Hassan’s Story Essay

A).Which clue would tell Stefan which scapular surface was anterior and which was posterior? What is the name of the shallow, oval socket of the scapular that Stefan placed next to the humerus? When he pulled out the two bundles, each containing a narrow S-shaped bone. Turning them over in his hands, he quickly decided which was right and which left, then placed each clavicle by its neighboring scapula. In order to determine if a scapula is right or left, orient it so the glenoid fossa (articulating surface) faces laterally (outward) and the spine is posterior (toward back) and superior (upper). The coracoid process should be superior and anterior. Glenoid cavity is what he place next to the humerus. B).Which bone is Stefan referring to as the Collarbone? Clavical C).Which surface markings could Stefan use to distinguish the right humerus from the left? The head, deltoid, tuberosity, and olecranon and pointed styloid process of the ulna, and the circular head and wide styloid process of the radius. The deltoid tuberosity on the right was somewhat larger on the left. D).Why would Stefan think that an enlarged right deltoid tuberosity might indicate right handedness? It was because the right was somewhat larger than the left. E).What is the location of the public symphsis Stefan refers to I the story? The pubic symphysis or symphysis pubis is the midline cartilaginous joint uniting the superior of the left and right pubic bones. It is located anterior to the urinary bladder and superior to the external genitalia; for females it is above the vulva and for males it is above the penis. F).Which adaptation would have taken place in the pubic symphysis of the female skeleton during the later stages of her pregnancy in preparation for the birthing process? Skeletal joints such as the pubic symphysis and sacroiliac widen or have increased laxity. G).What clues could Stefan have used to identify the gender of the pelvis? It’s lack of brow ridge development and pelvic appearance. H). How would Stefan have distinguished between the right and left hip bones? The hips have three separate bone, ilium, ischium, and pubis. I).Would the bones of each hip bone be fused in the female child’s skeleton? No, not until the age of 23.

Abigail Williams and How She Contributed to American History Essay

Abigail Williams was a suspicious 11 or 12 year old girl who was the leading cause of the Salem Witch Trial hysteria. There is not much background information on her, but as far as history goes, Abigail was born 1680 and lived with her Uncle Samuel Parris’ family, who was the head Reverend of Salem, Massachusetts at the time. â€Å"Although it was ordinary practice for young girls to live with relatives to learn about housewifery, we know very little about Abigail, including where she was born and who her parents were.† (Yost, 2002) In an indirect way, Abigail has contributed to American history being that she was the main cause of the Salem Witch Trial accusations. The 6th amendment of the American Constitution was highly influenced by the Salem Witch Trials. See more: Experiment on polytropic process Essay With the 6th amendment, the accused are entitled to have a witness, an attorney for their defense, and will be heard before a jury in court. The Salem Witch Trials affected the way America viewed reliable evidence used in court cases because they stopped using spectral evidence. During the Witchcraft trials, the only evidence available was hear-say information from the girls who were â€Å"afflicted.† More than 45 innocent people were killed, because the court believed Abigail and the girls without looking into further detail about the spoken â€Å"witches.† Nowadays, the accused are able to have a witness with them as well as some one who will look into their case and use accurate evidence to prove their innocence â€Å"until proven guilty.†

Mastering Management Essay Example | Topics and Well Written Essays - 250 words

Mastering Management - Essay Example tem to machine design as well as production, managing the shift from functional communication lines and responsibility to a plant-level dimension and handling unsatisfied employees at the plant based on their new task assignments and hence mitigate the chances of worker unionization. The selection of a plant manager can be challenging, especially in a situation facing Heritage Appliance Company’s River Woods plant. Consequently, the selection committee must take into consideration certain desirable aspect in order to find the right person for the crucial management position. As the selection committee, the suitable candidate must have expert, referent and reward power, which will successfully interplay with legitimate power accorded by the virtue of being the plant manager to steer the project to success. The candidate must generally have good interpersonal skills, critical problem-solving skills and be proactive. An internal candidate would be more desirable for the position because he/she is already familiar with the culture of the organization and what it intends to achieve. Besides, He already knows the strengths and weaknesses of the staff and can easily help them upgrade to match the new tasks facing

Extra Cridets Essay Example | Topics and Well Written Essays - 250 words - 2

Extra Cridets - Essay Example The code stipulates that anyone in violation of the law shall be liable to a fine of upto$500. The law affects individuals in the sense that, they make them aware of other pedestrians and motorists using the read; hence, ensuring that they protect them from any harm that may arise from dangerous driving. The law affects the business in Indiana in a positive way in that, in case people are not violating the law then it means that people get to their work places on time. Therefore, these creates a productive economic society; hence, improving the business in Indiana. In case, an individual was accused of violating the law the case would be a state case because the violation falls under the state laws of Indiana. The violation would also fall under public law, as it is a criminal offence to violate Indiana Code 9-21-8. In my opinion, I think the statute is a good law because it ensures motorist are aware of the laws; thus, making them careful about how they drive their vehicles. The law to some extent is effective although it has some loopholes, especially in the Indiana Code 9-21-8-59 when it comes to the confiscation or retaining of the cell phone. This is because besides texting there are many things that one can do with their

Article # 2 Essay Example | Topics and Well Written Essays - 250 words

Article # 2 - Essay Example According to New York Times article, Aetna will pay $27.30 in cash and 0.3885 of share for each of Coventry’s shares. This payment present around 20% premium paid over the latest closing share price. The announcement of the deal brought some reaction in the stock exchange with Aetna’s share going up by 5.6%, to $40.18 while shares in Coventry went up to close at $42.04. The realizable benefits include Coventry adding over 5 million members to Aetna’s plans, which include 4 million medical members and 1.5 million Medicare part D members. This transaction will ultimately increase Aetna’s Medicaid footprint. More opportunities would be created to facilitate participation in the expansion of Medicaid. Integrating Coventry into Aetna will enable Aetna expand its core insurance business especially the fast growing government health care programs. The acquisition comes with some goodies where Aetna will be able to expand its relationships with health care providers in local geographies. According to the article the deal is expected to close by the middle of next year. I think that Coventry should accept the offer from Aetna, because Coventry debt will be covered when the deal go through. Furthermore, consolidation among various players in the healthcare is time so as to provide health services to many

Proposal - short online course to training the faculty member how they Research

- short online course to training the faculty member how they can manage their online class - Research Proposal Example Indeed, in the current environment of advancing technology, online training hugely facilitates development of critical skills and knowledge. It provides a more innovative approach to education and acquisition of knowledge that can be adjusted to suit the needs and requirements of individuals. The role of faculty in online classes becomes important element of the success of the same. The proposal is for short training program for the faculty members of online courses so as to equip them with necessary skills to manage their online classes with high degree of efficiency 2. Problem statement The online training courses are major elements of constant learning environment that incorporates the demands of changing business compulsions. The online courses are distinct in their teaching methodologies that rely on digital communication vis-a-vis online conferencing techniques, email etc. The electronic interaction is much different to classroom communication. It requires multifunctional capab ilities that incorporate pedagogical skills like: effective learning processes that can be easily grasped by learners; creating comfortable learning environment; skills to resolve technical issues; and administrative knowledge that can explain the course logistics (Sargeant et al., 2006). Very often, the faculty members of online courses are not trained appropriately in the modalities of online classes. The working population and adult learners are therefore not able to exploit the vast potential of the same. Most importantly, the spatial features of learning environment and medium are crucial factors that influence the learning process. In online courses, the multimedia becomes the key component that is exploited judiciously by the teacher to make course curricula interesting, powerful and highly motivating (Sims, 2003). The efficacy of online teaching is considerably increased when teaching skills are integrated judiciously with managerial skills and use of technology. As such, it becomes essential to impart training to the faculty members to make them more effective online teachers. 3. Objectives 1. One week training course on management skills as required for online courses to equip them with the methodologies of electronic communication techniques. 2. To make online classes more effective and motivating. 3. Managing workload of teaching online. 4. Program description/ design framework The design framework of course is important for increasing the core competencies of the participants and equipping them with skills that add value to their knowledge and teaching skills. The various approaches to instructional designs offer effective teaching under different environment and medium of instructions. The training program would use ADDIE framework or Analysis, Design, Development, Implementation and Evaluation structure. Its stepwise approach helps the teachers to develop easy and iterative instructions which can be applied to real life situations, thus making t hem hugely relevant to the learners (Peterson, 2003). The ADDIE design process promotes active participation of the learners that exploits tacit knowledge of the learners and helps them apply critical thinking to resolve problems or look at problems from wider perspectives of creative advantages (Tee & Karney, 2010). The five stages are described as below: 4.1a. Analysis This part of the program is intended to identify and evaluate the needs of the learners so

