During the final term of my Diagnostic Radiography degree, I attended clinical placement for a total of 11 weeks to gain experience and practice my imaging techniques in various imaging departments. The placement module provided me with a learning experience in a hospital environment and helped to broaden my clinical skills in a variety of clinical environments. I was formally assessed by a member of the clinical staff on 2 different imaging procedures, a mobile chest x-ray and a CT head scan, as part of the degree evaluation process. I kept a reflective diary from the first day of my placement to help me record my feelings and thoughts on the examinations I was asked to perform, the varying patients I examined, the outcomes of these examinations and any problems or achievements I felt important in my time there. The most significant reflection, however, was in respect to my clinical staged assessments. I will be using this diary as a means to help me reflect on my experiences on this placement and on how I have developed both professionally and personally.

What is reflection and why does reflection help me in my learning? Reflection is a process of gradual self-awareness, critical appraisal of the social world and how it transforms your thinking. Johns and Freshwater (2005) state that “reflection is an active process that will enable me and other health care professionals to gain a deeper understanding of any experience with patients”. One definition that is appropriate for student radiographers is “Reflection in the context of learning is a generic term for those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new understandings and appreciations (Boud et al, 1985). The use of a reflective journal during my final placement helped me with my reflective development as it would have been difficult for me to remember all the numerous thoughts and feelings I experienced over an 11 week period. Kennison (2002) sees the reflective clinical journal as a method in which a learner may write about clinical learning experiences and reflect on them. He considers this as a beneficial tool of reflection which not only improves the learner’s writing skills but also essentially helps to “reflect on their practice, explore reactions, discover relationships and connect new meanings to past experiences”. On the other hand Newell (1992) states that any reflective practice is reliant on memory and interpretation of events – selective memory is a particular problem especially following a negative event. I can relate to this as I did find that a balance was required when recalling certain events, I was inclined to remember more negative situations than positive ones, these negative feelings and thoughts of particular events stayed with me longer and had a bigger impact on me.

If I am to approach this account of my clinical placement reflectively I must choose an appropriate

model of reflection

. Johns (2002) found that there are several models have been developed to guide the process of reflection. The first model I will use to aid my analysis and to explore my feelings is the Gibbs (1988) reflective cycle. This model has 6 stopping points which are – Description, Feelings, Evaluation, Analysis, Conclusion and Action Plan. I feel this cycle allows analysis to make sense of the experience, it takes into account a sequence of feelings and emotions which play a part in a particular event and leads you to a conclusion where you can reflect upon the experience and what steps you would take if the situation happened again. This model can also be used through different levels of reflection from novice to advanced. The second model I am employing is Boud et al (1985). This model helps reflect before, during and after an action and will be ideal to explore my feelings and experiences through the whole of my placement. Boud et al (1985) identify reflection as “a generic term for those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new understandings and appreciations”. This reflective model is therefore appropriate for radiographers and other health professionals to adopt in critical reflection exercises. Boud et al, (1985) & Schon, (1995) state that the development of the abilities to be reflective and critically reflective in practice can be perfected through active, repeated, guided practice.

Model of reflection (Boud et al 1985 from Johns 1995)

Stage 1: Return to experience

Describe the experience, recollect what happened

Notice what happened/ how you felt/ what you did

Stage 2: Attend to feelings

Acknowledge negative feelings but don’t let them form a barrier

Work with positive outcomes

Stage 3: Re-evaluate the experience

Connect ideas and feelings of the experience to those you had on reflection

Consider options and choices

Stage 4: Learning

How do I feel about this experience?

Could I have dealt with it better?

What have I learnt from this experience?

Starting at the beginning of the Gibbs (1988) cycle and Boud et al (1985) framework, I am asked to describe the two different clinical staged assessments that I completed and my recollection of thoughts and feelings before, during and after the process.

My timetable actually dictated that I would perform my mobile chest x-ray assessment first. This was due to me spending the majority of my first few weeks on placement in the General Department where I would be performing this type of procedure regularly on ward patients. I thought it best to be assessed during the third week after I had performed the examination many times and would be feeling confident. At the start of the second week of my placement I felt confident that I would be ready for this assessment in week 3 and was looking forward to my 2 timetabled days in the Accident and Emergency (A&E) Department prior to working in the General Department again. On the first morning in A&E the radiographer in charge asked if I had any staged assessments to be evaluated on, I advised her that I had a mobile chest x-ray to do but I was happy to do this in the General Department the next week once I had gained more practice. Unexpectedly, the radiographer suggested that she would assess me that morning and that I should carry out the examination on the next patient that required a chest x-ray in resuscitation.

My first instinct was to put this off and decline, as in my mind I had planned to be assessed on a ward patient the following week. I also felt panicked as I did not have much practice using the mobile x-ray machine in the resuscitation area at this point and the surprise of the request took away some of my confidence. This was a test of my mental strength and as a future health care worker I would have to get used to making quick decisions and rising to challenges on a daily basis. My response was to agree, which surprised myself, I accepted that I was going to be assessed that day. I did not have my assessment sheet and criteria to hand but I managed to find another student who had the information and photocopied it. The morning passed very quickly and I was worried every time a request card was passed through to the viewing area from the A&E staff as I thought it would my turn to carry out my assessment. When the request eventually arrived it was to image a 64 year old male that had breathing problems and a history of Chronic Obstructive Pulmonary Disorder (COPD), he was sitting upright on a trolley in the resuscitation area of Accident & Emergency. A chest x-ray was required and so I checked the request card and the patient’s history on the hospital information system (HIS) system to check for any previous history and corresponding images, I washed my hands, collected a cassette and proceeded to take the mobile unit into the required area. The radiographer accompanied me and asked the patient for his consent and his co-operation to have a student perform the x-ray, the patient agreed. She then observed the whole procedure to evaluate my performance.

The chest x-ray procedure was carried out routinely as an erect, antero-posterior view, the patient was very co-operative and aware of the situation around him which made it easier for him to understand and carry out the breathing instructions I was giving him. The resulting image showed prominence of hilar vasculature and was an acceptable diagnostic image. I received an excellent assessment mark from the radiographer and although I was relieved that it was over I still felt pleased with myself that I had carried out the mobile x-ray to a high level. I am thankful however that I kept my reflective diary on this occasion as everything happened so quickly and not to the plan that I anticipated that I benefit from reading my emotional conflicts that I experienced at a later date. This feeling is reinforced by Schön (1987) who argued that reflection is not a simple process and that practitioners need coaching and require the use of reflective diaries as tools for dealing with practice problems.

