you lose. You treat a person, I guarantee you’ll win.” The patient experience is more the stuff of Shakespeare than Gray’s Anatomy. Providers with that wisdom will transform health care forever.

http://www.forbes.com/sites/leahbinder/2013/12/11/the-courage-and-triumph-of-the-patient/

how to measure a professor

cubistcrystal

“Many of those personal qualities that we hold dear….are exceedingly difficult to assess. And so, unfortunately, we are apt to measure what we can, and eventually come to value what is measured over what is left unmeasured. The shift is subtle and occurs gradually”. So wrote Robert Glaser of the USA National Academy of Education in 1987.

Those words – written about the standardised tests used in American schools in the 1980s – ring so true today for the way we assess academics. The things we tend to measure, because they are easy to measure, are things like publication numbers, impact factors, H-index (regrettably not the Happiness index), citations, grant income. And we tend to value most those who have big grants and papers in big name journals. Are we “driving out the very people we need to retain: those who are interested in science as an end in itself…“?…

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Coaching or telling. Which works? Here’s the evidence… @leadmedit @muirgray @helenbevan

Given the name of my company, Head Heart + Brain you won’t be too surprised to learn I like to have an evidence base for what I do. The ‘brain’ part of the name represents understanding the science behind leadership and change. This links to my curiosity about ideas that ‘seem obvious’ to me but that don’t get traction. I talked about this in my article on Emotional Intelligence. I feel the same about coaching. Whilst many companies use external coaches to work with senior people HR find it harder to gain traction for the manger as coach. Companies we work with still have many managers who adopt a ‘command and control’ style; that is telling people what to do. What is the evidence of which works best; coaching or telling? Is coaching actually more effective than just telling people what to do especially in complex change? I will look at some of the evidence which may help to understand which will maximise performance.

Brain basics

Let’s look at how the brain works in an organisational context.

The brain functions by making connections and associations, linking what is happening now and what has happened in the past, the memories both conscious and unconscious. This combination creates a kind of map of connections in the brain. No two maps will be the same even though the biological process for creating them is. The maps are created by making over a million new connections every second. This gives you some indication of the complexity. The brain likes order so seeks to connect new information to what is already known, to categorise it. Gerald Edelman developed the Theory of Neural Darwinism which provides a physical explanation for how our mental maps compete for resources.

The way the brain seeks to predict and make connections is explained by Jeffrey Hawkins in On Intelligence. He says our prediction abilities differentiate us in the animal world. When we first encounter something we are relatively slow to understand it. Like this article we need first to get the foundations in place. In learning a new skill for example it takes a while, maybe a few minutes or days depending on the complexity, for it to become familiar, that is create the map. The more embedded these maps the more we free up mental resources. We call this process forming a habit. Habits are run by the older more energy-efficient parts of the brain. This process of shifting activity, including thinking, from the high energy, relatively inefficient, prefrontal cortex to the more efficient areas is a basic operating mode for the brain.

Linked to this is neuroplasticity. Expert Norman Doidge, in The brain that changes itself points out, there is substantial evidence we can “rewire our brains with our thoughts.” Hebbs Law states that ‘neurons that fire together wire together’. So the more you focus on something the deeper the neurological connection. When we delve into and analysis a problem we are reinforcing the connections in the brain. This occurs through a process called myelination, the more a pathway is used, the stronger it becomes. When we repeat an action, a fatty covering called myelin coats the neural pathway, making connections stronger and more secure. Because the default is to go with the pathways that are developed it is hard to change habits but easier to create new ways of working. But it is still difficult to change without focused support and intentional effort.

The other relevant question is whether there are distinct functions responsible for emotional, as opposed to general intelligence. Research by Reuven Bar-On isolated these regions by studying people with damage to the brain in areas correlated with diminished ability in understanding self and understanding others. His findings clearly point to brain areas which relate to understanding self and others, that is Emotional Intelligence, which are distinct to areas associate with general intelligence.

So with this understanding as background let’s look at the impact of telling someone to change verses coaching them to change.

Telling versus insight

A premise of coaching is that people work things out for themselves. The difference between being told and having insight is all about creating new mental maps. If you are thinking about something like how a new process will work or the reaction of your team to a new strategy you are creating a mental map. These new thoughts are energy consuming from a brain perspective so you often do this when your brain is freed up from other activity like in the shower or on the walk to work. This type of thinking creates what we call an ‘aha moment’ or an insight. This is literally new connections happening, a new map or part of a map is formed. If you are told how to carry out the new process or what the strategy means for your job you still have to create that mental map. So coaching insight is more brain-savvy than telling an employee the answer. To take any kind of action people have to think it through for themselves. They can do this for themselves and immediately create the map when the coach/manager asks questions that create insight or they do it later after they have been told. The additional issue with telling is that it is more likely to set up a threat response (see more in the CORE video) as the individual’s predictions and connections are different to what was expected. As we have observed before, this difference creates an error message and a sense of pain in the brain. This in turn moves people away from the new information and increases the likelihood of resistance.

Managers who tell rather than coach not only waste their own energy but they are potentially making it more difficult for employees to accept a new idea. Are your managers and coaches creating insight or giving advice?

Transferring skills

You will have experienced that an insight comes with a burst of motivation or energy but this quickly dissipates if not reinforced. Reinforcing the insight creates new connections and potentially new behaviour. Because this type of action and thinking is hard work, because it takes more brain energy, people may avoid it or give up too soon before a deep map is formed. But people are also adaptable and can find shortcuts.

new study provides strong evidence for a “flexible hub” theory of brain which has implications for using skills. “Flexible hubs are brain regions that coordinate activity throughout the brain to implement tasks – like a large Internet traffic router,” suggestsMichael Cole, the author of the study.