What is the Divine Command Theory and How Might Socrates' Dilemma Be Essay

What is the Divine Command Theory and How Might Socrates' Dilemma Be Supposes to Undermine it - Essay Example In his dilemma, Socrates asks the following questions: Are God’s orders morally superior because they are ethically acceptable? On the other hand, are they ethically righteous because God commands them? It is in response to this question that the DCT comes across intricacy. A supporter of the divine command theory might assert that an act is ethically correct because God orders its existence. Conversely, the inference of this response is that if God commanded something different from what is the norm, doing so would be morally correct. Human beings would be required to act so because God ordered its occurrence. The setback to this response to Socrates’ question, then, is that God’s orders – the fundamentals of morality – result in becoming illogical, which then call for ethically reprehensible actions to become ethically obligatory. Socrates’ assertions, hence, eliminate the rational validity of God being obedient. In addition, the fact that God orders something because it is right and is palpable to Him in His infinite wisdom, evades the arbitrariness of the preceding alternative but introduces a new problem which brings us back to the start. If God commands something because it is right, accepting an argument that has deserted a religious concept of right and wrong is morally acceptable. All these propositions will lead an advocate of the divine command theory into an ethically uncomfortable field. Furthermore, delving into the ED, one could argue that it is a false dichotomy since mean and evil are not independent of each other. God’s ethical commands, then, would be ethically acceptable because God is the objective moral remedy by which everything is measured. Hence, he cannot do an arbitrary act. To clarify, God may even decide that...This view is one that binds morals and religion as one. This often provides a comfort zone for most people as it presents a solution to darned arguments on moral relativism and the detachment of ethics. This theory also asserts that morality is somehow reliant upon God and that moral accountability consists in deference to God’s commands. The clear content of these divine commands differs according to the religion and the precise views of an individual divine command theorist; all versions of the theory hold in common the claim that morality and ethical obligation depends on God in the end. The issue of the probable links between religion and morals is of interest to ethical theorists, as well as those of religion, but it also guides us to regard the function of beliefs in humanity and the nature of moral consideration. Given this, the arguments presented for and against DCT have both hypothetical and realistic significance. This paper starts by vividly defining DCT, looking into Socrates’ refutations of the theory, while also explaining how his dilemma might undermine the DCT and how the theory is still salvageable in spite of Socrates†™ critique. We finally end this with a clear conclusion that gives a summary of the discussion. Some of the renowned religious thinkers such as St. Thomas Aquinas discarded the divine command theory because of the mere rational dilemmas presented here.

International Bank Essay Example | Topics and Well Written Essays - 500 words

International Bank - Essay Example With this combination of traits, F.C. will be perceived by her subordinates as highly professional and a less emotionally-attached supervisor. With the probable high-esteem perceived by these loan officers, they are being sent a clear and firm directive that this boss ‘means serious business.’ Thus, F.C.’s work characteristics will positively impact the subordinate loan officers’ behavior through the reinforcement of discipline and due diligence. To aid me in deciding which candidate is best for the position, I may require the invaluable information about the candidate’s capacity to solicit and rationalize the subordinate’s responses on the bank’s organizational approaches. This capacity is important because an understanding of the subordinates’ behavior is the primary key in formulating solutions in work problems like selling loans to low credit-worthy clients to reach or exceed the allotted quota, or lowering the set standards to accommodate all types of clients. Another criterion for judging the candidate’s suitability in the position is the capability to enforce individual accountability among the subordinate loan officers. The lack of such accountability may be the probable culprit behind the loan officers’ reckless exposure of the bank to financial risks. Moreover, the bank evidently fails or has a considerable lapse in enforcing accountability to these loan officers (else there would be no financial bath). The candidate who possesses such enforcing capacity and serves as a model of accountability has the potential to further and reinforce the bank’s risk-mitigating measures. For this particular supervisory position, personality assessment should be given as much weight as the technical qualifications. This is because technical tasks are difficult to delegate or coordinate without a healthy framework of soft skills. Moreover, decisions and actions are

History Essay Example | Topics and Well Written Essays - 250 words - 71

History - Essay Example Another reason why the Peloponnesian War was a defining moment in the Greek history is that it resulted in devastating economic costs that caused wide spread poverty across both the Peloponnese and Athens. Athens was completely devastated and the city state was never able to regain its pre-war prosperity. The weakened Greek city states became vulnerable to attacks by Persia and Macedonia and were eventually conquered by King Philip of Macedonia. Lastly, unlike the Persian war, the Peloponnesian War brought a number of social changes in Greece. For example, after the war, civil wars became a common occurrence in ancient Greece thereby resulting in devastation and complete destruction of ancient Greek cultures, whole cities, depopulation and the eventual end of the ancient golden age of Greece (Thucydides, 1.1 pg. 15). In conclusion, although the Persian war had a number of effects including the signing of the thirty years of peace, the Peloponnesian remains the most defining moment in the history of the ancient Greek. I therefore, agree with I agree with the assessment of Thucydides that Peloponnesian Wars were the most important wars in the Greek

Secularization in Britain-Sociology Dissertation Essay

Secularization in Britain-Sociology Dissertation - Essay Example How are these factors represented in the United Kingdom? In general, secularization is still the word of the day, yet while in the past trends directed almost exclusively towards secularization, now there are mixed trends leading both towards and away from secularization. Secondary data analysis is the reuse of quantitative data, the analysis of data collected by others. The following secondary data analysis is essential to guiding our research. First: It is important for us to understand the theoretical approaches of those who have gone before us. As the secularization theory (McGee) we review below indicates, things that might seem to be a sign of one thing (desecularization) can actually be a sign of another (secularization) if interpreted under a different framework. Understanding what data means, not just prior data, is essential. Second: It's impossible to identify trends without introducing longitudinal data. Thus, surveyed below are studies primarily from the 2000s, but with data and trend analysis going back much earlier than that. Third: To hedge against bias and presuppositions, it is vital to see what others think. The data below is drawn from a number of sources, including multiple major analyses of the UK's religiosity: An analysis of churchgoing; an analysis of the UK as compared to other countries; and longitudinal trends. The variety of sources is essential to get many different handles on the idea of secularization. As our data indicate, the exact definition and amount of religiosity is not something that can be ascertained from one vector. Someone can identify themselves as an atheist yet admit to prayer; someone can view themselves as not especially religious yet be uneasy with the idea of teaching evolution in the schools. We thus chose to look for many different factors to truly understand the face of secularization in the UK. Variables chosen include self-identification as religious or atheistic/agnostic, which is vital for understanding secularization since a secular society should presumably have more secular people; the degree of belief in prayer; the degree of value that people place on religion, such as people's beliefs that religion makes one a better person or causes wars and conflict; belief in evolution, an important specific choice because it acts as a prima facia plausibility test to see if the other variables might be exaggerating the secularization and overestimating its practical and social impact; etc. We did not focus on specific sectarianism as it generally is not important for the way that secularization is proceeding. The limitations of the data analysis below are obvious. The longitudinal data is good but doesn't take into account a broad enough set of variables or ways that people behave. Anomalies emerge, like a general trend towards secularization alongside increased scepticism about evolution. Secondary Data Analysis Unquestionably, the historical trend in the UK has been towards secularizati on. Brierly (1989) found that from 1900 to 1985 the trend was overwhelmingly towards more secularization, and predicted this trend would continue. The British Social Attitudes (2010) studies confirm this fact. The number of people from

