Search

Objective: Post-traumatic stress disorder following injuries unrelated to mass casualty events has received little research attention in New Zealand. Internationally, most studies investigating predictors of post-injury post-traumatic stress disorder focus on hospitalised patients although most survivors are not hospitalised. We compared the prevalence and predictors of symptoms suggestive of post-traumatic stress disorder 12 months following injury among hospitalised and non-hospitalised entitlement claimants in New Zealand’s Accident Compensation Corporation. This government-funded universal no-fault insurance scheme replaced tort-based compensation for injuries in 1974 since when civil litigation (which can bias post-traumatic stress disorder estimates) has been rare. Methods: A total of 2220 Accident Compensation Corporation claimants aged 18–64 years recruited to the Prospective Outcomes of Injury Study were interviewed at 12 months post-injury to identify symptoms suggestive of post-traumatic stress disorder using the Impact of Events Scale. Multivariable models examined the extent to which baseline sociodemographic, injury, health status and service interaction factors predicted the risk of post-traumatic stress disorder symptoms among hospitalised and non-hospitalised groups. Results: Symptoms suggestive of post-traumatic stress disorder were reported by 17% of hospitalised and 12% of non-hospitalised participants. Perceived threat to life at the time of the injury doubled this risk among hospitalised (adjusted relative risk: 2.0; 95% confidence interval: 1.2–3.2) and non-hospitalised (relative risk: 1.8; 95% confidence interval: 1.2–2.8) participants. Among hospitalised participants, other predictors included female gender, Pacific and ‘other’ minority ethnic groups, pre-injury depressive symptoms, financial insecurity and perceived inadequacies in healthcare interactions, specifically information and time to discuss problems. Among non-hospitalised survivors, predictors included smoking, hazardous drinking, assault and poor expectations of recovery. Conclusion: One in six hospitalised and one in eight non-hospitalised people reported post-traumatic stress disorder symptoms 12 months following injury. Perceived threat to life was a strong predictor of this risk in both groups. Identifying early predictors of post-traumatic stress disorder, regardless of whether the injury required hospitalisation, could help target tailored interventions that can reduce longer-term psychosocial morbidity.

This article discusses development and testing of the Provider and Staff Perceptions of Integrated Care Survey, a 21-item questionnaire, informed by Singer and colleagues’ seven-construct framework. Questionnaires were sent to 2,936 providers and staff at 100 federally qualified health centers and other safety net clinics in 10 Midwestern U.S. states; 332 were ineligible, leaving 2,604 potential participants. Following 4 mailings, 781 (30%) responded from 97 health centers. Item analyses, exploratory factor analysis, and confirmatory factor analysis were undertaken. Exploratory factor analysis suggests four latent factors: Teams and Care Continuity, Patient Centeredness, Coordination with External Providers, and Coordination with Community Resources. Confirmatory factor analysis confirmed these factor groupings. For the total sample, Cronbach’s alpha exceeded 0.7 for each latent factor. Descriptive responses to each of the 21 Provider and Staff Perceptions of Integrated Care questions appear to have potential in identifying areas that providers and staff recognize as care integration strengths, and areas that may warrant improvement.

In 2007, a 4-year longitudinal study of all people admitted to the two New Zealand spinal units commenced. It aims to (a) explore interrelationship(s) of body, self, and society for people with spinal cord injury (SCI) and (b) investigate how entitlement to rehabilitation and compensation through New Zealand’s Accident Compensation Corporation affects socioeconomic and health outcomes. Working within the emancipatory-transformative research paradigm, an underlying aim was to build research capacity among people with SCI by recruiting them onto the research team (in addition to the principal investigator who has a SCI). The primary focus of this article is not on the findings of the study but on building research capacity in the SCI population of New Zealand, which emerged from our commitment to the study being ethical and emancipatory. This will involve a consideration of what constitutes ethical disability research, the research paradigm chosen, assembling the research team, and the flexibility provided by the use of mixed methods to achieve these ends.

Part 1 (Waiting in the NHS: a diagnosis) highlighted the deficiencies of waiting-time targets as the principal means of managing lists and concluded that a more comprehensive approach is required1. Waiting-time targets introduce perverse incentives and are isolated from issues of health sector efficiency and opportunity cost. Furthermore, priority on waiting lists is determined not explicitly but implicitly, by clinical judgments. These vary between doctors and between regions and do not relate strongly to patient-experienced health status1. Consequently, we have a poor understanding of the health status of patients on waiting lists, and variation in general practitioner (GP) referral practices leads to differences in apparent need. Simple target-setting is therefore also divorced from NHS equity goals. In this paper we suggest a way forward. We describe moves towards explicit prioritization of patients in other countries, particularly New Zealand. These experiences suggest new directions for the NHS—and pitfalls to avoid. Box 1 summarizes the benefits and drawbacks of explicit prioritization in principle. The NHS is not pursuing improved waiting-list management in isolation2,3: explicit criteria for prioritizing access to surgery have been or are being implemented to varying degrees in several countries, including the UK4,5,6,7,8,9. However, to date, there has been little opportunity to evaluate the successes and failures of these systems in practice10. Experience in New Zealand provides an opportunity to explore the outcomes of explicit prioritization.

The denial of potentially beneficial treatment is a characteristic of all health systems. In a tax-funded cash-limited health system providing services irrespective of ability to pay—such as the NHS—waiting lists are a key means of rationing access to treatment. Understanding this is critical to the design and implementation of policies concerning waiting lists. A commentary on UK waiting-list management in the 1980s and 1990s stated: ‘None of the policy initiatives have been based on an adequate account of the nature of the problem to be tackled. The simple view...that the waiting list is a backlog, which extra resources and better management could clear, was never fully dispelled’1. The notion of infinite demand for elective surgery is questionable2. Nevertheless, the view that demand for surgery is both static and completely unresponsive to changes in waiting time is an inadequate basis for policy, for two reasons. First, the wait faced by patients is a determinant of their demand for taxpayer-funded treatment3. Second, potential patients can substitute privately funded treatment for publicly funded treatment at high waits (and vice versa). Demand for publicly funded elective surgery is more usefully characterized as being neither infinite nor fixed but responsive, to some degree, to waiting times and other factors. Despite a range of new initiatives since publication of the NHS Plan4, including a massive injection of funding to increase capacity, strategies for better waiting-list information and management5 and new waiting-time targets, the Government is unlikely to ‘solve’ the waiting-list problem. We go on to argue, in part 2, that a more explicit and comprehensive strategy is required to prioritize patients for treatment in a manner consistent with NHS aims.