By analysing activity as the flexible hubs connected during the processing of specific tasks, researchers found unique patterns that enabled them to see the hub’s role in using existing skills in new tasks. Known as compositional coding, the process allows skills learned in one context to be re-packaged and re-used in others, shortening the learning curve. By tracking and testing the performance of individuals the study showed that the transfer of these skills helped participants speed their mastery of new tasks, and use existing skills in a new setting.

Are your coach/managers focusing people on transferring existing skills to the ‘new world’ to speed up change?

Moving to action

Conventional wisdom, in many businesses, is that if people understand rationally why they need to do something the change will occur.  Kevin Oschner estimates 70% of what we do is habitual and that includes your job. As previously mentioned habits are run by the older parts of the brain, the basal ganglia. Because habits operate out of our conscious awareness our rational understanding is not enough. Coaching on why the new behaviour matters to the individual and designing a strategy might work.

Several things need to be in place to achieve behavioural change. Matt Lieberman says we must go beyond conscious systems and use our unconscious or “reflexive” systems. Goals for the new behaviour tend to be created in the conscious reflective system but we need to also control the unconscious habit system by managing triggers that generate the old behaviour. Elliot Berkman studies goal setting and achieving new behaviour and his research suggests there are several elements that must be aligned.

For example in new habit formation there is a sequence:

  1. cue;
  2. when to act,
  3. routine;
  4. the steps to take,
  5. and reward.

Are coach/manages working with both systems? Are they creating new behaviour by creating new routines and rewards? Are there strategies to manage the triggers that will prompt old behaviour?

We are social

The science shows social needs are primary in the brain, something many forget at work. Social pain activates the same regions as physical pain. When someone is put down, or their ways of working are controlled, or they are told what to do, especially publically, a threat response is activated reducing the ability to think clearly. You know that feeling – “I’m just blank, I have no mental space.” The frontal cortex is drained as the limbic system hijacks the energy. Again, a strike against telling!

This evidence base may go some way to persuading reluctant managers to adopt a different style.

But I am not going to fall into the same trap – and will practice what I preach.  So far be it for me to tell you that telling doesn’t work.  I’ll leave you with a few questions to generate you own insight.  What reaction have you experienced when telling someone to change? When has telling someone to do something differently worked?  What has been the benefit for you of creating insight in others?  What, good, surprises have you got from asking questions rather than telling?

Addressing Maslow’s Hierarchy of Needs with Technology

User Generated Education

A major criticism I have of most educational institutions is that their primary focus is on students’ intellectual and cognitive development.  Too often individual learner’s needs do not enter into the equation of their educations.  Maslow’s Hierarchy of Needs is a useful model for educators to use to help insure that they are addressing more of the whole child.

Applying Abraham Maslow’s theory of a pyramid-shaped hierarchy — physiological needs, personal safety, social affiliation, self-esteem and self-actualization — to education is an ideal way to assess lesson plans, courses and educational programs. By asking themselves whether these needs are being met in their school or classroom, educators can assess how well they are applying Maslow’s hierarchy to their teaching practice (How to Apply Maslow’s Hierarchy of Needs to Education).

Some general strategies for addressing these needs in the classroom can be found at Addressing Our Needs: Maslow Comes…

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Pubblicato 12° Rapporto Ospedali & Salute @WRicciardi @RSiliquini @leadmedit @Medici_Manager

Nadio Delai, Presidente di Ermeneia, ha presentato il 12° Rapporto Annuale “Ospedali & Salute 2014”, commissionato da AIOP.

Interessante la sintesi predisposta per la stampa in occasione della presentazione presso la Camera dei Deputati il 10 dicembre 2014.

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Presidiare dal punto di vista dell’interpretazione e delle prospettive il si­stema ospedaliero italiano richiede di guardare in faccia il significativo pas­saggio di fase che aspetta il nostro complessivo sistema di welfare che si trova oggi davanti a tre tipi di “minacce”:

–     una minaccia di riduzione della spesa, che ha assunto negli ultimi anni, anche per le urgenze di bilancio e per le pressioni europee, la forma di tagli per lo più lineari, finendo col premiare le strutture meno efficienti e col punire quelle più efficienti; e malgrado il recente Patto per Salute, non ci si può nascondere che se le Regioni sono chiamate a ridurre signi­ficativamente le loro spese complessive non sarà facile prescindere del tutto dalla componente di spesa per la salute, la quale rappresenta pur sempre 2/3 o più dei bilanci regionali;

–     una minaccia di traslazione dell’impegno nel fare efficienza, grazie a due meccanismi di “rimbalzo”: quello che tende a trasferire le esigenze di ra­zionalizzazione di un sistema ospedaliero pubblico (fortemente rigido) sui soggetti di offerta privati (farmaceutica, ospedalità accreditata, labo­ratori accreditati, in primis) e quello che tende a ribaltare sui pazienti e sui cittadini oneri aggiuntivi e crescenti derivanti dal pagamento di ser­vizi (tramite esborsi out-of-pocket) oppure dall’incremento delle addizio­nali Irpef;

–     la terza è una minaccia di corrosione, non tanto sotterranea, del sistema universalistico e solidale che ci siamo costruiti a suo tempo ma che la “tenaglia” risorse scarse/domanda crescente di servizi pone in una situa­zione critica e tale da dover essere affrontata in maniera strategica e con una visione di medio periodo, anche perché a seguito della corrosione suddetta è la componente più debole della popolazione a soffrire di più.