Reality TV Essay Example for Free

Reality TV Essay Reality TV is something that you are seeing more of today. Reality television is when people or celebrities are filmed living there normal everyday lives and are undertaking specific challenges (Farlex Inc., 2012). Reality television attracts many viewers and has become more popular over the past few years. Some shows you may have even heard of are the shows known as 16 and pregnant, Jersey Shore, Hoarders, and extreme couponing. These are all examples of some very popular realty television shows that are aired regularly. Some shows like â€Å"Teen Mom† or â€Å"16 and pregnant† focus on teenagers that become pregnant and the struggles they are facing as a teenager with a child. These shows are to focus on the consequences of having unprotected sex but sometimes they are viewed as rewarding teen pregnancy. The shows like â€Å"Hoarders† are based on families who have a problem with not throwing anything way which in turn causes clutter and a big mess. So they have people come out and help the people get rid of unneeded stuff and choose healthier habits and make it so they are living in a better environment. Now â€Å"Extreme Couponing’s† is about people who gather tons of coupons and buy things at the store very cheap. This show has definitely set a trend, because of this show you see more people in lines at stores with a whole book of coupons. This show has shown people how to walk out the store with ten items for 5 cents. Some examples of why these shows may be popular are because they are exciting ,and they are similar to what life is really like. Reality TV is not some fantasy or unrealistic show we like to watch and wish our life was like theirs. Instead reality television is something we watch  and think wow that is crazy, that person is crazy. Some of the stuff you see on these television shows is outrageous and it allows us to feel more comfortable with the things we do in our daily lives. When you see a whole bunch of teenagers having children or a whole bunch of crazy drunk people it somehow brings you to the realization that maybe your life is not as bad as you thought it was. There are also many other factors in why realty TV shows are so popular. The drama is probably the biggest factor as well as the WOW factor. Many viewers cannot believe that people get paid for filming such things but yet they are stuck to their TV screens watching. Reality television comes in different varieties which is another factor in its popularity, reality TV being so expansive reaches out to a number of different viewers. People interested in partying are able to view people like that as well as there are shows about doctors and about bidding on unknown items. Because there are different shows’ ranging from A-Z it causes more people to watch reality television which enhances reality televisions popularity. Reality television also has endurance, and it has many different personalities, as well as it always keeps it viewers wanting more. These are all superior examples of why reality television is so popular and why it continues to grow. One show that has been really successful on television is â€Å"Jersey Shore†. Jersey Shore has been a very successful and popular realty TV hit because of its drama and the craziness of the characters on the show. Snooki would have to be one of the main characters that have attracted viewers with her bad attitude and her drunken behavior. Let alone how wild and free she acts. All of the characters of â€Å"Jersey Shore† have their own personalities and occasionally watching them clash and the craziness that follows all these young people becomes very entertaining. Seeing them argue, cry, party, and laugh with each other is plenty of the reason for why it has become such a popular show. â€Å"Jersey Shore† gives their viewers the entertainment they are looking for. Reality television is becoming more successful and television producers are making investments on reality television. Some reason  television producers would invest in reality television is because it is cheaper than hiring actors and creating a television show. With reality television all you have to do is hire people and record their behavior and everyday life. Some of the script is probably written but there are many of things about reality TV that is not written into script and that causes for more entertainment. Other reasons producers are interested in investing in reality TV is because it does bring in good profits. People watch reality TV and it receives hits. Realty television brings money in because it is entertaining and viewers continue to watch, which brings rating on shows up and the producers get paid very decent money for investing in these shows. Some of the similarities between dramas and sitcoms are that they both bring in viewers. Drama is a lot of what is seen in sitcoms as well which makes them similar. Drama is different emotions and sitcoms are filled with different emotions and that is part of the reason for why they are so popular. Everybody enjoys a good laugh, a good fight, and you know it is good if it brings a tear to your eye every so often. This is entertainment and this is what dramas and sitcoms are all about. The differences between sit coms and dramas are the way they are presented. Dramas are well planned scripted productions. It takes more time and money to air a television drama then what it does to air a sit com. Sit coms are more or less people being hired just to put a camera in their face to be filmed doing whatever they do. Sometimes sit coms have scripts as well but there are made to appear non scripted and are made to seem realistic. Dramas take more time and planning then sit coms and seem more picture perfect then sit coms. There are many reasons for why reality television is so popular and why producers would invest in it. There are many shows that catch viewer’s eyes daily and raise the ratings of these shows which make realty TV even more popular. Reality TV as said before has many different personalities; it has variety, and endurance all of which builds on its popularity. Realty television is like an escape from reality and allows you to view your life in a different way because the stuff you view on  television sometimes can seem so much more outrageous then what you are used to. That is why realty television is so popular and why realty television continues to grow and become more popular over time, it is filled with what viewers like you want to keep you coming back for more. what makes reality TV so popular www.dishtv.com WWW.FREEDICTIONARY.COM/ reality+ show farlex 2012 www.ew.com entertainment weekly www.insidetv.com 2012 www.answers.yahoo.com 2012

