Gouvernance et éthique cliniques : deux outils complémentaires pour une meilleure coordination des soins et des traitements

“Governance”, “ethics” and “clinical” three words for a same goal: protect the human health. “Corporate governance” must be associated with the new theory of the firm, for which the theory of asymmetric information provides the foundations. Indeed problems of information represent a fundamental change in the prevailing paradigm within economics; they are central to understanding political economy. “Clinical governance”, promoted by the UK government, constitutes an overarching mechanism designed to improve clinical quality in the National Health Service. To the medical establishment, it is a means to improve the quality of medical practice through clinical guidelines. To make a significant impact on the improvement of healthcare quality, the principles of clinical governance must produce synergy by involving professionals in the modernization of the organization. To obtain excellence in heath care, collective actions and shared decision making were essential. In this context, Clinical ethics consultations could provide a structured approach to decision making that could assist heath professional to resolve conflicts or ethical problems that arise in the care of particular patients.     

Community‐oriented primary care: a multidisciplinary community‐oriented approach to primary care?

Developing more of a local public health focus, and involving local communities in Great Britain in health care decision‐making, are key aspects of the radically changing face of primary care. Community‐oriented primary care (COPC) is an international model for innovative primary health care delivery historically applied in developing or deprived communities, but increasingly seen as having broader relevance for a wider range of primary care settings. COPC has a long history of development in deprived communities, it is still however seen as innovative. It fits the current requirements of clinical governance and the ‘Modern and Dependable NHS’, but does its long history also provide information about it's pitfalls? COPC is promoted as an approach that is applicable to community mental health problems, community psychologists can provide the expertise to facilitate addressing community mental health in COPC programmes. This paper describes the COPC model and highlights the relevance of the COPC philosophy and the problems of its implementation for community psychologists in primary care. Copyright © 2001 John Wiley & Sons, Ltd.     

A new role for psychologists--hospital ethics committees

Over the past decade psychology has begun to appreciate that it represents more than "merely mental health care" and has become increasingly involved in the generic health care arena. The participation of psychologists in Hospital Ethics Committees (HECs) is presented as a professional activity for which psychologists are particularly well suited. The clinical mission of HECs, the historical importance of ethical considerations to psychology, and the field's specific training and psycho-social expertise suggest valuable contributions that psychologists can make in this particular area. Further, as psychology actively increases its participation in HECs, other professional disciplines outside of the mental health field will systematically have the opportunity to become more familiar with psychology and its clinical and research expertise.     

The Unmet Educational Agenda in Integrated Care

One of the reasons integrated care has not become a dominant service delivery model is the unmet training agenda. This article argues that the typical mental health professional is not trained to adequately address the challenges of integrated care. To insure competency both a macro and clinical training agenda are needed. At the macro-level, mental health professionals need to understand healthcare economics and basic business principles as any integrated care service delivery system is embedded and driven by economic forces. Integrated care practitioners also need some basic business skills to understand these forces and to create and manage a financially viable system, given the future flux of the system. Traditional mental health professionals also do not have the clinical skills to implement integrated care. Integrated care is not simply placing a traditionally trained mental health professional and letting them practice specialty mental health in a medical setting. Thus, the special skills needed in integrated care are enumerated and discussed. Finally, a new degree program is described as it is time given the huge need and advantages of integrated care to develop specialty training in integrated care.     