The second assessment on the other hand was not as stressful as the above experience and I feel I coped with the anticipation of this assessment better. I was timetabled for a week in the CT Department and so I knew that I would definitely be assessed then on a CT head scan. After discussion with the radiographer in charge it was agreed that we would wait until the Friday to be assessed to ensure that I had plenty practice in carrying out CT head examinations. On the day of the assessment I decided to be assessed on the first patient to attend for a CT head examination. I did not feel as nervous as the first assessment as the arrangements had been made at the start of the week and I knew when I was being assessed. I was also confident in my ability to use the CT scanner and my positioning skills. The first patient to arrive for a CT head scan was a 69 year old female who presented with a history of persistent headaches and dizziness. On checking her identification I found that the lady was hard of hearing and I had to make sure to explain the procedure slowly, clearly and slightly louder than usual. I instantly became concerned that the patient would not hear the instructions given immediately prior to the examination, e.g. that she should remain very still and not move her head which is very important in achieving a clear and diagnostic head scan. This was a scenario that again I had not predicted. Radiographers, medical students, and nurses alike are constantly faced with unique and ambiguous problems in the clinical setting, where they are required to stop, think, and problem solve in the middle of activities or procedures they are carrying out and is a challenging part of the job.

I proceeded to explain to the patient prior to positioning her in the CT scanner what the examination would entail as she would be lying in a supine position with her head resting on a head support which would further obscure her hearing. She acknowledged my instructions and I felt happy to continue with the examination. The patient was positioned head first into the scanner no intravenous contrast was necessary and the patient raised on the table so the lasers were at the level of the orbitomeatal line. I then carried out the appropriate CT head protocol on the computer system, the scout was carried out to make sure the patient was in the correct position and the x-ray beam was set at an angle along the base of the skull to prevent unnecessary radiation of the patients orbits, the slice thickness was selected between 5mm and 10 mm and the CT examination was started. Everything went smoothly and the patient was not found to have any significant pathology showing on the scan. The radiographer in charge was pleased with my technique and anatomy knowledge and gave me a good mark for my assessment.

Boud et al (1985) suggest that ‘In reflective practice, it is necessary to gain an appropriate balance between the analysis of knowledge and thoughts, and the analysis of feelings. It is also important to focus on positive feelings as well as trying to deal with negative feelings, in order for the process to be constructive.’ Bulman & Schutz. As I follow Gibbs (1988) cycle to explore my emotions and feelings I am aware that this step in Boud et al’s (1985) framework becomes appropriate. He advises to ‘acknowledge negative feelings but also to not let them develop a barrier. I did experience negative feelings, more so in the first staged assessment. This has been an emotion that has surfaced from the start of my training and continued until this point, although the fear factor has reduced significantly. I sometimes do let my nerves get the better of me but as I have come through this degree my worrying has lessened and my confidence has grown. Wondrack (2001) acknowledges that fear and feelings of guilt often accompany emotions which spring from a lack of confidence in how to resolve situations. On reflecting in past modules I have highlighted my nervousness and so I do not find it a barrier but a test of my determination now. With regards to my first staged assessment I was nervous and anxious as I was ‘put on the spot’ and not as fully prepared mentally as I would have liked. I think I coped as well as I did due to the fact that I have been learning how to adapt to changing circumstances since my first year placement. I know that I can deal with what is thrown at me now and ask questions if I am in any doubt of my actions. My general clinical placements have all required for me to think on my feet, in the case of the patient who was hard of hearing, the main problem was communication. Schön (1993, 1987 cited Moon 2001, p. 3) focuses on reflection in professional knowledge and its development. He identified two types of reflection which are ‘reflection in action’ and ‘reflection on action’.  Schön proposes that these types of reflections are used in unique situations, where the practitioner is unable to apply ‘theories or techniques previously learnt through formal education’ (Moon 2001).  It would therefore seem that ‘reflection in action’ and ‘reflection on action’ are highly beneficial to the healthcare environment as practitioners are working with individuals who are more often than not, text book examples.  Reflection is a fundamental part of my radiography practice and future career, as all patients are unique this means that every time I image a patient I may have to approach it differently as I will need to consider the individual needs of the patient.  The outcomes of both my staged assessments were very good and a positive result did come after my initial negative feelings.

Following both the reflective frameworks, I began to analyse what made me feel the way I did. As I considered the pros and cons as suggested by Gibbs (1988) I found that it was reasonable to feel the way I did and that it is all part of being a student. Every other student that I had spoken to felt nervous when both completing the staged assessments and facing new situations with patients. It was to be expected in the lead up to potentially becoming a radiographer. The cons were that I showed my weakness to the radiographer and maybe came across as less confident as I should have, the pros were that I used these feelings to push myself forward and it made me want to do my best to prove that I was capable of producing good diagnostic images.

Reflection is more than just thinking about something, it should be an active process, which should result in learning, changing behaviours, perspectives or practices (Boud et al, 1985). By reflecting I have certainly changed my perspectives and behaviours on clinical placement. I am a more positive student and person due to the challenging situations and people that I have encountered. Where I previously became flustered I now take a deep breath and think through the situation and take my time. I have the knowledge to back up my skills and vice versa now so it is my application of these tools that can move me forward. Gibbs (1988) cycle concludes by asking what could I have done differently, both staged assessments were not extreme cases and I was lucky to examine co-operative patients. I would not have done anything differently in the practical aspect. Experience will help me to become more confident in my own skills and capabilities and will help me in adapting to change quickly. This is where I prefer Boud et al’s (1985) framework as it encourages you to reflect on how you feel about the experience and what you have learned. Gibbs (1988) is slightly more negative and asks ‘what would you change and do differently’. I was unable to turn my nerves and emotions off and on but I could learn to control them and make them work for me.