La minaccia dal lato della spesa va affrontata – è bene ricordarlo – con una serie di consapevolezze condivise, visto che (cfr. tabella 1):

–     il nostro Paese spende meno rispetto ai Paesi del G7 e ai Paesi dell’Ocse in termini di spesa sanitaria pubblica sul Pil (6,9%) e in termini di spesa ospedaliera pubblica (3,9%) rispetto al gruppo del G7: e questo pur do­vendo affrontare una contrazione del Pil in questi anni di crisi;

–     il sistema ospedaliero è riuscito malgrado questo a mantenere standard mediamente elevati di prestazione ed anzi a incrementarli nel tempo come mostrano i relativi indicatori, a cui si aggiunge un riscontro com­plessivamente positivo da parte degli utenti nei confronti delle diverse ti­pologie di strutture (il che non deve far dimenticare l’esistenza di signi­fi­cative differenze territoriali e di tensioni sul fronte domanda/offerta di servizi);

–     il confronto tra sanità “finanziaria” e sanità “reale” costituisce certamente una tenaglia, ma rappresenta anche un’occasione in positivo per fare effi­cienza e “liberare” così risorse aggiuntive in grado di affrontare i nuovi e più evoluti bisogni che provengono dalla domanda (con l’invecchiamento della popolazione, con il permanere di vecchie patologie e con il manife­starsi di nuovi disagi, con il ricorso a tecnologie sempre più avanzate, tanto per fare qualche esempio);

–     ma per liberare risorse si dovrà applicare in maniera consapevole ed estesa il principio less is more, basato sul saper fare di più e meglio anche con meno risorse, con la conseguenza di dover riorganizzare la macchina sanitaria e ospedaliera, attuando una revisione profonda del relativo modo di essere e di operare come del resto è richiesto oggi indistinta­mente a tutti i soggetti: aziende, Pubblica Amministrazione, istituzioni, sistemi di rappresentanza.

Proprio tenendo presente quest’ultimo ragionamento si è effettuata quest’anno una stima del disavanzo “reale” complessivo delle Aziende Ospedaliere e degli ospedali a gestione diretta, predisponendo un’apposita simulazione, a partire dalle voci di Conto Economico 2013 delle Aziende, con riferimento alle attività di produzione ospedaliera in senso stretto. An­che perché non bisogna dimenticare che l’86% della spesa ospedaliera pub­blica fa capo proprio agli istituti pubblici, contro un 14% destinato alle strutture accreditate nel loro complesso (cfr. sempre tabella 1): e non è certo realistico ipotizzare un “rimbalzo” degli oneri di razionalizzazione su quelle accreditate, alle quali fa capo solo 1/6 delle risorse complessive.

Il risultato cui si è pervenuti (cfr. tabella 2) è che le Aziende Ospedaliere e gli ospedali a gestione diretta presenterebbero, a livello nazionale, un disa­vanzo reale complessivo valutabile tra il 13,2% e il 20,1% della spesa soste­nuta per le prime e tra il 12,6% e il 14,0% della spesa per i secondi. Anche scegliendo l’ipotesi più prudenziale di stima (rispettivamente il 13,2% e il 12,6%) si sarebbe comunque davanti a cifre dell’ordine di 3,3 miliardi di euro di disavanzo effettivo per le Aziende Ospedaliere e di 2,7 miliardi di euro di disavanzo effettivo per gli ospedali a gestione diretta. Tali dati sono prudenziali anche perché ci si è limitati a valutare i disavanzi dichiarati nei Conti Economici a cui sono stati aggiunti i contributi (al ripianamento) esplicitamente attribuiti in conto gestione ordinaria: ma ad essi andrebbero anche a sommarsi i contributi straordinari come pure il trasferimento impli­cito di risorse che ha a che fare in particolare con le attività “a funzione”.

Naturalmente ragionare su Ricavi e Costi ha richiesto di andare più a fondo per quanto riguarda non solo i primi, ma anche per ciò che concerne i se­condi. A tale proposito si è pervenuti, dopo alcuni passaggi, alla tabella 3 che fornisce il costo medio per singola voce di costo, con riferimento al gruppo delle Aziende Ospedaliere inizialmente analizzate: solo che i valori in euro, calcolati nel modo suddetto, sono stati poi ponderati per il valore dell’indicatore di case-mix della singola Azienda Ospedaliera così da met­tere a confronto non solo il costo grezzo per singolo ricovero, ma anche quello che tiene conto della complessità delle prestazioni fornite. È chiaro che tali risultati andrebbero valutati tenendo conto delle loro differenze re­ciproche, ma anche delle caratteristiche della singola Azienda Ospedaliera (a seconda della tipologia di DRG certamente, ma anche della qualità dell’organizzazione, delle attività specialistiche, delle attività a funzione, delle attività di file f come pure della capacità di attrazione di pazienti da fuori Regione e infine anche dal contesto territoriale in cui l’Azienda opera).

Sono state poi avanzate alcune ipotesi di recupero potenziale dei disavanzi (cfr. sempre tabella 2), proprio in vista di individuare nuove risorse da inve­stire sulla qualificazione dei servizi per il cittadino.