Implementing a Primary Mental Health Service for Children: Administrator and Provider Perspectives

The Child Mental Health Service (CMHS) is an Australian primary care program introduced in July 2010 to provide mental healthcare to children who have, or are at risk of, developing psychological disorders. The Australian Government provided supports (e.g., training for mental health professionals), resources (e.g., funding for positions devoted to fostering inter-agency linkages or partnerships) and various flexibilities in service delivery. This study aimed to explore the processes used in the implementation of the CMHS in order to achieve its objectives of delivering a high quality standard of service, and forging linkages and support networks with other relevant health and non-health agencies. Structured interviews were conducted with 20 program administrators, six referring professionals and eight mental health professionals. Interviews were recorded, transcribed and analysed for themes using NVivo. The CMHS appears to have made good progress towards achieving its objectives by implementing processes that facilitated the delivery of a high quality service (e.g., engaging appropriately qualified, and encouraging additional training and clinical support for, mental health professionals; employing quality assurance mechanisms and clinical governance arrangements) and establishment of inter-agency linkages (e.g., devoting a professional role—Coordination and Liaison—to this purpose). Provider perspectives suggest that the CMHS has had a positive impact on children and their families. Comparable countries implementing primary mental health programs for children may benefit from considering similar additional supports (e.g., training for mental health professionals), resources (e.g., funding positions devoted to fostering service inter-agency linkages) and service delivery flexibilities as those available in the CMHS.     

The Future of Psychology in Family Medicine

Psychology has been integral to the field of family medicine since its inception as a medical specialty in the 1960s. Psychologists and other behavioral scientists contribute to family medicine in teaching clinical skills, in defining research questions, in developing research methodology, and in creating integrated physical/mental health care delivery systems. Future developments in the field of psychology in family medicine are likely to emphasize development and evaluation of screening measures which identify mental health problems in primary care, development of early intervention for those mental health problems, and more precise measurement of process and quality of care and health outcomes. Psychologists have an important role to fulfill in educating physicians on alternatives to pharmacologic and medical interventions for common presenting problems in primary care. However, current economic forces shaping the practice of medicine may work against further enhancing the efficacy of the physician in dealing with psychosocial issues. The future role of psychology in family medicine is not yet delineated, and while the move toward parity of reimbursement for mental and physical health care delivery may enhance this collaboration, there is a need to continue to evaluate how the psychological well-being of patients is influenced in the evolution of new models of care delivery.     

The Church as an Agent of Help in the Battle Against Late Life Depression

Late life depression has become recognized as a serious mental health problem. Almost 1 in 6 elderly suffer (often in silence) with late life depression. New care delivery agents need to be uncovered and mobilized. Because older Americans' religious habits positively impact their sense of well-being and physical health, the church becomes an ideal medium to offer educational programming focused onprevention and early intervention. This article presents a proposal for how the church could become an agent of help to depressed elderly and their families.     

Gay,Lesbian, and Bisexual Adolescents: A Critical Challenge to Counselors

Meeting the health care needs of gay, lesbian, and bisexual teenagers has become a public health imperative, and mental health professionals should be prepared for the challenge. The stigma of homosexuality often gives rise to psychosocial problems for adolescents, who are in the process of sexual identity development. The stigma also may complicate delivery of appropriate, ethical, and sound mental health treatment. Suggestions are offered to support healthy development, to assist recovery from stigma, and to avert the disastrous consequences of suicide and AIDS.     

Schools as Health Service Delivery Sites: Current Status and Future Directions

Summary

The health of our nation is inextricably linked with the health of our children. While families and professionals alike have recognized this truth for decades, current social reform movements in education and health services have provided an unprecedented opportunity for schools to become equal partners in addressing the needs of children, families, and communities in a wholistic, boundary-free, and collaborative manner. Since schools are the one social institution with which every child has contact, they offer a natural environment for assessment, services, and follow-up to promote the convergent education and health agendas articulated in Goals 2000 and Healthy People 2000. This article examines the components of education and health care reform with particular attention to a recon-ceptualization of health care services in schools. Within this framework, special services professionals are highlighted as leaders in service coordination and delivery for students, staff, and the community at large.     