From following both Boud et al (1985) and Gibbs (1988) models of reflection I have analysed the situation in detail in a logical order. These experiences have been immensely helpful in evaluating my emotional reactions and professional limitations in the clinical setting. Therefore, my diary has been an essential tool in my development. According to Maggs & Biley (2000) evaluating practice through reflection can bring advantages. The challenge is to recognize and use these advantages, together with the knowledge they generate.

The inpatient prospective payment system (IPPS) is a structure of payment that comprises the instances of diagnosis-related groups (DRGs) as acute care hospital inpatients. It is founded on resources that are employed to take care of recipients of Medicare in those groups. Each one DRG has a weight of payment allocated to it, founded on the standard cost of treating patients in that DRG. IPPS participates a significant function in deciding all costs of hospital as well as the costs of all tools for treating the patient all through a precise stay of inpatient (CMS. Gov, 2012). The outpatient prospective payment system (OPPS) on the other side is controlled for service groups of diverse outpatient as classifications of ambulatory payment (APCs).

Outpatient services in every APC are alike in expressions of clinical aspects and entailed resources. The APC payment rate In addition, for every group is wage adjusted to rationalize differences of geographic and functional in the group to all services. Hospitals In this get a fixed sum for all services of outpatient founded on classifications of ambulatory payment. Medicare apart from this, employs it to repay physicians and additional health care providers for the items and services that are not division of prospective payment systems (Herbert, 2012). A Medicare physician fee schedule (MPFS) establishes the rates of payment for therapy and physician services that are founded on conversion factors, relative value units, and cost indices of geographic practice.

Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) is recounted to reimbursement rates for these specific things to suppliers that make certain admission of a high-class of these things to the patients. It includes more than a small number of regulations of payment managing the delivery of DMEPOS things for beneficiaries of Medicare. It renders the process of competitive and authorization bidding, supplier enrollment, that have an force on suppliers payment made by the hospitals. It advances the capability of physicians to offer these things to their patients in an suitable manner. It make sure efficient supply of the required resources like health techniques, equipments, and technologies to the deprived at the right cost. There is most important divergence of recipients, provider groups, and their services offered for medical beneficiaries in these models, (CMS. Gov, 2012).

OPPS and IPPS are executed for the similar provider i.e. health organizations and hospitals, nevertheless different in their recipients, who are out patients and inpatients correspondingly. DMEPOS and MPFS don’t comprise prospective payment systems and focus on supplier and physicians groups correspondingly. All these methods are structured to restrain on raise in health care services cost to the patients. It aids for the beneficiaries of medical to get quality and effective health care services at low down cost (Green & Rowell, 2012). Hospitals With this are also confined to get a precise amount for their services, which they offer to the patients.

Payment Expectations

Both inpatient and outpatient prospective payment system methods of reimbursement are employed by Medicare to reimburse hospitals for outpatient and inpatient services, in addition to rehabilitation hospitals, skilled nursing facilities, and home health services. It is anticipated from both providers that they ought to provide outpatient and inpatient services to the patients efficiently. It is as well anticipated that these hospitals for all time emphasize improving effectiveness and efficiency of care, while generating a results-oriented, patient-focused, market-driven environment (Zweifel, Breyer & Kifmann, 2009). It is supposed to be noted down In this context, that in the instance that someone is not capable to recompense for hospitahealth services it is anticipated from the hospital that it offer the free of cost health services. It in addition have to serve a least amount number of beneficiaries of Medicare.

Non-physician and physicians practitioners Under the MPFS, are remunerated that offer fundamental health services to beneficiaries of Medicare. For this group Payment expectation is to advance the quality of care for patients while eradicating barriers to thriving participation of physician. They ought to follow Medicare laws with this, consecutively to accomplish the medical beneficiaries expectation. It is essential for them In addition, to offer facilities of Medicare to the patients at decided prices with no any conflicts. It is as well presumed to non-physician and physicians practitioners that they construct of the majority of their knowledge and skills consecutively to offer patients health treatment (CMS. Gov, 2012). All hospital and physicians practitioners acquire a fixed sum for every patient and are accountable for making accessible all services for that patient above a assigned period.

DMEPOS is employed for paying back suppliers of prosthetics, durable medical equipment, orthotics and supplies to the patients. Value based purchasing of health care services are Payment expectations for this provider that can offer additional transparency on quality and cost to make certain Medicare beneficiaries optimal care. Providers In addition, have to be additional spotlight to supply to CMS performance data, which is probable to have an effect on potential reimbursements to provider. There are financial penalties for those providers In condition of any infringement of CMS’ standards,who don’t meet up these standards (Mayes & Berenson, 2006). It is as well anticipated from suppliers that they offer efficient supplies to the hospitals in considers ensuring the eminence of the patients health.

Implication of a Case Mix Involving IPPS, OPPS and DMEPOS for A Small Hospital

Implication of a case mix In a small hospital, concerning OPPS IPPS,and DMEPOS is to develop the hospital care quality and center on designing effectual improvement facilities of quality. Hospitals are a most important constituent of the delivery system of health care, which are required to implement and develop an important outcome on quality, costs and admission to care. Small hospitals can attain their payments in a appropriate way in the course of executing these methods. They might be capable to get diverse equipments and required resources at rational price all the way through suppliers (Chalfin & Rizzo, 2011).

It can facilitate them to offer healthcare services based on quality to the patients at a lower cost. They can obtain an appropriate amount for offering healthcare services to the outpatients and inpatients. It facilitates them to classify their services according the health regulations in an effectual way. It as well offers them equivalent opportunity to get growth since of security for payment of their services as indicated by fixed standards and sets.

Hospitals of Small specialty and centers in concern of this, are obtaining the latest technology and equipment consecutively to draw high-end customers from commercial hospitals. DMEPOS can aid them to obtain these services with easiness at low down cost. These hospitals Apart from this, are proficient to administer their cash flow competently regarding their inventories and services. A fixed and proper amount of payment to the small health care providers employees can stimulate them to offer quality services to the beneficiaries of medical effectively (CMS. Gov, 2012). Small hospitals can acquire bonus payments for offering health professional shortage care. Consequently, a small hospital can associate these payment methods suitably in its operations.