Analysing SME Policy in Ireland

Analysing SME Policy in Ireland Social Network Analysis CHAPTER I: INTRODUCTION 1.0 Introduction 1.1 Research Design The proposed design for this study is a flexible mixed-method design making use of both qualitative and quantitative methods for data collection and analysis in order to understand and later analyse policy implementation networks for MSEs in Ireland, particularly concerning those in the Dublin 15 area. This approach was required for two reasons: 1) time and resource constraints; and 2) the literature reviewed for this research indicated that such an approach would provide better answers to the questions being asked. As shown in Table 1 below, this method was also important to establish the complimentary nature of the methods being used for the enquiry. For example, qualitative methods were required initially for content analysis of documents produced by the European Commission and the Dept. of Trade, Enterprise and Employment. However, a quantitative approach is given to the treatment of the relationships under investigation namely, mandatory and voluntary cooperation for policy implementation. Therefore, the following steps were taken for this particular research:- 1. Internet research for qualitative content analysis and name generation of policy actors and policies being made at both European and Irish levels; 2. Short open-ended qualitative interview with a major policy actor in Ireland for name generation of policy implementation actors; 3. Quantitative data collection and non-random sampling and estimate number of start-up companies in the Dublin 15 area; and 4. Data collection and analysis using Social Network Analysis methodology for all names generated to measure the effects of mandatory and voluntary cooperation among policy actors. Patience A follow-up interview with a key informant on the network composition and to confirm that the relationships drawn on the literature for policy implementation indeed existed in the manner they were in the questionnaire. In this case, a Head of Small Business Unit in the Department of Enterprise, Trade and Employment could confirm the relationship among the actors in the network from an ‘ego’ perspective and pros and cons for this approach will be discussed further in the methodology chapter. The table below gives an illustration of the design being used and it follows the design approach suggested by Creswell et alli 2003:- Table 1 – Sequential Research Design Implementation Priority Integration Theoretical Perspective Sequential – Qualitative first Quantitative At Data Collection   and Interpretation Explicit With Some Combination As mentioned earlier, this design draws on Creswell’s (2003) work about various research design approaches – with special attention to the use of mixed-methods in the human sciences. A rather overt and systematic use of the methods have grown in popularity and it is evidenced in the work entitled Handbook of Mixed Methods in Social Behavioral Sciences, launched in 2003 by Abbas Tashakkory and Charles Teddlie and from which Creswell derives most of his useful explanations on the advantages and weaknesses of such a design. In a flexible design, the researcher is given a greater freedom to change research questions as the research progresses since she would be rigidly attached to one philosophical paradigm or the other, but would find relevant to include those that make sense to the enquiry as it evolves. On the other hand, making use of both qualitative and quantitative methods for data collection and analysis – whether they take place sequentially or concurrently, allows for a richer understanding and, hopefully, explanation of the problematic under investigation. Details of the methodologies and paradigms they are associated with are dealt with in the Methodology chapter. For this section is imperative now that the researcher makes the esteemed reader aware of the possible biases and the actions taken to deal with them. Bias statement It has been argued that bias is when systematic random or non-random errors are not accepted or acknowledged by the researcher at any point of her work, such as in the design, measurement, sampling, procedure, or choice of problem to be studied. Bias is also related to the accuracy of the information produced and reliability and validity may also be sacrificed, though not necessarily. Hammersley and Gomm (1997), however, assert that nonfoundationalist realism is rather appropriate for it neither relies on foundational epistemology nor it does on relativist and standpoint theory and its aims are to favour the production of knowledge rather than one’s political or personal agenda. According to these authors, foundationalism makes bias a rather evident matter in a research once the researcher’s ideological commitments are indentified as affecting research procedures hence compromising outcomes expected credibility. But bias is not as straightforward as foundationalists, according to them, would like it to be. In a nonfoundationlist realistic perspective, social researchers are not part of the phenomena they want to describe or explain nor can they construct phenomena through their accounts, but merely account for these realities and be judgemental of the influence that what they understand for established knowledge can have on their accounts of social r eality. (1997) In this research, in a foundationalist perspective, the biases that could possibly compromise the commitment with knowledge production is that:- 1) the researcher is a micro-entrepreneur from the vicinities; 2) her commitment with epistemological views of policy networks as ineffective given the predominant hierarchical structure and political agendas; 3) Snowball sampling technique may introduce bias for it may not represent a good cross section of the population investigated; and 4) Questionnaires sent to MSEs were not returned for reasons which will be explained in the Methodology chapter. This can also lead to incorrect conclusions. However, this is not an action research and the methodologies applied for enquiry on policy implementation networks aim to control for bias arising from the researchers’ own point of view regarding cooperation for the benefit of Small and Micro Enterprises in Dublin 15. Moreover, from a nonfoundationalistic realism view point, efforts were consciously made in order to avoid that knowledge so far taken as established in the field of cooperation among actors in policy networks compromises the knowledge produced by the evidence on cooperation among actors in this research. Taking the above into consideration, one of the methodologies used is a qualitative approach considering respondents’ representations of reality through a qualitative content analysis and qualitative techniques in social network analysis. Once data were generated, they were treated by using quantitative data analysis techniques and were converted into algebraic formulae reflecting responses given, i.e. whether a relation exists or not between two actors or more and if it is reciprocal one is a matter of replacing YES and NO answers, or in this case BLUE and RED arrows, for 1 and 0, respectively. This is not to say that social network analysis will serve as a complete assurance for validity and credibility, as questionnaire return rates and responses can indeed compromise it. It is hoped, however, that the weaknesses evident on this work are rather derivative from the very limited time afforded to Taught Masters students, effectively from May to August 2009, than from research bias. 1.2 Justification This work has a scientific and practical relevance and they are equally important as it is hoped that its findings and conclusion will not just add to the scientific knowledge but also reach the actors involved in policy implementation for micro and small enterprises in Ireland as well as those concerned with aspects of economic development. In the scientific sphere, this study will be initially guided by O’Toole’s (1997) work stressing the increasing complexity of networked settings in the public administration where he also urges for more empirical research to be conducted in order to comprehend the impact of such settings on policy implementation. This is also Blair’s (2002) views in his work on implementation networks in which he infers that complex systems formed by actors both coming from both the public and private sectors are assumed in now-a-days public administration. According to Blair, this will help measure the level of direct action by the government so to assess the complexity of such networks and he goes on to borrow from Alexander (1995) the concept of compulsory and voluntary links as the essence of policy implementation systems. Further to such concepts, the focus of this study is on mandatory and voluntary cooperation amongst MSEs stakeholders both in the public and private sectors. Having it all said, measuring service integration among agencies is not the objective of this study. Instead, it will try to leverage on social network analysis practice and theory to measure centrality, closeness, structural holes and brokerage (Freeman 1979; Burt 1995 and 2005). Other theorists, especially those whose studies are within social network analysis (Simmel 1995; Wellman 1983; Hanneman 2005), and regarding the bureaucratic aspect of the public administration (Weber 1978 and Blau 2006) and the (potential) social capital resulting from networks (Bourdieu 1986; Putnam 1995; and Fukuyama 1996) will also be used in the hope to complement existing literature on the topic. The above will, indeed, guide this study all the way through. 1.3 Chapter Outline CHAPTER III: LITERATURE REVIEW Defining the size of a business This research does not aim to be seen under the umbrella of business studies, but a sociological study of cooperation among policy implementation actors for policies in benefit of micro and small businesses in Ireland. Nevertheless, it is found pertinent to use business literature in order to outline the most commonly used definitions of business’ size according to factor inherent to its life cycle. The literature on organisation life cycle (OLC) has been found to be the most appropriate to define the size of a business. However, it is important to note that professionals used to working with businesses may find their own ways of defining business’ size and may as well widely disagree from the scholarly models created and widely used to date. The traditional models for sizing a company were given mostly in the 1980s first through conceptual works and eventually through empirical research which attempted to establish the phases of an organisation according to the environmental issues it faced throughout its existence (Rutherford et al. 2004). The literature consulted for this section has shown that one of the models that has been most cited and used as a reference is that created by Miller and Friesen (1984) whereby the organisation life cycle was divided into five phases: birth, growth, maturity, revival and decline (1984: 1162). These phases can be summarised according to the age, size and growth rate of the organisation. In summary, these phases were the birth phase for small companies, the growth phase for medium-sized companies, the maturity phase for larger organisations, the revival for very large and finally the decline phase for market size companies. The latter phase is linked with the decline in innovation and with environmental factors such as market dry-up. Meanwhile the earlier phases of the business are linked with the most innovative, although unstructured, stages of the organisation (1984: idem). Figure 2 below exemplifies the above:- Figure 2. Organisation life cycle (OLC) and its expected size per phase. The head count for the traditional models is shows as 0-4 persons employed in the birth phase, then 5-19 employees in the medium-sized firms and finally above 20 in the larger ones (Huang and Brown 1999 cf. Rutherford et al. 2004). Weaknesses of this model have been pointed by more recent works (Stubbart and Smalley 1990; Tichey 1980 cf. Rutherford, Buller and McMullen 2004) which took different views and approaches to establishing the different phases an organisation goes through. Other works making use of open-ended choices rather than forced-choice methods to identify an organisation’s problems according to its size, have found that obtaining external financing, internal financial management, economic environment and regulatory environment are problems often experienced by organisations in their start-up and growth phase (Terpstra and Olson 1993 cf. Rutherford, Buller and McMullen 2004) Taking definition from a different angle, the authors Rutherford et al. (2004) infer that other models have been created to overcome the weaknesses presented in previous models and the model by Kihenen (1990), which makes use of Artificial Neural Network (ANN) in order to depict rather realistic stages of an organisation given a series of other factors not limited to age, size and growth rate and it is similar to a cluster analysis and named as self-organising map (SOM). This model, different from traditional models, including the model created by Miller and Friesen (1984), does not force firms to fit into predetermined groups but allows for stages to fall into categories given by the data under study (2004: 328). Nevertheless, the traditional model remains imperative throughout their work and so it will throughout this work. The reason is twofold: a) the traditional definitions have been confirmed through empirical work and across countries; and b) it is assumed here that the proble ms faced by an organisation in each phase of its existence can be logically linked with the needs of these organisations for growth. Hence, policy-making and implementation, as it will be demonstrated later on, is more likely to follow traditional models than novel models. Though this is not to say that new findings on an organisation’s functioning will not be appreciated by policy actors. Moreover, taking into consideration the criticism on the traditional models it is therefore acknowledged that the adoption of traditional model is merely as starting point for reference given the insufficient time for the maturing of this study. Table 3 below shows the most common problems in organisations given their size and phase found by traditional models which have also been confirmed by more current studies utilising different organisational typology techniques:- Table 3. Problems helping establish the size and stage of an organisation. Problems Stage/Phase Headcount Newness, obtaining external finance, internal finance management, unstructured, informal, product development, economic and regulation environment, weak client base, owner/manager dominated. Birth/Start-up (Small firms) 0-4 employees Production efficiency and effectiveness, human resources management and re-organisation, economic and regulation environment. Growth (Medium-sized firms) 5-19 employees Maintaining growth momentum and market