Ma un processo di “rimbalzo” ancora più importante, stante le rigidità che caratterizzano il sistema ospedaliero pubblico e la conseguente difficoltà ad operare riorganizzazioni significative, è costituito dal trasferimento su utenti e cittadini di oneri diretti come pure di carichi fiscali aggiuntivi. Basti con­siderare (cfr. tabella 4):

–     l’aumento delle spese derivanti da ticket per prestazioni sanitarie (+34,9% tra il 2009 e il 2013), oppure da ticket sui farmaci (+66,8% nello stesso periodo) o ancora dal ricorso da parte dei pazienti alle pre­stazioni intramoenia degli ospedali pubblici (+11,8%, sempre tra il 2009 e il 2013);

–     come pure il continuo incremento delle addizionali Irpef che natural­mente diventano ancora più pesanti per le Regioni commissariate e per quelle sottoposte a Piano di Rientro;

–     senza contare la netta percezione del logoramento del sistema di coper­tura sanitaria pubblica, che è stato registrato già lo scorso anno: il 54,6% dei care-giver riteneva che la copertura si fosse ridotta a seguito della contrazione della spesa pubblica ed ammetteva di aver rimandato o addi­rittura rinunciato ad alcune prestazioni per motivi economici (il 22,6% ammetteva di aver rimandato o rinunciato a cure dentarie per i membri della propria famiglia ristretta o allargata e così nel 19,5% dei casi è ac­caduto per le visite specialistiche e nell’11,7% dei casi per le analisi di laboratorio).

Ma una serie di difficoltà del tutto particolari sono state approfondite quest’anno attraverso un’ulteriore indagine, sempre su un campione nazio­nale rappresentativo di care-giver. Ci si riferisce al tema delle “giunzioni” e cioè alle tante fasi di passaggio, al debole presidio per i pazienti e per le fa­miglie, che hanno a che fare con le strutture ospedaliere: rispettivamente nella fase di accesso, nella fase di permanenza, nella fase di dimissioni e nella fase di post-ricovero.

Tra le tante difficoltà afferenti alle “giunzioni” si ricordano le seguenti (cfr. tabella 5):

–     il grande tema dell’informazione appropriata e del counselling, specie nella fase di accesso ma anche nella fase post-ricovero, quando si deb­bano trovare le opportune saldature con le strutture di riabilitazione, di lungodegenza nonché con la medicina e il sistema socio-assistenziale del territorio;

–     i rapporti con gli operatori e con il sistema organizzativo ospedaliero du­rante il ricovero, nel cui ambito si manifestano delle carenze sotto il pro­filo dell’“umanizzazione” nel trattamento dei pazienti (anche se spesso compensate, sul piano informale, dalla disponibilità personale da parte degli operatori);

–     in particolare la mancanza di un sistema di riabilitazione, opportuna­mente articolato su almeno tre livelli di complessità diversi tra loro e coe­renti rispetto alle esigenze derivanti dalle differenti necessità che fanno capo ai pazienti sul piano dell’attività riabilitativa;

–     la mancanza di una struttura ospedaliera di medio livello post-ricovero, in cui poter completare il percorso di cura del paziente, specialmente nel caso di malattie/interventi di tipo grave, quando la degenza risulta troppo breve nell’ospedale di primo ricovero (anche a seguito di liste di attesa troppo lunghe che riguardano altri pazienti bisognosi di interventi e/o di cure).

In conclusione, se vogliamo affrontare in positivo il terzo tipo di “minaccia” cioè quello di una progressiva corrosione del sistema universalistico e soli­dale, bisogna accettare di condividere un maggior livello di verità sul fun­zionamento attuale e su quello necessario (e auspicabilmente più efficiente) della macchina ospedaliera, in modo da poter premiare le strutture migliori, indipendentemente che esse siano pubbliche o private accreditate. E a tale proposito disporre di una maggiore trasparenza dei bilanci dell’ospedalità pubblica diventa a sua volta un passaggio-chiave che per ora sta affron­tando, con un percorso triennale, il tema della certificabilità, per poi arrivare (sperabilmente non troppo in là nel tempo) ad una certificazione vera e pro­pria. Anche questo fa parte di un processo di maggior verità, attraverso cui ci si potrà permettere di fare confronti credibili di prestazioni, con una com­petizione legittima tra pubblico e privato allo scopo di produrre servizi mi­gliori a vantaggio dei cittadini.

Forse le nostre Mappe Mentali sono già cambiate e sono (almeno in parte) pronte ad affrontare tale processo di riorganizzazione e di recupero di effi­cienza e di risorse, ma bisogna giungere a cambiare anche i comportamenti concreti sin da oggi se si intende dare un nuovo e più avanzato equilibrio al nostro sistema ospedaliero e di welfare, che consenta di salvarne le caratte­ristiche positive di fondo.

 

 

Tab. 1 – La tenuta di fondo del sistema, malgrado una spesa inferiore alla media dei Paesi Ocse