There possibly will be likelihood of risk to get lesser amount on the other hand, for their services since of the nature of illness of patients, high treatment cost involvement, or additional situational factors. It is since the fee is charged for the anticipated expenditure of caring for the patient. If the on the whole cost of care is additional than anticipated, the profit the hospital and doctor receive can be decreased. It can force growth of hospital in unconstructive manner. It relies on the equipped efficiency of the hospital that they can acquire additional profits by offering care at a lower-than-anticipated cost. Furthermore, there possibly will be a likelihood of less increase in standard payments for services of small hospital in novel reforms of these models of payment (Wachter, Goldman & Hollander, 2005).

Public programmes have absorbed huge amount of money for health improvement, social welfare, education, and justice. However, the result of the programmes are still unkown whether improve people’s lives or not and experts knowledge is not used in policy decisions (Oxman, et al. 2010). Gaps between research of effectiveness and policy implementation are also clearly seen (Brownson, Chriqui, Stamatakis 2009). These gaps occur because policy makers have different priorities. Black (cited in Wallace 2006) argued that ‘ideological blinders, economic pressures (both in governmental budgets and their own campaign coffers), electoral realities, bureaucratic inertia, and a host of other factors that can make good data irrelevant, influence policy maker in decisions making. Wallace (2006) also stated that political concerns lead to ‘immune to facts’ in policy makers. Brownson, Chriqui, Stamatakis (2009) stated that the process of making public policies can be complex and messy and the policies are not only ‘technically sound, but also politically and administratively feasible’.

The first step of health-policy making-process is problem identification and agenda setting. In this stage, public problems will be political agenda if the problems are converted into political issue (Palmer & Short 2000). Evidence-based public health enable to influence policy makers in public health decisions because evidence-based practice use a particular type of evidence and focus on clear reasoning in the process of appraising and evidence interpretation (Rychetnik et al 2004). Evidence-based practice rises evidence from research which encompass a wide variety of public health research. Rychetnik et al (2004) also mentioned several type of studies which used in evidence-based public health such as decriptive, taxonomic, analytic, interpretive, explanatory and evaluative. Prinja (2010) asserted that evidence and information contribute to policy making process through research and consultative process or published documents or reports. Moreover, Rychetnik et al., expanding on earlier Brownson’s argument (cited in Fielding & Briss 2006) argued that evidence-based public health decisions can be supported by three types of scientific evidence. Type 1 evidence is that ‘something should be done’ is determined by causes and magnitude of disease, severity and preventibility. Type 2 evidence shows that ‘which intervention or policies should be done’ may effective in specific intervention to promote health. Type 3 evidence describe ‘how something should be done’ that how and under what circumstances interventions were implemented and how they were received. Those type of evidence are useful in public health decision because they may improve the quality and availability of the evidence (Rychetnik et al 2004).

Evidence for evidence-based policy can be determined into two categories, quantitative evidence and qualitative evidence. Both of them are important for policy relevant evidence (Brownson, Chriqui, Stamatakis 2009). Quantitative evidence for policy making, which provides data in numerical quantities, is collected from many sources, such as scientific information in peer-reviewed journals, public health surveillance systems, or evaluations of individual programs or policies (Brownson, Chriqui, Stamatakis 2009). Quantitative evidence, for example prevalence, incidence and cumulative incidence, may express the magnitude and severity of public health problems through frequency or proportion and rates measurments (Rychetnik et al 2004) but this type of evidence presents little understanding of why some relationships exists (Brownson, Fielding, Maylahn 2009). On the other hand, qualitative evidence or non numerical data may be taken from methods such as participants, group interviews, or focus group. Qualitative evidence may influence policy deliberations, setting priorities and proposing policy solutions by telling persuasive stories (Brownson, Chriqui, Stamatakis 2009). However, according to Rychetnik et al (2004) one of qualitative evidence that is expert opinion is positioned at the lowest level in ‘levels of evidence’ hierarchies and identified as the least reliable form of evidence on the effectiveness of interventions. Nevertheless, the combination between two type of evidence leads to a stronger persuasive impact in policy making process than using only one type of evidence (Brownson, Chriqui, Stamatakis 2009).

Evidence-based practitioner shoul build strong evidence to convince public health policy makers. Brownson, Fielding, Maylahn (2009) proposed three concept to achieve a more evidence-based approach to public health policy. First, scientific information on the programs and policies is required to make more effective in health promotion. Second, combination between information on evidence-based interventions from the peer-reviewed literature and the realities of a specific real-world environment is required to translate science to practice. Third, the prove of effectiveness of interventions must be informed in wide-scale consistently at state and local levels. Brownson, Chriqui, Stamatakis (2009) also recommended that evidence should show public health burden, identify priority of an issue over many others, present relevance at the local level, show benefits and harm from intervention, explain the issue by how many peoples’ lives are affected, and estimate the cost of intervention.

In the article example (Lee&Park 2010) which is about HBV immunisation policy in the US, it is clear that the policy was based on convincing evidence, in this case was epidemiological data. According to these data which taken from different sources, such as American Cancer Society (ACS) and Centers for Disease Control and Prevention (CDC) showed that chronic HBV infection is responsible for the majority HBV-related morbidity and mortality. Some quantitative evidence was provided such as 1.4-2 million (0.4%) people had chronic HBV invection. The policy also relied on other successful policy intervention which might produce similar result if the HBV immunisation was implemented in population. The CDC reported that the incidence of acute HBV infection decreased 80% which was largely due to universal vacination programs for children. Characteristic of the HBV infected population was also identified such as 2.7-11% among injecting drug users, 1.1%-2.3% in homosexual, 1.5% among pregnant women. The data convincingly showed that there was corelation between HBV and HIV infection. The natural history of the disease also clearly identified led to assumption that HBV vaccination was important for community.

The next stage of the health policy making process is policy formation. In this stage, policies are formulated or changed to a new policies. The formation stage, which is also referred to policy design or development, specific attention will be provided when policies are examined relating to the issues (Palmer & Short 2000). According to Brownson, Chriqui, Stamatakis (2009) that formulation of health policies in public health practice is complex and depends on ‘variety of scientific, economic, social, and political forces’. However, huge number of people want policy and practice to be relied on the best scientific evidence. Maximising policy effectiveness and efficiency depend on evidence base (Wallace 2006). On the other hand, policy makers require a reasonable and justifiable policy solution. Hence, health public practice should develop a convincing message based on research evidence to explain policy makers how the intervention may solve the public health problems (Goldstein 2009).