Contemporary Psychotherapy and Cultural Adaptations

As our understanding of the human mind, idioms of human distress and mental health has improved, it has become apparent that culture has an impact on all aspects of our lives, including mental illness. Systems of care across the globe need to adapt and adjust delivery of care in order to accommodate the impact of globalisation and therefore be able to deliver person-centred care. A key aspect of delivering personalised care is the development and delivery of culturally adapted interventions that benefit cultural minority groups in developed countries and the majority cultural groups in developing countries. The journey of acknowledging the need for culturally relevant services has begun but we are a long way from delivering the personalised care that people deserve. This paper makes a case for action in this important area.     

Psychological‐Mindedness and American Indian Historical Trauma: Interviews with Service Providers from a Great Plains Reservation

The concept of historical trauma (HT) was developed to explain clinical distress among descendants of Jewish Holocaust survivors and has since been ascribed new meanings to account for suffering in diverse contexts. In American Indian (AI) communities, the concept of AI HT has been tailored and promoted as an expanded notion of trauma that combines psychological injury with historical oppression to causally connect experiences with Euro‐American colonization to contemporary behavioral health disparities. However, rather than clinical formulations emphasizing psychological injury, a focused content analysis of interviews with 23 AI health and human service providers (SPs) on a Great Plains reservation demonstrated strong preferences for socio‐cultural accounts of oppression. Reflective of a local worldview associated with minimal psychological‐mindedness, this study illustrates how cultural assumptions embedded within health discourses like HT can conflict with diverse cultural forms and promote “psychologized” perspectives on suffering that may limit attention to social, economic, and political determinants of health.     

Pediatric Psychology: Child Psychological Health in the Next Century

The future of pediatric psychology is reviewed and placed in brief historical context in relation to children's psychological health care. Contemporary trends affecting the delivery of psychological services, research, and clinical training are highlighted, with suggestions for future development. Pediatric psychology is a child-based, developmentally-focused multidisciplinary practice directed toward psychosocial and neuropsychological issues of health and illness in children and youth. Pediatric psychologists need to develop strong professional identities as health care psychologists combined with a collegial and collaborative arrangement with physicians to ensure the future growth and development of pediatric psychology in the next century as a major vehicle to promote children's health care.     

The physician and social renewal: Julius B. Richmond as role model

We live in an age of “high tech” medicine which affects both health care recipients and physicians who are taught its many wonders and uses. It is easy in this atmosphere of specialization for clinicians, professors and medical students to become isolated and to ignore social issues which affect health care in its broadest sense. Individuals who are committed to the “common good” are the ones historically who have been effective change agents. It would be tragic simply to stand back and allow the cynical and greedy to dominate any profession which deals with the poor, the uninsured and the homeless. It is imperative for physicians to take a broad view of today's problems in health care delivery systems, for they can have an enormous impact on the kind of world our children will inherit. It is essential for physicians to become involved in social concerns, and in improving health care delivery, at all levels in their practice. Given their power and prestige, it is crucial for physicians and aspiring physicians to have positive role models. Dr. Julius B. Richmond provides an admirable example of a physician who cares about his profession, his patients and his nation. Through his research, his public service and his teaching, Dr. Richmond has demonstrated the difference a single individual can make in improving the quality of life for all Americans.     

The Future of Psychology in Departments of Psychiatry

Health care reform has put increasing pressure on faculty of medical schools to become self-supporting. Opportunities for clinical revenue will decrease, but psychologists who are able to generate research funding will become increasingly competitive, albeit as mercenaries, i.e., capable of paying their own way plus generating a profit to support departmental operations and educational programs. Changes in the health care system signal an end to psychiatry's paternalistic relationship to psychology and present opportunities for psychology proactively to influence its future role in health care. Research, political action, and revised scientific mission, models, and roles represent important strategies in the redefining of psychology as a basic science and major profession in health care.     