position, economic environment, production stagnation and lack of innovation, and employee retention. Stability/Maturity and Decline (Large firms) 20+ employees Source:Miller and Friesen 1984; Kazanjian 1988; Terpstra and Olson 1993 and Huang and Brown 1999 (cf. Rutherford et al. 2004). Conceptualising the phases and problems of organisations will help us understand the policies made in benefit of micro and small businesses in the European Union. However, a point in time must be made regarding the micro-enterprises that may not fit into the typology above given the ethos of their existence. In Europe, the crafts industry is within the definition for micro-enterprises as well as entrepreneurs in the rural areas. However, one should also consider the large number of self-employed professionals such as plumbers, carpenters, painters and also accountants whom may never expand their business, formalising it into a company hence adhering to the organisational life cycle above. Nevertheless, they too generate employment and tax revenue on top of their networked oriented business behaviour hence contributing to the country’s economy but as well as for social and local integration in Europe (European Commission’s SME Portal Observatory Report of European Enterprises 2003/7). Given the above, the needs for micro and small enterprises will vary according to their problems and other human aspects inherent of the cultural and social settings and mindset businesses are found. These settings have been acknowledged by the European Commission in providing assistance to groups widely seen as minorities in large scale businesses, but forming a large number among micro and small entrepreneurs, namely women and immigrants. The Concept of Policy Implementation Networks In policy network theory, implementation networks have been categorised and conceptualised mostly according to the context in which they have emerged in order to either reduce transaction costs or resolve problems effectively. Such a context will determine the resources and power that members will share on their way to achieve their shared goals or resolve their common problems (Provan and Milward 1995 and Bozer 1996). The subject of context is here defined as the ethos and habitus of policy implementation networks in general and they will be explained later on in this chapter. Modern states are now dealing with problems of greater complexity and this requires a superior level of negotiation and public participation in order for services to be delivered to the public as effectively as it is possible. For this reason, O’Toole (1997) asks researchers and public administrators to take networks more seriously and calls for a whole research agenda on the effects they have on hierarchical structures common to public agencies and ultimately affecting policy making, implementation and evaluation (O’Toole 1997; Provan and Milward 1995, 1998 and 2001; Bolzer 1996; and Sandstrà ¶m and Carlssson 2008, among others). The last decade saw a particular growth in research interest on policy implementation networks. Most of the work produced, once satisfied with the working concepts and theoretical frameworks on the subject, now concentrates on measuring implementation effectiveness from different angles and using different methods (idem). While O’Toole (1997 and 1999) remained mostly in the theoretical field hypothesising on management action in hierarchical structures (O’Toole and Meier 1999) and Bozer (1997) strived to conceptualise networks as forms of governance, others like Blair (2002) took the empirical road either by putting to test models created by O’Toole and Meier (1999) or utilised Social Network Analysis in order to analyse networks for what they really are, social structures with interdependent interests (ibidem). As to the initial theoretical framework for policy implementation networks, O’Toole and Meier (1999) created models for managerial action in public administration taking into account the prevailing hierarchical structure of public agencies. For them, networks are of great help to public servants and they see the two structures, linear and non-linear, as poles of a continuum related to buffering in the interests of stability (1999: 510). However, it is important to note that the emphasis of their work is on improving hierarchical systems rather than replacing them for networks since the authors see the informal and inconsistent nature of networks as a weak structure for buffering environmental issues common to policy implementation or service delivery while they also believe that a hierarchical system can maximise management resources more than networks as the latter demands more of such resources in order to maintain reciprocal ties. Though, they do acknowledge that not all networks have inconsistent relationships and have achieved stability by sharing a consistent policy agenda away from a hierarchical habitus, e.g. US farmers’ network, borrowing the term in italics from Tocqueville (2004: 329). Blair (2002), on the other hand, deals with empirical quantitative research on policy implementation in the field of economic development by studying the so-called Enterprise Zones in Southern United States, very popular in the 1990s, especially during Reagan’s second term in presidency. He makes use of policy tools theory and methodology while also drawing from O’Toole and Meier’s (1999) conceptual framework and models for public management in policy systems to formulate his three major hypotheses that aim at measuring the level of direct government intervention in service delivery systems for Enterprise Zones in distressed areas. The first hypothesis states that less government direct intervention means more complex implementation networks, while the second hypothesis continues from the first by asserting that less government participation also means that more actors are involved in implementation, especially private and non-profit organisations. Finally, the third hypothesis, which will later provide the most confounding findings, posits that the private sector takes a greater role in implementing programs in economic development policy networks (2002:170). The first two hypotheses were validated by the findings and agreed with the theoretical concept framework by O’Toole and Meier (1999) on the structure of new policy implementation systems. However, the third hypothesis for which he expected a negative correlation between private and public participation in implementation, he, in fact, obtained a positive one. His findings indicated that the more active is government intervention in the EZs investigated, the more participative businesses were in implementing the programs. However, this finding, according to Blair, does not contradict what had been theorised by O’Toole and Meier’s (1999) (cf. Blair 2002), but he classifies O’Toole’s (1997) system as the old implementation system and the later as the new system. Although policy tools theory is one good way of measuring government intervention in economic development, other approaches may also provide fruitful findings and ways of analysing policy implementation networks. Bozer (1997), for example, explains that policy networks are conceived as a particular form of governance in modern policy systems (Kenis and Schneider 1991; Kooiman 1993; Mayntz 1994, cf. Bozer 1997). In fact, she notes that their main focus is on problem-solving and not on intermediating interests. Any cooperative game members play in order to negotiate strategies to arrive at a solution and based not only on mutual goals, but mostly on communication and trust while acknowledging that their values, ideas and identities are essential to the network. Therefore, Bozer understands:- Policy networks as ‘webs of relatively stable and ongoing relationships which mobilise and pool dispersed resources so that collective (or parallel) action can be orchestrated toward the solution of a common policy’ (Kenis Schneide 1993: 36 cf. Bozer 1993:5). A policy network includes all actors involved in the formulation and implementation of a policy in a policy sector. They are characterised by predominantly informal interactions between public and private actors with distinct but interdependent interests, who strive to solve problems of collective action on a central, non-hierarchical level. (Bozer 1997: idem) She asserts that scholars whom have dedicated their work to see these network members as rational actors, following a horizontal self-coordination, may forget to include some of the main aspects making for such networks in the first place. For Bozer, looking at the intermediation position that networks can have, one may realise that policy-making can be ‘blocked by dissent’ and create what she sees as the ‘bargaining dilemma’ (or prisoner’s dilemma) where ‘defection from cooperation is more rewarding than compliance for a rational actor, owing to the risk of being cheated’. (1997:4) The exception exists when ‘bargaining is voluntary’. As approaches to research change over time and so do concepts and theoretical frameworks on policy implementation networks. Though, most references analysed for this work, showed that there is more of a convergence of knowledge on the topic rather than any radical change. It was noted, however, that works on the subject matter have become more and more empirical and it was found that using structural analysis has proved rather fruitful for a much needed progression on studying it. Aside policy tools, strategic decisions and interest intermediation to share resources and increase productivity and effectiveness, networks are social structures where norms are created and crystallised or otherwise and as such they must be analysed for their properties, the opportunities (advantages) and constraints (disadvantages) that these properties can originate. In other words, since networks are dynamic social structures, the questions asked, either to understand their modus operandi or more so to measure their effectiveness, refer to how actors organise themselves to problem-solving and what are the properties that this can originate. This seems to be the approach taken by a recent study on four policy networks in the educational system in Sweden by Sandstrà ¶m and Carlssson (2008). They acknowledge the organisational roots of policy network theory and from which important concepts have emerged, such as advocacy coalitions, implementation structures, iron triangles, issue networks, policy communities, and subgovernments (Sabatier Jenkins-Smith 1993; Hjern Porter 1993; Jordan Schubert 1992; Heclo 1978; Jordan 1990; Rhodes 1990; cf. Sandstrà ¶m and Carlssson 2008). Nevertheless, their research is justified by the reasons mentioned earlier, being a lack of substantive empirical work using the methods of social network analysis to study policy networks, since only network theorists in different disciplines (Sociology, Political Science, Business Administration etc.) have been interested in the social capital derived from network properties and which is capable of evaluating outcomes and performance. The authors concluded that their theoretical and methodological approach, as aforementioned, proved fruitful for the understanding of policy networks as a structural process where heterogeneity and centralisation are beneficial to network performance whereas structural holes (poorly or non-connected actors) should be avoided when the objective is to achieve efficiency (2008:517). In this view, concepts and knowledge generated by their study converge with those generated by previous works mentioned earlier in a complimentary manner. Evidently, there are several theoretical and empirical works making valuable contribution to the conceptualisation and setting an ever richer theoretical framework to rely on. However, given the short time given for this research, we will settle for what was seen as some of the most useful works with which to begin with. The ethos and habitus of policy implementation networks After contemplating some of the most prominent and recent concepts and theories on policy implementation networks and having touched on the subject of context, we now proceed to further the discussion on the latter beginning with seminal works on bureaucracy, the original ethos of public policy making and an aspect of the context which policy networks can be found. After that it will be discussed the idea of habitus as conceived by Tocqueville on his work about the associational ability of North Americans in the United States of his times. Beginning with the former, Max Webber interpreted the bureaucratic organisation by using terms such as money economy (for its existence), but also stability and rigidity as forming the ‘mechanised bureaucratic apparatus’ while emphasising its ‘technical superiority over every other form’. (1978:345-50) In parallel to contemporary public administration systems, the bureaucratic systems conceived by Weber had similar reasons to evolve and proliferate, being the always increasing complexity in administration, pressure from interested parties for social policy and willingness by the state to increase efficiency while reducing transaction costs. Still according to Weber, authority and hierarchy are also essential to the universe occupied by the public office. However, networked systems, although still embedded in bureaucracy, being hierarchy its essence, would not posses the same strictness and uniformity. As we have seen earlier, this is not to say that todayâ⠂¬â„¢s public administration cannot achieve stability through ways other than hierarchy. (O’Toole and Meier 1999) However, it is well known that Weber came from a rather theoretical perspective, which is the opposite of Peter Blau’s (1963) case, whom has written an entire book on the American bureaucratic system as a result of his ethnographical work in the 1950s. For Blau, this type of social organisation could not be defined merely through hypotheses, but was rather the subject of empirical investigation. Moreover, he opted to see bureaucracy as an orchestrated effort of public officials to ‘transform exceptional problems into routine duties of experts’. (Hughes 1951, cf. Blau, 1963:251) In fact, Blau acknowledges that the bureaucratic system in Germany during Weber’s times were very different from the same system on Blau’s times, especially if we consider they also refer to different countries, hence of different cultures. Even if we accept that expertise, or specialism, has been the raison d’à ªtre of public administration (again, for transaction cost reduction and efficiency’s sake), social interaction among servants are always changing and recurrent cooperation among workmates and just not friends would help contribute to the emergence of the new ethos of policy implementation networks. (Blau 1963:259; Bozer 1997) Therefore, one can hypothesise that repeated social interaction among individuals within the same group or organisation will lead to cooperative behaviour and as Bozer (1997) has inferred, such interactions combined with the notion of good communication