To develop policy formulation, research evidence should be reviewed and evaluated before being proposed to policy makers. The aim of the research evaluation is to determine the degree of credibility (validity and reliability) of information and usefulness (relevance and generality) in a different context (Rychetnik et al 2004). Systematic Reviews and Critical Appraisal are required in evidence review processes as a guide to understand the research methods (Rychetnik et al 2004). Systematic review implementation leads to practitioners and policymaker to understand all of relevant information, how the evidence was collected and assembled, and how the conclusions and recommendations relate to the information (Fielding & Briss 2006). Then, the result of evidence review will be integrated with social consideration which obtained from practitioners, policy makers and consumer to produce evidence based recommendations (Rychetnik et al 2004). Through systematic appraisal of research, public health practice enable to demonstrate the effectiveness of interventions based on available evidence (McMichael, Waters, Volmink 2005). In other words, the evidence-based recommendations are based on the nature and strenghth of the evidence. Furthermore, the recommendations should be evaluated with respect to the balance of advantages and disadvantages (Rychetnik et al 2004) or the benefits of interventions must be weighed against the costs (Cookson 2005). However, systematic review tend to have narrow and regressive interpretation of the nature of evidence which leads to exclude a wide range of research-based information and professional experience that may be important to policy development (Nutbeam 2001). Therefore, combination between systematic review and narrative review may bring convincing evidence rather than systematic review alone.

Iit is obvious in the article example that the recommendation of HBV immunisation in the US was based on previous research evidence. For example, in June 1982, the CDC Advisory Committee on Immunization Practices (ACIP) released the first inactivated HBV vaccines for individuals at a high risk for HBV infection (Lee & Park 2010). The reason why the first HBV vaccine recommendation only for high risk community because epidemiological data showed that the distribution of hepatitis B cases was not uniform across populations. Large and urban immigrant-dense areas had higher prevalence of chronic HBV infection. The CDC concluded that high morbidity and mortality from chronic HBV infection in the US would be unavoidable if those high risk populations were not interfered by immunisation programs. In 1989, the recommendation of HBV vaccine were expanded to health care workers after obtaining surveillance data of the HBV infection prevalence and input from health professionals through public and private requests (Lee & Park 2010).

The third stage of the health-policy-making process is adoption. In this stage the policy formulation is enacted and brought into force, such as state legislation (Palmer & Short 2000). Public health practice requires advocacy and lobbying to influence policies, change practice and achieve public health action. Nevertheless, the process of achieving influence is often difficult rather than appraising evidence and formulating recommendations because the process requires more complex social and political negotiations and often detrmined by social, political and commercial factors (Rychetnik et al 2004). Brownson, Fielding Maylahn also argued that translation from research to community applications may require many years. Moreover, evidence-based policy and practice inform the policy maker through evidence consideration whereas policy making will depend on prevailing values and priorities. Therefore, it is challenging for public health practice to close the gap between research and practice (Rychetnik et al 2004).

According to Nutbeam (2001), policy development is a political process rather than scientific-based process. Hence, evidence-based public health requires a strong public health voice and advocacy supports within political system in which may be obtained from public and mass media. Another support may come from public servants who have skill in critical appraisal of evidence to use research evidence in the policy development.

The article example of HBV immunisation programs in the US shows that several groups influenced the US government decisions in HBV immunisation programs. From inside of the government, such as National Health and Nutrition Examination Surveys (NHANES), American Cancer Society (ACS), Centers for Disease Control and Prevention (CDC), the CDC Advisory Committe on Immunization Practices (ACIP), supported the HBV immunisation proposals by providing convincing data to the government. WHO, as an outside of government institution, might influence the US government to consider the spread of the disease by presenting international data of HBV prevalence. Health professional also forced the government to expand the HBV immunisation program not only for infant and high risk groups but also children and all adolescents.

The next step of the health-policy-making process is implementation of the policy. In this stage, policy document is changed into reality (Palmer & Short 2000). Evidence-based public health is challenged to translate research evidence to practice among organisations, practitioner groups, or general public. Evidence-based practitioners enable to identify the most important component of an intervention to bring effective actions to the community (Brownson, Fielding, Maylahn 2009). Interventions in public health should focus on the benefit of communities or populations rather than individuals, although many intervention bring secondary advantages to individuals (Frommer & Rychetnik 2003). Rychetnik et al (2004) stated that public health interventions include ‘policies of governments and non-government organisations; laws and regulations; organisational development; community development; education of individuals and communities; engineering and technical developments; service development and delivery; and communication, including social marketing.’ In the example article, the recommendation of HBV immunisation in the US was implemented by ACIP whereas the federal provided vaccine for health care workers and children.

The final step of the health-policy-making process is evaluation which include monitoring, analysis, criticism and assessment of existing or proposed policies. The result of the evaluation is used as data sources in agenda setting and policy formation. The goal of the evaluation is to bring policy implementation in effective and efficient ways (Palmer & Short 2000). Evidence-based policy requires documenting the effect of implemented policies to undertand the impact of interventions on community and individual which may change people’s behaviour (Brownson, Chriqui, Stamatakis 2009). McMichael, Waters, Volmink (2005) believed that evidence around intervention effectiveness plays important role to address health priorities for the next policies particularly in developing countries or resource-poor areas. Evidence-based practice use evidence as valuable sources in evaluation to maximise the benefits and limits the harms of public health policy and practice. The evidence enable to inform evaluation planning to improve the quality and relevancew of new research (Rychetnik 2004). Evaluation may also be useful to explain failures in policy implementation, unintended side effects, and monitoring the policy application towards achieving the policy goal (Wallace 2006).

Evidence-based practice also evaluate public health policy in economic perspective because it can provide information about the association between economic investment on public health programs and policies and health impacts, such the prevelance of prevented disease or years of life saved. This method, named ‘cost-effectiveness analysis (CEA), can explain the relative value of alternative interventions on public health programs and policies (Brownson, Fielding, Maylahn 2009).