Fenomeni Dati
Incidenza della spesa sanitaria pubblica sul Pil1 2010 2011 2012
–   Italia 7,2 7,0 6,9
–   Media Paesi G7 7,9 7,9 8,0
–   Media Paesi Ocse Europa 7,5 7,4 7,4
–   Media totale Paesi Ocse 7,5 7,4 7,8
Incidenza della spesa ospedaliera pubblica sul Pil2 2010 2011 2012
–   Italia 3,9 3,9 3,9
–   Media Paesi G7 4,0 4,1 4,1
–   Media Paesi Ocse Europa 3,6 3,7 3,8
–   Media totale Paesi Ocse 3,8 3,8 3,9
2009 2010 2011 2012
Andamento crescente degli indicatori di complessità delle prestazioni (peso-medio)3:        
–   Indice di peso medio degli istituti pubblici 1,07 1,09 1,12 1,18
–   Indice di peso medio degli ospedali privati (case di cura accreditate) 1,14 1,18 1,17 1,25
Valutazione degli utenti 2011 2012 2013 2014
–   Livello di apprezzamento degli ospedali italiani da parte degli utilizzatori del sistema misto pubblico/privato (giu­dizi “molto + abbastanza soddisfatto”)4        
–     Ospedali pubblici 87,8 88,0 84,7 86,3
–     Ospedali privati (case di cura accreditate) 95,3 92,7 91,3 94,3
Articolazione della spesa sanitaria pubblica5   2011 2012
–   Spesa ospedaliera 54,5 54,3
–   Spesa extraospedaliera 45,5 45,7
Totale 100,0 100,0
V.a. in miliardi di euro 112,8 113,7
Spesa pubblica per gli ospedali6   2011 2012
–   Ospedali pubblici 85,6 86,0
–   Ospedali privati accreditati nel loro complesso 14,4 14,0
Totale 100,0 100,0
V.a. in miliardi di euro 61,5 61,7
Numero giornate di degenza7   2011 2012
–   Presso ospedali pubblici 72,7 72,6
–   Presso ospedali privati accreditati nel loro complesso 27,3 27,4
Totale 100,0 100,0
V.a. in milioni 67,9 65,2
  • tavola 11/Parte prima, pag. 52.
  • tavola 10/Parte prima, pag. 51.
  • tavola 1/Parte prima, pag. 35.
  • tavola 4/Parte prima, pagg. 42-43.
  • tavola 5/Parte prima, pag. 47.
  • figura 2/Parte prima, pag. 30.

Fonte: indagine Ermeneia – Studi & Strategie di Sistema, 2014

 

 

 

Tab. 2 – Simulazione di un possibile recupero del disavanzo “reale” complessivo delle Aziende Ospedaliere e degli ospedali a gestione diretta con riferi­mento all’anno 2013 (°)

Tipologia di spesa

per destinatari

1 2 3 4
Spesa (arrotondata) per l’ospedalità pubblica

(in milioni

di euro)1

 

 

Disavanzo “reale” stimato

(in milioni di euro)

Recuperi percentuali di efficienza con riferimento al disavanzo reale massimo stimato

(in milioni di euro)

Recuperi percentuali di efficienza con riferimento al disavanzo reale minimo stimato

(in milioni di euro)

Massimo Minimo 20% 40% 60% 20% 40% 60%
–     Spesa per Aziende Ospedaliere 25.200,0 -5.066,02 -3.334,52 1.013,2 2.026,4 3.039,6 666,9 1.333,8 2.000,7
–     Spesa per ospedali a gestione diretta 21.600,0 -3.031,03 -2.725,13 606,2 1.212,4 1.018,6 545,0 1.090,0 1.635,1
Totale 46.800,0 -8.097,0 -6.059,6 1.619,4 3.238,8 4.058,2 1.211,9 2.423,8 3.635,8

(°) Corrispondente alla tavola 16/Parte prima, pag. 64.

Fonte: indagine Ermeneia – Studi & Strategie di Sistema, 2014

 


 

 

Tab. 3 – Costi medi per tipologia e per singolo ricovero, secondo la ponderazione di tipo A (utilizzando il Case-mix delle singole strutture) (°)

  1 2 3 4 5 6 7 8 9 10 11 12 13
Aziende Ospedaliere

esaminate, per circoscrizione geografica

Case-mix medio Aziende Ospedaliere circoscrizione geografica Totale numero ricoveri

(Ord. + DH

+ DS)

Costo medio di personale, per singolo ricovero (in euro) Costo medio per acquisto prodotti farmaceutici, per singolo ricovero (in euro) Costo medio per acquisto di altri beni sanitari, per singolo ricovero (in euro) Costo medio per la mensa e per i prodotti alimentari, per singolo ricovero (in euro) Costo medio per la lavanderia (o noleggio) e materiale di guardaroba, per singolo ricovero (in euro) Costo medio smaltimento rifiuti, per singolo ricovero (in euro) Costo medio utenze telefoniche, per singolo ricovero (in euro) Costo medio utenze elettricità, per singolo ricovero (in euro) Costo medio premi di assicurazione, per singolo ricovero

(in euro)