Blessed Are Those Who Mourn: Depression as Political Resistance

In this essay, I explore the political significance of depression, particularly as a prominent form of resistance to conditions of life under contemporary global capitalism. After noting the political context of the second beatitude, which suggests a form of mourning that bears witness to public suffering, I assert that under the current dominance of the disease model, depression has lost its political voice. This loss is of grave concern given evidence that the culture of late capitalism (neoliberalism) has initiated a global epidemic of depression. I reframe depression as the final cry of souls diminished under these conditions. Finally, I denote the qualities of such souls, illustrating with a pastoral psychotherapy case summary. A dream presented during the termination phase not only provides a clinical presentation of the attributes of souls under neoliberal governance, but suggests how voice may ultimately be restored even when depression has become unconscious.     

卫生经济伦理学对医疗完全市场化的质疑

不管处于什么发展水平的国家,都需要进行持续的卫生保健改革,这已成为整个社会政治改革的一部分,卫生保健改革已经融入整个世界的社会大变革中。卫生经济问题无一不具有道德成分,无一能离开伦理政策得以解决。我们对中国医疗卫生体制改革的伦理学展望中,提倡一种“公平优先,兼顾效率”的价值观。我们需要正确认识市场的目标、价值和规律,正确理解和发挥政府和市场的调节作用,促进医疗卫生体制改革的健康发展。     

我们为什么能战胜"非典"

当代社会的历史潜能,表明我们能够战胜非典是一种历史必然。对维护人类健康的理性认识和历史责任感,当代医学发展的水平,密切合作的国际关系,信息公开和全民共事的新思维,医务人员的高尚情操,决定了昔日传染病流行的灾难不可能在今天重演。而抗典所形成的共识及其经验,将成为今后战胜各种传染病乃至提高全民健康水平的宝贵财富。     

Affirming the Existential within Medicine: Medical Humanities, Governance, and Imaginative Understanding

This paper first distinguishes governance (collective, autonomous self-regulatory processes) from government (externally-imposed mandatory regulation); it proposes that the second of these is essentially incompatible with a conception of the medical humanities that involves imagination and vision on the part of medical practitioners. It next develops that conception of the medical humanities, as having three distinguishable aspects (all of them distinct from the separate phenomena popularly known as "arts-in-health"): first, an intellectual enquiry into the nature of clinical medicine; second, an important dimension of medical education; third, a resource for moral and aesthetic influences upon clinical practice, supporting "humane health care" as the moral inspirations behind organised medicine. Medical humanities sustains these three aspects through paying proper attention to the existential and subjective aspects of medicine. By encouraging authentic imagination among health care practitioners, medical humanities aligns well with both humane health care and governance in the sense of self-regulation. However, it can neither be achieved mechanistically nor well-measured through proxies such as patient satisfaction. Above all, it should not be allowed to supply, through inappropriate qualitative "targets," new forms of management tyranny.     

Health services and health care economics: the health psychology marketplace.

In an effort toward cost containment, the health care system in the United States has undergone radical changes in the last decade. These changes have influenced the delivery of clinical health psychology services. This article reviews several economic and marketing factors salient to the clinical health psychology marketplace. For example, these economic changes have placed greater emphasis on the need for cost-effectiveness and accountability in the health psychology field. Implications for education and training, collaboration with other health care specialties, new practice initiatives, and public relations are reviewed. Future challenges and opportunities for clinical health psychology are discussed.     

Justice, health care, and the elderly

Concern over rising health costs in the United States has led to an intensifying policy debate over health care for the elderly and a rethinking of questions on intergenerational justice and the claims of the aged on social resources. Major contributions to this debate have been made by Daniel Callahan in his Setting Limits (Simon & Schuster; 1987) and by Norman Daniels in his Am I My Parents' Keeper? (Oxford University Press; 1988). Brock reviews Callahan's and Daniels' work, identifying the central focus of both as the age-group problem of resource allocation. He sees Callahan as calling upon a communitarian political philosophy and Daniels as arguing from a tradition of political liberalism. While disagreeing in part with both authors, Brock identifies compatible elements in their arguments that contribute significantly to the public debate over health care and the aged.