Another important evaluation of evidence-based policy is ‘health impact assessment (HIA)’ that enables to estimate the possibility impacts of policies or interventions in out side of health perspective, such as ‘agriculture, transportation, and economic development, on population health’. HIA also analyse the envolvement of stakeholders in the policy interventions. Evidence-based practitioner use this method because there is much evidence that population health and health disparities are influenced by many determinants such as social and physical environments (Brownson, Fielding, Maylahn 2009). Therefore, it is essential to evaluate health policy implementation in different ways.

In the article of HBV immunisation in the US, CDC always conducted evaluation and found that the incidence of HBV infection had declined after releasing recommendation of HBV vaccination. The CDC also identified that education of health care providers was clearly important to make the program successful (Lee & Park 2010). The result of CDC’s evaluation, which formulated into epidemiological data, can help to build new strategies to eliminate HBV infection, such as expansion of HBV immunisation recommendation for other groups and routine screening for HBV positive persons.

In conclusion, evidence-based public health is important in public health policy making because evidence-based approach enables to provide policy suggestion based on convincing evidence generated from rigorous research. Since many determinants influence public health, analysis of quality and quantity evidence is essential to convince policy makers in identification of policy priorities and the best public health interventions. This essay also suggest that faster and better scientific information may influence public assumption in public health which leads to support evidence-based policy making in public health interventions.

A Critical Analysis of the Impact of a Current Healthcare Policy on a Group of Clients/Users

Introduction

In considering the impact of a current healthcare policy on a group of clients/users, the United Kingdom’s National Service Framework (NSF) for Coronary Heart Disease (CHD), offers a classical example for examination of the foregoing. In particular women as a subject group provides an interesting basis by which to analyze user experience, quality of service as well as fairness/justice. Globally, 10 million of the 27 million deaths of women are as a result of Coronary Heart Disease with one third of the foregoing total, 10 million, occurring in developed countries (Bonita, 2000). And while Coronary Heart Disease is known to be a leading cause of death among men, it is also ‘the’ leading cause of death for European women (Mcguire, 2000).

In the United Kingdom Coronary Heart Disease is the number one cause of premature death among both men and women and shows a marked skew with regard to social classification. The death rate attributed to Coronary Heart Disease among males from manual worker classifications is forty percent (40%) higher than for those from non-manual segments (National Health Service, 2005). And while coronary heart disease is four to five times more prevalent in males than females for the age groups under 65, the gap narrows considerably after this age. And this particular age occurrence discrepancy is one of the critical sources of misunderstanding, focus, appropriation, resources and service as the medical profession, insurance industry, and public in general tend to view coronary heart disease as primarily affecting males.

And while the preceding is true, in terms of the age groups under 65 (Mcguire, 2000), the fact is that women live longer than men thus as the incidence of coronary heart disease and the associated care is spread out over a longer period as well as at a more advanced age. The circumstantial inequities that the preceding give or gave rise to shall be the examination points addressed herein in terms of considerations with respect to the impact of current health care policy in terms of analyzing user experience, quality of service as well as fairness/justice, with particular emphasis on women. In order to accomplish this broad and sweeping analysis, an understanding of the disease, and allied points will need to be established to provide the foundation from which to reach a determination as to the three subject areas indicated.

Coronary Heart Disease

A distressing fact that has been uncovered as a result of a study by the World Health Organization (1997) is that coronary heart disease is rising in developed countries. The World Health Organization (1997) attributed the foregoing to the increased overall age of relative populations as well as the onset of increasingly poor health behavioral patterns. Dr. Abby King (2000) indicated that of the forty plus studies that have been undertaken on a global basis concerning various aspects of coronary heart disease it was found that there was a correlation between physical activity and premature mortality. Dr. King (2000) stated that said study consisted of a field that was comprised thirty-three percent (33%) of woman. Said studies have shown that inactivity in women revealed on average a two-fold risk or the development of cardiovascular problems as compared to their peers who were or are more active. It was also uncovered through these studies that the economic costs in terms of not only the direct treatment but also, those associated with the relative inactivity of patients amounted to substantial outlays.

The increase in coronary heart disease has also been attributed to the elevated cholesterol levels that are prevalent in Western countries. Dr. Anita Schmeiser-Rieder (2000) has found that approximately forty percent (40%) of women above the age of fifty-five (55) have serum cholesterol levels that are elevated. Dr. Schmeiser-Rieder (2000) indicated that the preceding condition peaked in women between the ages of sixty-five (65) and seventy-four (74) and that fully sixty-one percent (61%) of those researched had hypercholesterlomia. The disturbing finding that was uncovered in studies by the World Health Organization (1997) is that coronary heart disease and stroke will continue to be the leading cause of death among both men and women over the next twenty years, increasing to the second and third causes of death from its present ranking of fifth and sixth by 2020. The World Health Organization (1997) cites that the major causes of both stroke and coronary heart disease are:

1. smoking
2. high blood pressure
3. cholesterol
4. body mass index

And while studies conducted by the WHO (World Health Organization) MONICA (2000) Project shows a decline in smoking trends, a rise in smoking among young woman as well as adult women has been noted in:

1. Russia (Novosirbirsk)
2. Germany (Augsberg)
3. Belgium
4. Spain (Catalonia), and
5. Poland,

where the recorded increase has been as much as ten percent (10%). As the number one cause of stroke and coronary heart disease, the rise in female smoking is alarming, made even more dramatic by the fact that females historically smoke less than their male counterparts across all age groups.

The findings of varied studies has conclusively indicated that the incidence of stroke and coronary heart disease increases with respect to those individuals whose lifestyles expose them to the additional risks that are associated with the two conditions. The World Health Organization (1997) has determined that changes in lifestyle as well as personal habits effectively reduce the risk associated with contracting these diseases. The foregoing is of particular significance to women, as the emphasis on efforts to change lifestyles and habits has been primarily focused upon the male segment of the population whose rate of incidence with respect to stroke and coronary heart disease has been higher. The corresponding increase in poor lifestyle and smoking habits among females in the countries indicated reveals that such an approach has not only been short sighted, by failed to take into account the longer life cycle of females thus increasing the onset of coronary heart disease and stroke in later years as a result of higher age where female incidents almost match those of males. The foregoing factors are important base line informational points to develop an understanding of the varied inputs and considerations that comprise the complex variables inherent in equating the range of aspects to be addressed in analyzing user experience, quality of service as well as fairness/justice.