Altri costi: media per singolo ricovero (in euro) Totale costi medi totali per singolo ricovero (in euro)
Aziende del Nord
AO 1 1,26 33.500 1.666 528 535 42 67 9 2 27 28 754 3.658
AO 2 1,12 24.000 3.613 2.656 904 109 147 32 18 145 158 1.592 9.375
AO 3 1,29 47.000 3.842 739 744 136 56 19 9 7 15 2.829 8.395
AO 4 0,90 36.500 4.314 344 679 120 81 32 16 114 24 1.994 7.717
AO 5 0,94 56.500 4.282 1.248 1.254 131 133 34 9 188 107 2.325 9.712
AO 6 1,17 55.000 3.209 1.647 1.242 147 111 28 18 105 65 2.408 8.980
AO 7 1,17 52.500 2.724 578 768 103 81 47 5 127 52 1.873 6.357
AO 8 1,06 44.000 2.858 798 900 70 94 37 5 99 43 1.140 6.044
AO 9 1,11 53.000 2.371 411 469 77 71 24 5 95 63 821 4.408
AO 10 1,19 72.000 2.673 766 622 62 110 45 8 108 61 2.092 6.547
AO 11 1,10 42.500 2.734 652 593 106 80 28 12 144 53 1.976 6.376
Totale Nord 1,12 516.500 3.067 891 793 100 93 32 9 104 58 1.865 7.013
Aziende del Centro
AO 12 1,26 81.500 2.689 683 982 27 102 25 6 91 10 1.605 6.219
AO 13 1,13 44.000 2.711 790 895 35 122 53 30 95 88 1.572 6.391
AO 14 1,33 74.800 1.617 476 586 23 61 21 7 24 33 818 3.666
AO 15 1,32 60.300 3.084 380 666 137 91 63 8 15 1.785 6.228
AO 16 1,05 34.600 3.581 545 600 85 72 36 18 83 6 1.974 7.001
AO 17 1,18 31.900 2.901 279 1.113 102 95 38 22 58 1.513 6.122
Totale Centro 1,21 327.100 2.666 549 808 62 91 38 12 49 31 1.501 5.807
Aziende del Sud
AO 18 0,94 41.400 2.765 874 848 84 86 42 17 75 182 1.001 5.972
AO 19 1,00 38.000 4.697 916 832 307 114 51 14 135 68 1.990 9.123
AO 20 1,04 15.000 4.314 545 788 161 68 15 19 87 119 1.715 7.832
AO 21 1,05 20.000 3.819 1.005 876 188 47 16 20 174 37 1.960 8.142
AO 22 0,89 34.500 3.000 394 769 109 82 6 42 104 88 741 5.336
AO 23 1,10 63.400 2.233 786 753 64 24 13 5 103 78 1.106 5.164
AO 24 1,09 43.200 3.506 686 743 85 28 26 13 135 144 1.491 6.857
Totale Sud 1,02 255.500 3.262 761 795 128 59 25 16 115 105 1.359 6.624
Totale Generale 1,11 1.099.100 3.008 761 806 95 86 33 12 89 60 1.657 6.606

(°) Corrispondente alla tavola 22/Parte prima, pag. 83.

(*) Elaborazioni sui dati dei Conti Economici delle Aziende Ospedaliere (Anno 2013).

(*) Valori calcolati sulla base dei dati contenuti nella Tabella All./2 dell’Allegato statistico.

Fonte: indagine Ermeneia – Studi & Strategie di Sistema, 2014

 

Tab. 4 – Il “rimbalzo” delle inefficienze sugli utenti e sui cittadini

Fenomeni Dati
Incremento del valore dei ticket incassati dalle Aziende Sanitarie nel periodo 2009-20131: 2009 2013
–     V.a. in milioni di euro 1.176,2 1.586,9
–     N.I. 100,0 134,9
Incremento del valore dei ticket sui farmaci (+ spread generici/ branded)2:
–     V.a. in milioni di euro 861,0 1.436,0
–     N.I. 100,0 166,8
Incremento del valore delle prestazioni intramoenia, fatturate dagli ospedali pubblici3:
–     V.a. in milioni di euro 1.131,9 1.266,0
–     N.I. 100,0 111,8
Incremento delle aliquote Irpef regionali tra il 2009 e il 20134:
–     Incremento minimo: Veneto +7,0
–     Incremento massimo: Piemonte +82,9
–     Regioni commissariate:
•      Lazio

•      Abruzzo

•      Molise

•      Campania

•      Calabria

+57,9

+17,1

+46,4

+45,0

+45,0

–     Regioni sottoposte a Piano di Rientro
•      Piemonte

•      Puglia

•      Sicilia

+82,9

+37,4

+23,6

  • tavola 24/Parte prima, pag. 90.
  • tavola 25/Parte prima, pag. 91.
  • tavola 26/Parte prima, pag. 93.
  • tavola 27/Parte prima, pag. 94.

Fonte: indagine Ermeneia – Studi & Strategie di Sistema, 2014


Tab. 5 – Le difficoltà derivanti dalla debolezza delle “giunzioni”, nell’opinione dei care-giver (val. %)(°)

Fenomeni Dati
Principali difficoltà affrontate nell’accesso all’ospedale1
–   Qualche tipo di difficoltà (seria, media o leggera) 47,0
–   Trovare informazioni affidabili sull’ospedale al fine di scegliere la struttura più appro­priata2 29,7
–   Non aver ottenuto alcuna informazione dal medico di medicina generale perché non era in grado di indirizzare il paziente verso l’ospedale più oppor­tuno2  

27,3

–   Aver aspettato troppo a lungo poiché non c’era posto al momento del bisogno2 24,2
–   Aver dovuto cambiare struttura ospedaliera per non dover attendere troppo rispetto alle esigenze di intervento e/o di cura2 24,0
–   Aver utilizzato il Pronto Soccorso (o il 118) per poter sfruttare il ricovero d’urgenza, ricovero che non si sarebbe potuto ottenere o sarebbe stato spostato troppo in là nel tempo2  

24,6

–   Aver utilizzato conoscenze e relazioni personali per abbreviare l’attesa, per ottenere il ricovero in uno specifico reparto dove opera un medico di fiducia, ecc.2  