Role Expansion of Support Staff in the NHS

Role Expansion of Support Staff in the NHS Abstract In this dissertation we examine the various aspects of role expansion of support staff within the confines of the NHS. We consider it on both a broad front and also make specific examination of those issues that concern staff connected with the operating theatres. We consider the background and political pressures that make role expansion desirable and possible. We also consider the implications of expansion in the NHS on both a professional and practical level. The issues are discussed in both specific and general terms. We illustrate three types of role expansion by reference to specific professional examples. One example is of the expansion from a caring role to that of the specialist provider, the second can be considered an example of role extension within a professional setting and the third is a natural expansion of the role which is required as technology and practice evolve. Methodology The methodology of this exploration was primarily by literature research. Progressive lines of enquiry were identified, researched and recorded. New lines of enquiry were identified as research progressed, and these were also examined for relevance and researched if considered appropriate to the theme of the dissertation. The literature search was mainly from library facilities. Local University, Post-Graduate hospital and public library facilities were extensively used together with some Internet based investigation. Some personal email enquiries were made from individuals who had experienced professional expansion and advice was taken in regard to both literature and direction of research. Introduction There is little doubt that the role of support staff has changed within the working lifetime of professionals currently working in the NHS. The thrust of this dissertation is to examine the means, the mechanisms and the degrees by which their role has changed. It barely needs stating that the NHS has changed. The political climate in which it operates has seen the NHS occupy varying positions of political prominence. Politicians are frequently seen publicly promising various sums of money for various projects of modernisation, expansion or generally to improve services. Every so often there is a major structural realignment of the management focus and mechanisms which, inevitably percolate through the tiers of control until the changes are felt at the level of the worker. In addition to this there are the technological changes which are largely independent of the politicians and the management structure. The rate of change in techniques, technology, support equipment and expertise appears to be increasing at an exponential rate. It clearly follows that the professional requirements of the support staff must keep pace with these changes and the training that they receive must inevitably reflect the needs of the ever changing working environment. (Ashburner L et al 1996) Evidence of change In any rational discussion, it is vital to work from a firm and secure evidence base. (EHC 1999). This requires careful and critical appraisal of the evidence and a decision as to just how applicable it is to the situation under consideration. In this dissertation we shall therefore be presenting evidence to support this evidence base together with appropriate assessments and judgements as to its validity. Most professionals working in the NHS would attest, if asked, to a perception of a continuous pace of change. Such anecdotal evidence, although interesting, is of little value to any form of critical appraisal. There are a number of reasonably â€Å"hard† statistics that give us much firmer evidence of change in the NHS. Let us consider some of the employment statistics published by the Department of Health for the NHS (whole of UK) and refers to non-medical staff. In 1997 the total number of NHS hospital and community based staff was 935,000. Of these 67% were direct care staff and 33% were management staff. The 67% direct care staff could be broken down into 330,620 nursing, midwifery and health visiting staff (246,010 being qualified) 100,440 scientific, therapeutic and technical staff 17,940 healthcare assistants 21,430 were managers the rest were estates, clerical and administrative staff 79% were women and 6% were from ethnic minorities (NSO 1998) If we compare this with the situation in 2000 by looking at the same parameters we can see: 346,180 nursing, midwifery and health visitor staff (256,280 were qualified). 110,410 scientific, therapeutic and technical staff 62,870 support staff and 23,140 healthcare assistants. 68% were direct care staff and 32% were management and support staff. 79% were women and 7% from the ethnic minorities (NSO 2001) And in 2001 we find a further difference, which is rather more dramatic: 458, 580 nursing, midwifery and health visitor staff (330,540 were qualified) 139,050 scientific, therapeutic and technical staff 23,140 healthcare assistants. 82% were women and 6% from the ethnic minorities (NSO 2002) If we go further back we can find evidence of 93,950 scientific, therapeutic and technical staff were employed, and there were 13,090 healthcare assistants in 1995 (NSO 1996) If we consider the documented trends in support staff we can trace 1995 93,950 1997 100,440 2000 110,410 2001 139,050 Over a comparatively short time there has clearly been a demonstrable increase in terms of numbers employed , nearly a 50% increase on the 1995 levels in six years. Reasons for change In opening this dissertation we made anecdotal reference to the political agenda that shaped the NHS. The NHS has historically been high in the public’s perception of a tangible measure of a Government’s success in delivering its regularly promised higher standard of living. It is partly for this reason, that successive governments have felt it politically expedient to invest increasing sums of money in measures for both expansion and improvement together with various drives aimed at increasing efficiency. (Ham C 1999) In the recent past there have been a raft of measures that have been produced which have all played their part in the evolution of the NHS to its current configuration and in doing so have expanded the role of not only the support worker but virtually all of the workers in the NHS at the same time. One of the first measures which was an overt indication of the forthcoming changes in working practice was the introduction of the performance indicators (Beecham L 1994) These were progressively introduced form 1992 onwards and in some respects could be considered the forerunner of the move towards National Service Frameworks. The original performance indicators imposed a duty or obligation on Trusts to carry out certain procedures within a specified maximum time. For example the indicators introduced in 1994-5 were on waiting times for first outpatient appointment and also for charters in General Practice. Although there were clear obligations on medical and nursing staff to make available sufficient sessions in order to see the patients, it is clear that the increased throughput of patients would clearly impact on the working practices (and work load) of the support staff. To a large extent, this can be seen from the figures presented at the beginning of this work. The 50% increase in staffing levels amongst the support staff reflects, in a large part, the changes that were consequent on the imposition of the performance indicators. The initial indicators proved to be quite onerous in terms of achieving compliance even though the later ones gave tighter requirements still. For example the 1994 indicators set a target of 90% of patients seen by a consultant within 26 weeks of a written referral letter being received from the General Practitioner in the major specialities of general medicine, general surgery and dermatology. (Editor BMJ 1994) It follows that this target is not quite as innocuous as it might at first appear. If we accept the fact that a substantial number of patients were already waiting for considerably longer than 26 weeks it represented a major shift in working practices to meet this particular deadline. Once the patients were seen it followed that they then had to have whatever treatment was thought to be appropriate. An increase in outpatients seen inevitably means an increase in patients waiting for inpatient treatment. So either the waiting lists go up further for inpatient treatment, or there is also a change of working practice to accommodate an increase in demand. This inevitably also impacts on the support staff as much as it does on the medical staff. (Langham S et al 1997) We shall consider this particular phenomenon in greater depth later when we consider the expansion of the nurse to specialist endoscopist and the running of one-stop clinics. Some novel methods were invoked to try to accommodate this shift in demand. There was a substantial increase in the frequency of day case surgery. Not only were a greater variety of surgical procedures being routinely carried out as day cases but it also resulted in more patients being assessed as suitable to undergo day case surgery. (HSE 2001) The same phenomenon of knock on effects arose form some of the other performance indicators. One of the original indicators was the percentage of patients seen within 5 mins of entering the casualty department. It follows that as hospitals strove to increase their performance indicators and the percentage of patients seen promptly rose, having been seen they then had to be treated and the same argument applies. Either there is an increase in the number of patients awaiting treatment in the A E departments, or there is a change in working practice to accommodate them and also to get them treated sooner. The organisation and efficiency of this system falls heavily on the support staff who clearly had to be able to accommodate this increased demand. (Langham S et al 1997) The indicators eventually began to involve inpatient statistics as well as outpatient ones. One, introduced in 1996, was on the number and availability of emergency operating theatres. More evidence of the reasons for this change comes from a paper by Scally and Donaldson (1998). We note that it was actually written by Liam Donaldson when he was a Regional Director of the NHS before he subsequently became Secretary of State for Health, so his comments can be taken with suitable gravitas. A critical analysis of the paper shows that it makes a number of points that are really overtly political, but it outlines the trend of change of emphasis where the improvements expected through clinical governance will not only be an â€Å"ideal goal† but will become a statutory requirement. This clearly pre-empts the changes prescribed in the NHS Plan. The paper outlines new goals â€Å"in which financial control, service performance, and clinical quality are fully integrated at every level† are behind the major thrust of the piece. Careful reading of the paper strongly suggests that inherent in the restructuring plans is a change in emphasis onto expansion of professional roles and greater working flexibility between professions which is fundamental to our considerations here. (Gray C 2005). We also note that the â€Å"stage was being set† for the potential role change of healthcare professionals in general and the four main precepts of this paper impact on that belief, namely: Clinical governance is to be the main vehicle for continuously improving the quality of patient care and developing the capacity of the NHS in England to maintain high standards (including dealing with poor professional performance) It requires an organisation-wide transformation; clinical leadership and positive organisational cultures are particularly important Professional self regulation will be the key to dealing with the complex problems of poor performance among clinicians New approaches are needed to enable the recognition and replication of good clinical practice to ensure that lessons are reliably learned from failures in standards of care It is clearly significant that all of these points were implemented and indeed, expanded, when Donaldson was appointed to the office of Secretary of State for Health and they can be seen as both enhancing and reinforcing the points that we have presented relating to the guidance from the Nursing Midwifery Council about the expansion of professional roles. Because of their seminal importance in the examination of our subject, let us consider the background to these points further. We note that Donaldson was originally recruited from a business background and the record shows that he has chosen to apply a great many sound and proven business principles to both the structuring and the workings of the NHS. Many of his strategies and perhaps ideas, have a clear ancestry in the Cadbury Report (1992) which effectively analysed the overall impact of governance and issues of changing working practices and consequent responsibility in the business world. The report focused on the issues surrounding an expansion of responsibility and a consequent failure to take responsibility for one’s actions, frequently passing on the implied responsibility to another employee in the same company. It found this practice to be both counterproductive and inefficient and frequently would lead to defensive stances and attitudes being adopted. When problems arose, they were therefore far more difficult to actively solve. (Lakhani M 2005) Donaldson was instrumental in applying this strategy to a clinical setting within the working practices of the NHS. This particular paper takes the view that by promoting individual professional responsibility he would be encouraging a system that would allow:- NHS organisations to be accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. By implication this argument extends to the expansion and role realignment in general