The preceding points out the need to utilize what is termed as a ‘high reach’ strategy (Bonita, 2000) that reaches both the male and female segments of the population in terms of alerting them to the relative risks, preventive measures, lifestyle augmentation, and allied aspects known to have demonstrated a decrease in stroke and coronary heart disease when utilized in a proper manner. Such an initiative when conducted on a population-wide (high reach) basis helps to alert individuals to the relative dangers and causes of high blood pressure, negative connotations associated with smoking and lack of physical activity, the three highest contributors to the condition. Alerting populations to reduce the intake of salt, alcohol, saturated fat as well as the benefits of increased physical activity would reduce the relative levels of blood pressure and thus the corresponding reduction in medical costs assumed not only by individuals, but society at large.

By combining the aforementioned with what is termed a high-risk strategy (Bonita, 2000), in efforts that are directed at the identification of women in this category, along with offering treatment to the women within this group whose risk factor(s) are above the norm in terms of the potential for a coronary disease event can generate significant improvements in long term results. The utilization of educational media efforts in combination with treatment availability is a preventive measure that recognizes the need to head off the high costs of medical facilities, and allied costs to the government via preventive measures. As the subject country being utilized for this examination is the United Kingdom, the foregoing is applicable. The same holds true for countries where insurance coverage’s are used to supplement individual treatment costs, along with the calculated losses to society with respect to the associated costs that accompany coronary heart disease events. In the case of the United Kingdom, with the taxpayers bearing the cost of medical care under the country’s socialized medical program, the realities of the treatment and after care costs of coronary heart disease are a real expenditure concern. In particular the recognition of the heretofore hidden costs in this area as a result of the scant attention paid to the real costs associated with women, the foregoing represents an opportunity to make an significant impact in cost controls, and more importantly the health of an entire segment of the population.

And while women as a group have an overall lower absolute risk factor than men, in terms of the potential for women to have a coronary heart disease event, this differs depending upon the age group category. As indicated by Dr. Anita Schmeiser-Rieder (2000), forty percent (40%) of females who are above the age of fifty-five (55) years of age have elevated cholesterol levels and this condition actually peaked for the age group between sixty-five (65) through seventy-four (74) where sixty-one percent (61%) if the research group had this condition. The aforementioned supports the view that strategies aimed at high-reach in conjunction with high-risk represent a necessary approach to bring the incident of the risk of conditions that contribute to increased onset of coronary heart disease under preventive type control program measures. The preceding analysis takes on additional importance when one considers that estimates regarding the probability factors concerning woman above the age of fifty, as well as the increased incidence of smoking in young women and the need for education regarding lifestyle and health preventive measures to reduce probabilities later in life represent contributory factors that can be somewhat controlled.

Prevention approaches to call attention to the risks of smoking, high cholesterol diets, and the lack of proper exercise represent measures that have shown to produce a reduction in coronary heart disease numbers over specified periods. Classified as lifestyle and personal habit changes, the reduction or elimination of known contributors that increase the potential of CHD (Coronary Heart Disease) has yielded positive results. It is important to note that in the instance of women, the absolute risk of coronary heart disease remains at relatively low levels until they reach their seventies and eighties, however, the reduction in conditions attributable to said condition in earlier years has been shown as a positive preventive measure (Bonita, 2000). As pointed out by Dr. Bonita (2000) the primary contributors to the coronary heart disease epidemic are:

1. the onset of population aging,
2. rapid urbanization,
3. changes in nutrition,
4. and smoking patterns,
5. along with reduced physical activity

Any program that purports to achieve relative success will need to incorporate the preceding along with post CHD treatment and follow up measures as well.

Cardiac Rehabilitation Services

The United Kingdom’s National Service Framework for coronary heart disease is under a revision program which the Secretary of State for Health, Alan Milburn, states the primary focus is the “saving of lives” by the reduction of “…the death rate from heart disease and … stroke …” by “… two fifths…” for individuals under the age of seventy-five (75) by the year 2010 (National Health Service, 2005). The preceding will be accomplished through the following measures (National Health Service, 2005):

1. the development of a new vision concerning coronary heart disease,
2. the establishment of a government-wide agenda,
3. further development and improvement of the National Service Framework for CHD
4. providing effective services to all individuals in the United Kingdom that can benefit

The preceding directly address the three points user experience, quality of service as well as fairness/justice, along with other concerns. Through the modernization of the National Health Service’s treatment, care and public awareness approaches the objective is to improve the foregoing across age, gender, cultural, race, disability, locale, and religious lines, as well as being “… responsive…” to the needs of individuals (National Health Service, 2005). Some examples of the need to revise and modernize the system is evidenced by the following facts (National Health Service, 2005):

1. The wives of workers in the manual class are at twice the risk factor in developing coronary heart disease and stroke than the wives of workers whose jobs are of a non-manual classification.
2. The morbidity rate among the manual class group is also higher than in the non-manual group designation, and this group also reflects increased incidences of angina, heart attack and stroke.
3. The disparity in come between poor and rich has widened over the previous twenty years creating a further gap in health survivability as the more affluent segment of society has been able to afford private medical care as well as increased nutritional guidance and lifestyles that promote as well as can afford more physical activity.
4. Historical records have shown that death rates are higher in the northern locales of the United Kingdom, representing almost three times the rate for individuals over the age of sixty-five (65) in cities such as Manchester than for Richmond or Kingston.

The preceding further illustrates the inequities in terms of user experience, quality of service as well as fairness/justice. The new National Health Service program sets forth that it seeks significant improvement in the following areas, all of which will enhance the indicated three examination points (National Health Service, 2005):

1. Standards

The National Health Service is aiming to establish a ‘standard of care’ that includes an invitation for individuals whom have been admitted to a hospital for coronary heart disease to participate in programs consisting of cardiac rehabilitation and secondary prevention. The preceding is aimed at reducing future risk of cardiac problems and to help them to return to a normal life.

2. Rationale

Admission to a hospital represents individuals whose condition is severe. This signals that their lifestyles to this point have consisted of various high-risk exposures, such as smoking, high cholesterol diets, and other conditions that if changed can lead to significant improvements in rehabilitation. To accomplish the preceding said patients must be analyzed and then coached concerning the lifestyle changes and modifications needed to aid them in returning to a healthier manner of living to reduce future incidents and effect recovery.