37,9

Principali difficoltà affrontate durante il ricovero3
–   Hanno avuto qualche difficoltà nelle “giunzioni” interne 34,0
–   Non si sapeva a chi chiedere informazioni sull’andamento della salute del paziente 43,4
–   Non si è rilevata una sufficiente “umanizzazione” nel trattamento riservato ai pazienti 44,6
–   Si è avuta l’impressione talvolta di “dar fastidio” al personale e all’organizzazione dell’ospedale 43,0
–   Non si è avvertita abbastanza la “passione professionale” del personale medico 40,2
–   Non si è avvertita abbastanza la “passione professionale” del personale infermieristico 34,4
–   Si è avuta difficoltà nel far accettare eventuali consulti medici all’interno dell’ospedale 18,5
Principali difficoltà affrontate al momento delle dimissioni (Giudizi “molto + abbastanza importante”)4
–   I tempi per ottenere la copia della cartella clinica sono stati lunghi o lunghissimi e si è rischiato di iniziare le cure specifiche troppo tardi 25,7
–   Il collegamento col medico di base si è rivelato non appropriato e/o inesistente 30,1
–   Non esiste una buona procedura circa le dimissioni e gli impegni eventuali legati al dopo-ricovero cosicché si è lasciati un po’ a se stessi 31,0
Principali difficoltà affrontate nel post-ricovero (Giudizi “molto + abbastanza d’accordo)4
–   Il paziente è dovuto rientrare in ospedale a causa delle conseguenze cliniche manifesta­tesi dopo l’intervento e/o le cure avute in ospedale 24,5
–   Le strutture di riabilitazione post-ricovero non si sono rivelate adeguate rispetto all’intervento chirurgico e/o alle cure precedentemente avute in ospedale  

21,7

–   Si è rilevata la mancanza di una struttura ospedaliera di medio livello, in cui completare il percorso di cura da parte del paziente, specie nel caso di disagi di tipo grave (la de­genza risulta ormai troppo breve con dimissioni troppo rapide)  

15,4

(°) Corrispondente alla tavola 28/Parte prima, pag. 98.

Fonte: indagine Ermeneia – Studi & Strategie di Sistema, 2014

L’importanza delle vaccinazioni

Girolamo Sirchia

Le vaccinazioni restano oggi uno dei più efficaci e convenienti strumenti di prevenzione della malattie infettive. Stupisce quindi che esistano gruppi di opinione che contrastano questa pratica, spesso basandosi su opinioni e credenze non dimostrate che ingenerano timori nella popolazione. La figura riporta i progressi compiuti dalle vaccinazioni USA nei 50 anni passati.

(Schwartz JL e Mahmoud A. A half-century of presentation. The Advisory Committee on Immunization Practices. NEJM 371, 1953-56, 2014)

1

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The Precipice: Influence and Manipulation @helenbevan @leadmedit @wricciardi @pash22

BY 

In some ways, to influence and to manipulate can seem to be the same thing. After all, the intent of both influence and manipulation is to get other people to behave, think, or make the decision you want them to. But is that really the case as demonstrated by these definitions from thefreedictionary.com?

Influence:  (n) 1. A power affecting a person, thing, or course of events, especially one that operates without any direct or apparent effort. 2. Power to sway or affect based on prestige, wealth, ability, or position.  (v) 1. To produce an effect on by imperceptible or intangible means; sway. 2) To affect the nature, development, or condition of; modify.

Manipulate: (v) 1. To move, arrange, operate, or control by the hands or by mechanical means, especially in a skillful manner. 2. To influence or manage shrewdly or deviously. 3. To tamper with or falsify for personal gain.

As indicated in the definitions, the main purpose of both influence and manipulation is  to sway; however, there is a definite difference between the two. Influence is an ethical behavior; manipulation is unethical. We admire leaders who have mastered the power of influence; equally, we mistrust leaders we believe to be manipulative. They are both getting us to see things their way. Taken too far, influence can move to the other end of the spectrum and become manipulation.

The differences between influence and manipulation include the:

  • reason behind the intention to persuade another person
  • truthfulness and accuracy of provided information
  • transparency of the process
  • benefit, affect, or impact on the person.

Manipulation implies an intent to fool or trick someone into doing, believing, or buying something that leaves them harmed in some way. We view manipulators as schemers. Out to get what they want using whatever means possible, manipulators selfishly pursue their own agenda, trying to control instead of wanting to influence another person. For example:

Influence Someone offers a proposition that is beneficial to both parties.

Manipulation: Someone offers a proposition that serves their own purposes and is against the other person’s interest. They conceal a desire to move the person to their point of view in a way that will only benefit themselves. In addition, if their intention were uncovered, the discovery would cause the other person to be less receptive to their idea.

Influence: All information provided is accurate and shared openly.

Manipulation:  Information is withheld or distorted to trick or deceive.

Influence Someone is willingly led to something they want or that will benefit them.

Manipulation: Someone is led to something that will harm them or lead them to eventual regret.

Influence Requesting someone to do you a favor you believe they won’t want to do using sincere appreciation.

Manipulation: Getting someone to do you a favor you believe they won’t want to do using guilt or emotional blackmail.

Many years ago I worked with a manager who often ended his directives with, “And if I find out you didn’t follow what I said, you’re fired,” Looking back now, I assume that he was not confident in his role, his ability to do the job, and/or his effectiveness as a manager and leader. We have all known people who, like my former colleague, get others to do what they want through fear and intimidation. Using these tactics may accomplish what they want, but it does not make them leaders. Like love and hate, there is a fine line between influence and manipulation.

 

Prevarranno gli interessi industriali sulla salute pubblica?