terms throughout the NHS. We shall consider the elements in this paper which are of relevance to these arguments. Staff self-esteem is of great value to an organisation. Frequently this is associated with increased responsibility and a firm professional footing. (Davies HTO et al. 2000). Donaldson and Scally clearly espouse the virtue of professional responsibility at all levels in an organisation and encourage staff to take, rather than to devolve responsibility for their actions and indeed seek to ideally provide a ambience that is conducive to expansion of responsibility which therefore generally benefits the whole organisation. Tools of change Although we are primarily considering the support worker in this dissertation we must first broaden the agenda in order to set our examination in an appropriate context. There have been a number of Government White Papers, consultative documents and advisory initiatives that have concerned the workings of the NHS. Some have greater practical significance than others. There appear to have been significantly more in the last decade than previously and anecdotal and observational evidence would seem to suggest that these too, are increasing at an exponential rate. One of the landmark plans in recent years has been the NHS Plan. It has been compared by some commentators as being on comparative magnitude as the original inception of the NHS in 1948 (Shortell SM et al 1998). It is quite possible that a cynical appraisal of the Plan would see it is little more than the result of political rhetoric and pre-emptive manoeuvring as a response to the perceived public disquiet about the state of the NHS. On the other extreme the optimist might view it as a positive plan for major improvement. (Moss et al 1995). Having the benefit of hindsight, there is no doubt that it has been the catalyst for a number of significant changes in the NHS, it is, of course, totally dependent upon your own particular viewpoint as to whether these changes are regarded as beneficial or otherwise. One has to be extremely careful in evaluating such comments as clearly it depends on the criteria chosen for evaluation as to whether the reform will appear to be positive or negative. (Bilsberry J. 1996) One only has to consider the debacle which ensued after the introduction of the Griffiths Report in the 1980s (Griffiths Report 1983). This was considered to be a major reform of the management structure of the NHS. There was general agreement that the management had become to unwieldy, detached and inefficient with too many layers of management. (Davies,C et al. 2000), The Griffiths Report was commissioned with the specific purpose of streamlining the management profile and was charged with the specific responsibility of improving both efficiency and accountability. The subsequent plan was unveiled and introduced piecemeal. In the words of the Government appointed reviewer of the episode :- These were a set of reforms that were designed to â€Å"streamline the administration â€Å" of the NHS. It involved a major change in emphasis in the way that the NHS was run, and in short, it was badly conceived, patchily implemented and introduced piecemeal. By any critical analysis it proved to be a complete disaster. (Davidmann 1988) It is not actually possible to pass judgement on whether the plan would have been successful or not as its method of introduction was generally seen to be its downfall. In essence, its introduction was not managed in any contemporary sense of the word, it was simply imposed and the chaos that ensued prompted the government to institute another report to glean what lessons it could form the whole affair. (Davidmann 1988). It is fair to comment that the majority of reforms that have been introduced since that time have been far more professionally managed and their introduction (whatever their eventual outcome) have generally been comparatively smooth and uneventful (Bennis et al 1999) The area of change management as a science and discipline is both extremely involved and complex. Changing the structure of a massive and established organisation such as the NHS is clearly difficult with established attitudes, working practices and inherent inertia. The lessons learned from the Griffiths Report appear to have been successfully applied to the introduction of the NHS Plan (Bryant 2005) In specific consideration of the NHS plan we should note that the specific stated aims of the plan were to:- Increase funding and reform Aim to redress geographical inequalities, Improve service standards, Extend patient choice. These aims have been, to some extent translated into reality. Let us examine each in detail. The increased funding was specifically delivered in the March 2000 budget settlement and has been honoured in successive budgets since. The Chancellor of the Exchequer stated that the money made available would ensure that the NHS would grow by one half in cash terms and by one third in real terms in just five years. Our examination of staffing levels (above) would seem to suggest that this trend has been successfully established. In addition, he promised a  £500 million â€Å"performance fund† for specific areas which were to be identified by separate investigation as being in particular need of assistance. (Halligan et al 2001) This certainly directly impinges upon our considerations of support staff and we shall return to this point later. The geographical inequalities and service standards are specifically addressed in the introduction of the National Service Frameworks which are mechanisms for specifically addressing inequalities and setting of both targets and goals of performance and excellence on a National rather than a local level, (Rouse et al 2001) and have been progressively rolled out across the country. These measures have been established in collaboration with assistance and guidance from bodies such as the National Institute for Clinical Excellence (NICE) which has a remit to examine both practices and facilities with the specific aim of achieving national standards. ( viz. NICE 2004) (NHS KSF 2004) It has made a number of recommendations which appear to have a firm evidence base. (Berwick D 2005) We should perhaps take this opportunity to note that the Institute, although undoubtedly set up in response to a worthy ideal, is already finding itself short of funding to do the job that it was originally conceived for. Spokesmen have already commented that it is short of money to achieve the research necessary to justify its continued activity (Shannon 2003) Patient choice is a far more complex issue that it might originally appear. Initial examination might suggest that to give patients the freedom to go where they wish to get their medical care is a fine objective, but closer examination of the issue would reveal that it has numerous pitfalls. In the specific terms of the NHS plan, it actually means that the patient’s primary healthcare team has a more wide-reaching choice of where they choose to refer the patient. (Wierzbicki et al 2001). A patient may consider any number of factors which may influence their choice of hospital including such factors as the general look of the buildings, the geographical site in relation to their friends and family and what they have read or heard anecdotally about the hospital. None of these factors have any major bearing on the treatment that they will receive. It may be that they will discover that the waiting list is shorter at hospital A than hospital B. what may well be less obvious to the patient is that hospital A may have a shorter waiting list because the local primary healthcare teams know that it has a number of serious shortcomings and so they tend to refer their patients to hospital B which consequently has a longer waiting list. Of course , we mustn’t ignore the possibility that hospital A is actually more efficient that hospital B or that hospital C provides a more comprehensive, courteous and efficient service with greater expertise than hospital D, but the primary healthcare teams are generally best placed to see the outcomes of their local hospitals and will generally know where their patients are served better in each individual circumstance. (after Donaldson L 2001) In the context of our examination here, all four of these aims have potential impact on our subject as each of these objectives are effectively resolved by expanding, and in some cases changing, the roles of staff within the NHS. Clearly the impact will vary between different disciplines and indeed, different geographical areas, but the overall objective of improving the efficiency and introduction of patient orientated goals has largely been met by the three expedients of: a) making more money available b) adopting progressive management strategies c) increasing staffing levels and redefining some roles within the NHS ( after Dixon et al 2003) It is perhaps useful to consider the whole of the NHS Plan as part of a reform continuum which has shaped the evolution of the NHS since its inception. We have already highlighted the Griffiths Reforms, but other landmark reforms that impact upon our considerations of change must include the Agenda for Change (2004) which is primarily staff and employment orientated and is concerned with a number of measures including staffing levels, staff role descriptions and staff pay levels. It has only recently been implemented (September 2005) and, for our purposes here, should be viewed in conjunction with another Government White Paper which is the complimentary NHS Knowledge and Skills Framework (KSF 2004). This particular paper targets the need for both recognising and rewarding specific speciality orientated enhancement of both skills and knowledge that are actually relevant to professional performance in both designated areas and in professional performance generally. Reading of the provisions reveals that the general provision of  £280 million over a three year period to â€Å"develop specific designated staff skills†. One of the proposed mechanisms is to set up individual learning accounts which will be worth  £150 per year. It is not yet clear what the impact will yet be on support staff in either specific or general terms. The impact of these reforms seems to be felt on many levels. There appears to be a move towards the redesignation of roles, flexible working, skill mix and the redesignation of professional boundaries. The NHS Plan itself calls for a number of changes to be made in working practices, both general (conceptual) and specific. It also calls for a change in the actual roles of some healthcare professionals, including support staff. It goes into great detail about the need for some of these changes need to be established but it also has to be observed that there is actually very little detail in the Plan as to how these changes are either to be introduced or managed. It refers to the changes in general terms, there is actually very little detail relating to what it expects these changes to actually be in reality. (Krogstad et al 2002) If one were to produce an analysis of the pre-2000 structure of the NHS one could conclude that it had three major problems which were not consistent with the function, structure and organisation of a typical 21st century industry a lack of national standards old-fashioned demarcations between staff and barriers between services a lack of clear incentives and levers to improve performance over-centralisation and disempowered patients. (Nickols 2004) One observation that is also relevant to our considerations here is the phrase â€Å"seamless interface† appears very frequently throughout the document. Although it is primarily applied to the interface between primary and secondary care, it is also, both explicitly and by implication, applied to the interface between different groups of professionals within both aspects of the service. (Rudd et al 1997) In direct consideration of our subject, we can take this to mean that there is a requirement for seamless interaction between all factions of the operating theatre staff and between them and the other professionals in the hospital. (Dixon et al 2003) Other significant milestones in the changes in the role of support staff were the introduction of the National Service Framework. These are a series of recommendations, stipulations and targets which are designed to raise the performance to the level of the best across the nation rather than to have pockets of excellence surrounded by a sea of mediocrity (White M 2005). The issues surrounding the National Service Frameworks are huge, as they collectively cover most of the major therapeutic areas in medicine. The reason for their inclusion in this particular consideration, is because of their collective impact on the role of the support staff, who have to expand their role and skills in order to comply with their requirements. It is completely impractical to consider all of the implications of the National Service Frameworks so, as a representative â€Å"sample† we will consider just one, the National Service Framework for the elderly. In distinct contrast to our comments in relation to the Griffiths Report earlier in this piece, the introduction of the National Service Frameworks could be considered nothing short of exemplary. There have been consultation periods, pre-implementation pilots and possibly most importantly, a well publicised and staged National roll-out programme which was designed to implement each of the strategies in a graded and controlled fashion with the intention of trying to ensure smooth implementation across the country. (Nickols F.2004). If we consider as an exploratory example, a small portion of the National Service Framework for the elderly Standard Two, this states that it should ensure that: Ensure that older people are treated as individuals and that they receive appropriate and timely packages of care which meet their needs as individuals, regardless