The World Health Organization (1997) defines cardiac rehabilitation as consisting of a “… sum of activities…’ that are necessary to effectively influence and identify the underlying causes of the disease to individuals through their own actions can help to effect their recovery. Through increasing the quality of service that offers comprehensive assistance that is custom tailored to their individual circumstances. The aforementioned provides the foundation to enable counseling and aiding individuals in understanding ways in which to change their lifestyle habits, as well as better understand their illness and effect the transition back to as normal and full a life as possible. The aim is to make rehabilitation “… an integral…” aspect of the active as well as secondary preventive care regime. By establishing rehabilitative procedures immediately after discharge and the establishment of a long term formal program that focuses on returning the individual to the best health possible the government estimates a net gain of approximately £15,700 per instance over a three year period.

In the case of women, they represent one third of the individuals with coronary heart disease, yet just fifteen percent (15%) of their total utilize rehabilitative services (Green, 2000). The attention to improving the quality of service the initiative also aims at removing the disproportionate care provided that does not adequately cover rural parts of the country.

3. Effective Interventions

Participation barriers can be a result of varied causes, such as the lack of proper motivation to difficulties in attending rehabilitative sessions. In the case of women it was discovered that there was a lack of appropriate provisions, which the current modernization program seeks to correct to provide fairness as well as justice throughout the system. The foregoing also includes minority groups as well.

In terms of improving the quality of service the new program consists of Four Phases (National Health Service, 2005):

1. Phase 1

This Phase comes into effect before the discharge of an individual from the hospital, and is to be offered as a part of the acute care plan. It includes the following elements:

1. review and assessment of psychological, physical and social needs for rehabilitation
2. development of a written plan to meet identified needs
3. counseling and advice on detrimental lifestyle aspects such as smoking, cholesterol, exercise, alcohol, etc.
4. prescribing of medication and education on its proper use
5. information concerning cardiac support groups

2. Phase 2

As part of the early post discharge period individuals will receive the following:

1. a comprehensive assessment of their cardiac risk which will include their psychological, social and physical needs for rehabilitation and the plan to achieve these ends
2. lifestyle advice from trained therapists
3. resuscitation training for members of the affected individual’s family

3. Phase 3

This segment of the four phase plan comes into utilization four weeks after the cardiac events initial phase and consists of a series of structured exercise sessions along with ongoing access to support and advice from people trained to provide them with psychological interventions, promotion of health, exercise and associated advice.

4. Phase 4

The final aspect of the four-tiered program that consists of:

1. long term primary care follow up
2. local cardiac support group involvement
3. referrals to identified support services as initiated in Phase 1

The modernized and revised National Service Framework is a highly structured series of interlocking programs that are designed to alleviate as well as eliminate the missing components of the prior coronary heart disease plan which evolved over decades, into a comprehensive system that has been revised based upon today’s understandings. It aims to achieve coverage of all groups and categories of individuals through education, assessment, contact and a cardiac event that provides qualified, balanced and comprehensive coverage and care whose major components are as follows (National Health Service, 2005):

1. The identification of individuals that are likely to benefit from a structured cardiac rehabilitation program before discharge from a hospital,
2. the assessment of individual risks as well as needs, along with the development of a structured plan to achieve successful cardiac rehabilitation,
3. the documentation and provision to deliver the proper treatment as well as advice
4. the integration of required and agreed upon care that is weaved into the patients local network of primary and secondary treatment, preventive and related care,

The experiences gained under the prior system, as well as all of the inequities have been addressed under the National Health Service’s new modernization plan that provides and sets relevant standards with effective interventions under structured service models that define and addresses the immediate priorities of each individual patient.

Conclusion

The scope and complexity that comprises the field of coronary heart disease makes this a subject whereby the factors inherent in its causes as well as manifestations entail equating aspects of human behavior across the entire spectrum of demographic, cultural, social and psychological realms to codify commonalities and possible associative elements that tend to explain the reasons and causes for the world’s most pervasive killer. As the field of examination represents healthcare, the core of understanding evolves an evolutionary process based upon decades of exposure, analysis and experience gained within the United Kingdom as well as on the world stage. The National Health Service has recognized the significance of the preceding and has crafted a program that seeks to build upon the known(s) within the subject field in a program that is flexible enough to improve upon itself to incorporate those aspects, considerations and new understandings that will inevitably will occur with new discoveries and as a result of the comprehensive data based system that will permit further modification and evolution.

Thus, user experience, along with quality of service, and fairness/justice with respect to the new National Service Framework has been addressed to exclude the existing inequities and shortcomings, yet understands that it is an evolutionary process that will continue to modify and improve upon itself using past experiences along with the new framework as the foundation from which to accomplish this. The Secretary of State for Health, Alan Milburn (2000) firmly establishes the preceding in referring to the “… National Service Framework for Coronary Heart Disease…” as the nation’s “… blueprint for tackling heart disease…” Mr. Milburn’s statement goes on to add that the new ‘Framework” is based upon the understanding and recognition of past inequities and shortcomings which this new initiative addresses, along with the understanding of “… the importance of modern prevention and primary care as well as the contribution of the more specialized services.” The fact that the National Health Service has undertaken this modernization program clearly indicates that it understood and recognized the prior user experience, service quality and fairness/justice components needed considerable improvement. Regardless of how deeply one would delve into the inequities of the past, there could be an argument made for areas and points that were not covered, as the list is extensive. And no matter how comprehensive the present system is, it is an evolutionary framework that will have its own initial and ongoing issues and inequities to face as well as resolve. The difference between the two systems is that the present one was developed with the understanding that it will continue to improve upon itself as it learns from its base of past expertise.

In the complex and ever changing world of medical care, the preceding is all that can be asked from its healthcare agency, with the understanding that no matter how comprehensive the plan, modern changes and developments can and will render segments as obsolete, thus the need for a built in foundation that incorporates this as its framework. The very fact that past user experience, service quality and fairness/justice had shortcomings, along with other points is the reason behind the new Framework initiative, and this in itself is a progressive view that is responsive to the needs of the populace, which is the rationale for the government’s existence.

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