Girolamo Sirchia

Il Trattato Transatlantico (USA-Unione Europea) sul commercio e gli investimenti è un grave pericolo per la salute pubblica. Il Trattato include anche la Sanità e prevede una competizione per tutti i servizi che rischia di travolgere i Servizi Sanitari nazionali, con perdita di almeno 1 milione di posti di lavoro in USA e Europa, seri rischi per la sicurezza alimentare e per l’uso di pesticidi (assai meno limitato in USA), meno riguardo alla già lacunosa tutela ambientale dell’industria, riduzione del principio di precauzione (che cerca di opporre la salute pubblica e l’integrità ambientale agli interessi dei gruppi organizzati). Anche il costo dei farmaci risulterà maggiore e verranno rinforzati i diritti proprietari dell’industria farmaceutica, specie quella americana che preme fortemente in tal senso sul Governo USA: ciò porterà ad una maggior spesa per i Servizi Sanitari nazionali e quindi a restrizioni in altri ambiti di prevenzione, cura e riabilitazione. La cosa…

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How and why do countries vary so much in their use of health services? @WRicciardi @leadmedit @Medici_Manager @pash22

BY ADAM WAGSTAFF , http://bit.ly/1e48HAI

I’ve been struck recently by how little we (or at least I) seem to know about variations in use of health services across the world, and what drives them. Do people in, say, India or Mali use doctors “a lot” or “a little”. Even harder: do they “overuse” or “underuse” doctors? At least we could say whether doctor utilization rates in these countries are low or high compared to the rate for the developing world as a whole. But typically we don’t actually make such comparisons – we don’t have the numbers at our fingertips. Or at least I don’t.

I’m also struck by how strongly people feel about the factors that shape people’s use of services and what the consequences are. There are some who argue that the health problems in the developing world stem from people not getting care, and that people don’t get care because of shortages of doctors and infrastructure. There are others who argue that doctors are in fact quite plentiful – in principle; the problem is that in practice doctors are often absent from their clinic and people don’t get care at the right moment. There are others who argue that doctors are plentiful even in practice and people do get care; the problem is that the quality of the care is shockingly bad. Who’s right?

WHS to the rescue – again

As in a recent post of mine on Let’s Talk Development, I thought the World Health Survey might shed some light on these issues. The WHS was fielded in the early 2000’s in 70 countries – spanning the World Bank’s lower-, middle- and high-income categories. The WHS enumerators asked a randomly-selected adult in each household about his or her use of inpatient care and outpatient care; in the numbers that follow I’ve focused on use in the last 12 months. As I said in the earlier blog post, the WHS does have some drawbacks: it covers some regions fairly fully, other much less fully; it’s 10 years old; and all we can tell is whether inpatient or outpatient care was received, not the number of contacts. But despite these problems, the WHS gets us quite a long way.

A lot of variation – but not necessarily what you’d expect

The maps below show the inpatient admission and outpatient visit rate – actually the fraction of people who had at least one admission or visit in the last 12 months. Green countries are above the developing-country average; red countries are below it.
For IP admissions, most of the OECD countries are above the developing-country average (6.98%). Brazil, Namibia and the European and central Asian countries are also above it. African and Asian countries are mostly below or close to the developing-country average.

The picture is different for outpatient visits. Several OECD countries are actually below the developing-country average (27.52%). And for the most part, the countries below the developing-country average are in Africa: many are considerably below it (Mali stands out dramatically); only a few are above it (Kenya and Zambia stand out). By contrast, several countries in Asia are above the developing-country average: India and Pakistan are dramatically above it, but China and Vietnam are also above it; a few Asian countries are below it – Laos and Myanmar are considerably below it, Malaysia and the Philippines less so.

Do variations in doctor numbers and infrastructure explain variations in utilization?

The maps below show data on doctors and hospital beds per 1,000 persons. I got the data from the World Development Indicators, and took the country averages for the first half of the 2000s. As before, green countries are above the developing-country average; red countries are below it. The countries above the developing-country averages are mostly those in the OECD and Europe and central Asia, though in the case of doctors per 1,000 some of them are also in Latin America and the Caribbean. Except for China, most of Asian countries fall below the developing country average.

Correlating the WHS utilization data with the WDI doctor and beds data shows that doctors and beds per 1,000 persons are positively associated with outpatient visit and inpatient admission rates. A lack of doctors and beds looks like it could indeed be part of the explanation for low utilization rates, though of course we haven’t established causality.

But a lack of doctors and hospital beds is only part of the story. Together they “explain” only 60% of the cross-country variation in inpatient admission rates, while doctors “explain” an even smaller 20% of the cross-country variation in outpatient visit rates.

Some countries – India and Pakistan are examples – are below the developing-country average on doctors per 1,000 persons, but above the developing-country average on the outpatient visit rate. Doctors and hospitals in these countries treat far more patients than one would expect given the number of doctors and hospital beds in these countries. In these countries, it doesn’t look like accessibility is the pressing issue; as research by my colleague Jishnu Das confirms, at least in India, poor quality is the bigger problem.

By contrast, much – but not all – of Africa is in the opposite camp: these countries have inpatient admission and outpatient visit rates that are below what would be expected on the basis of their doctor and beds per 1,000 figures. So it’s not just that these countries lack doctors and beds; it’s also that people are not getting the level of contacts you’d expect from the existing staff and infrastructure. Here it looks like absenteeism could well be part of the story; recent research from my colleague Markus Goldstein confirms it – pregnant women whose first clinic visit coincided with a nurse’s attendance were found to be 46 percent more likely to deliver their baby in a hospital.

Two take away messages

Message #1 is that countries differ considerably in their utilization rates. Much of Asia visits doctors more regularly than both the developing world and the entire world; India’s consultation rate is a third higher than the global average. Africa stands out as the continent where outpatient visits and inpatient admissions lag behind the rest of the world.

Message #2 is that these variations are partly explained by differences in doctors and hospital beds per capita, but only partly. The problem goes deeper than hiring more doctors and building more hospitals. Africa has lower outpatient visit rates than its doctors per 1,000 figures would suggest, while the opposite is true of India and Pakistan. In Africa, it looks like the binding constraint may well be absenteeism, while in S Asia it looks like the first-order problem is the poor quality of care that’s actually delivered.