of health and social services boundaries. One could perhaps reasonably hope that such aspirations would have been unnecessary, but behind the actual words are a number of other concepts that are central to our consideration to the expanding role of the support staff. The concept of â€Å"Person Centred Care† is a central precept of the Standard Two. It is described with the intention of trying to allow the elderly to feel entitled to be treated as individuals and also to allow them to retain responsibility for their own choices for their own care. The expansions of the roles of the support staff comes primarily in the adoption of the main tenet of the concept of Person Centred Care and that is the introduction of the Single Assessment Process (SAP). This recognises that there are effectively a great number of support agencies that potential can be involved to look after the needs of the elderly, both in hospital and after discharge. Prior to the introduction of the National Service Framework, it was common practice for each agency to separately make contact with the patient and make their own assessment in terms of their own distinct considerations. We shall discuss this point later in the context of insularity of specialities. The end result of this process was the fact that, very commonly, the same (or similar) facts are repeatedly elicited on different occasions with all the implications that this type of duplication has on inefficient working and waste of resources. (Fatchett A. 1998). The SAP is designed so that any member of the health care team can assemble the information in such a way and in such a format that it will be of use to the other members of the team, or for that matter any of the agencies who might have a legitimate need for the information. This particular role expansion is designed to assist in reducing the amount of red tape that appears to be an inevitable encumbrance of many of the measures that are designed to assist the elderly patient, and only appears to finish up by hampering them. (Gott M 2000). The adoption of the Single Assessment Process is no more than one example, perhaps not so much of an expansion of the role, but a realignment of the role of support staff. It is still a fairly new concept and is central to the aims of the National Service Framework that the needs and wishes of the patient should be at the heart of the whole process. Because it is new, the extent to which it can accommodate these aims and aspirations alongside the day to day practicalities of service provision still has yet to be fully assessed. (Mannion R et al 2005) In some ways, this new role expansion can be viewed in parallel with the concepts of seamless interfacing and multidisciplinary team working which we have examined elsewhere in this dissertation. Given the fact that the Single Assessment Process has only been operational since April 2004, but the move towards multidisciplinary team working and the concept of the seamless interface has been apparent and espoused for some years (Mason et al 2003). The latter were effectively translated into reality without major upheaval, one can be reasonably confident that the same will eventually be said for both the Single Assessment Process and its implications for both staff and patients. We have described this particular example of role expansion more as a realignment because, at first sight, its implications are quite subtle when compared to other examples that we shall be considering, but equally they are quite fundamental, as they impinge upon the role Role Expansion of Support Staff in the NHS Role Expansion of Support Staff in the NHS Abstract In this dissertation we examine the various aspects of role expansion of support staff within the confines of the NHS. We consider it on both a broad front and also make specific examination of those issues that concern staff connected with the operating theatres. We consider the background and political pressures that make role expansion desirable and possible. We also consider the implications of expansion in the NHS on both a professional and practical level. The issues are discussed in both specific and general terms. We illustrate three types of role expansion by reference to specific professional examples. One example is of the expansion from a caring role to that of the specialist provider, the second can be considered an example of role extension within a professional setting and the third is a natural expansion of the role which is required as technology and practice evolve. Methodology The methodology of this exploration was primarily by literature research. Progressive lines of enquiry were identified, researched and recorded. New lines of enquiry were identified as research progressed, and these were also examined for relevance and researched if considered appropriate to the theme of the dissertation. The literature search was mainly from library facilities. Local University, Post-Graduate hospital and public library facilities were extensively used together with some Internet based investigation. Some personal email enquiries were made from individuals who had experienced professional expansion and advice was taken in regard to both literature and direction of research. Introduction There is little doubt that the role of support staff has changed within the working lifetime of professionals currently working in the NHS. The thrust of this dissertation is to examine the means, the mechanisms and the degrees by which their role has changed. It barely needs stating that the NHS has changed. The political climate in which it operates has seen the NHS occupy varying positions of political prominence. Politicians are frequently seen publicly promising various sums of money for various projects of modernisation, expansion or generally to improve services. Every so often there is a major structural realignment of the management focus and mechanisms which, inevitably percolate through the tiers of control until the changes are felt at the level of the worker. In addition to this there are the technological changes which are largely independent of the politicians and the management structure. The rate of change in techniques, technology, support equipment and expertise appears to be increasing at an exponential rate. It clearly follows that the professional requirements of the support staff must keep pace with these changes and the training that they receive must inevitably reflect the needs of the ever changing working environment. (Ashburner L et al 1996) Evidence of change In any rational discussion, it is vital to work from a firm and secure evidence base. (EHC 1999). This requires careful and critical appraisal of the evidence and a decision as to just how applicable it is to the situation under consideration. In this dissertation we shall therefore be presenting evidence to support this evidence base together with appropriate assessments and judgements as to its validity. Most professionals working in the NHS would attest, if asked, to a perception of a continuous pace of change. Such anecdotal evidence, although interesting, is of little value to any form of critical appraisal. There are a number of reasonably â€Å"hard† statistics that give us much firmer evidence of change in the NHS. Let us consider some of the employment statistics published by the Department of Health for the NHS (whole of UK) and refers to non-medical staff. In 1997 the total number of NHS hospital and community based staff was 935,000. Of these 67% were direct care staff and 33% were management staff. The 67% direct care staff could be broken down into 330,620 nursing, midwifery and health visiting staff (246,010 being qualified) 100,440 scientific, therapeutic and technical staff 17,940 healthcare assistants 21,430 were managers the rest were estates, clerical and administrative staff 79% were women and 6% were from ethnic minorities (NSO 1998) If we compare this with the situation in 2000 by looking at the same parameters we can see: 346,180 nursing, midwifery and health visitor staff (256,280 were qualified). 110,410 scientific, therapeutic and technical staff 62,870 support staff and 23,140 healthcare assistants. 68% were direct care staff and 32% were management and support staff. 79% were women and 7% from the ethnic minorities (NSO 2001) And in 2001 we find a further difference, which is rather more dramatic: 458, 580 nursing, midwifery and health visitor staff (330,540 were qualified) 139,050 scientific, therapeutic and technical staff 23,140 healthcare assistants. 82% were women and 6% from the ethnic minorities (NSO 2002) If we go further back we can find evidence of 93,950 scientific, therapeutic and technical staff were employed, and there were 13,090 healthcare assistants in 1995 (NSO 1996) If we consider the documented trends in support staff we can trace 1995 93,950 1997 100,440 2000 110,410 2001 139,050 Over a comparatively short time there has clearly been a demonstrable increase in terms of numbers employed , nearly a 50% increase on the 1995 levels in six years. Reasons for change In opening this dissertation we made anecdotal reference to the political agenda that shaped the NHS. The NHS has historically been high in the public’s perception of a tangible measure of a Government’s success in delivering its regularly promised higher standard of living. It is partly for this reason, that successive governments have felt it politically expedient to invest increasing sums of money in measures for both expansion and improvement together with various drives aimed at increasing efficiency. (Ham C 1999) In the recent past there have been a raft of measures that have been produced which have all played their part in the evolution of the NHS to its current configuration and in doing so have expanded the role of not only the support worker but virtually all of the workers in the NHS at the same time. One of the first measures which was an overt indication of the forthcoming changes in working practice was the introduction of the performance indicators (Beecham L 1994) These were progressively introduced form 1992 onwards and in some respects could be considered the forerunner of the move towards National Service Frameworks. The original performance indicators imposed a duty or obligation on Trusts to carry out certain procedures within a specified maximum time. For example the indicators introduced in 1994-5 were on waiting times for first outpatient appointment and also for charters in General Practice. Although there were clear obligations on medical and nursing staff to make available sufficient sessions in order to see the patients, it is clear that the increased throughput of patients would clearly impact on the working practices (and work load) of the support staff. To a large extent, this can be seen from the figures presented at the beginning of this work. The 50% increase in staffing levels amongst the support staff reflects, in a large part, the changes that were consequent on the imposition of the performance indicators. The initial indicators proved to be quite onerous in terms of achieving compliance even though the later ones gave tighter requirements still. For example the 1994 indicators set a target of 90% of patients seen by a consultant within 26 weeks of a written referral letter being received from the General Practitioner in the major specialities of general medicine, general surgery and dermatology. (Editor BMJ 1994) It follows that this target is not quite as innocuous as it might at first appear. If we accept the fact that a substantial number of patients were already waiting for considerably longer than 26 weeks it represented a major shift in working practices to meet this particular deadline. Once the patients were seen it followed that they then had to have whatever treatment was thought to be appropriate. An increase in outpatients seen inevitably means an increase in patients waiting for inpatient treatment. So either the waiting lists go up further for inpatient treatment, or there is also a change of working practice to accommodate an increase in demand. This inevitably also impacts on the support staff as much as it does on the medical staff. (Langham S et al 1997) We shall consider this particular phenomenon in greater depth later when we consider the expansion of the nurse to specialist endoscopist and the running of one-stop clinics. Some novel methods were invoked to try to accommodate this shift in demand. There was a substantial increase in the frequency of day case surgery. Not only were a greater variety of surgical procedures being routinely carried out as day cases but it also resulted in more patients being assessed as suitable to undergo day case surgery. (HSE 2001) The same phenomenon of knock on effects arose form some of the other performance indicators. One of the original indicators was the percentage of patients seen within 5 mins of entering the casualty department. It follows that as hospitals strove to increase their performance indicators and the percentage of patients seen promptly rose, having been seen they then had to be treated and the same argument applies. Either there is an increase in the number of patients awaiting treatment in the A E departments, or there is a change in working practice to accommodate them and also to get them treated sooner. The organisation and efficiency of this system falls heavily on the support staff who clearly had to be able to accommodate this increased demand. (Langham S et al 1997) The indicators eventually began to involve inpatient statistics as well as outpatient ones. One, introduced in 1996, was on the number and availability of emergency operating theatres. More evidence of the reasons for this change comes from a paper by Scally and Donaldson (1998). We note that it was actually written by Liam Donaldson when he was a Regional Director of the NHS before he subsequently became Secretary of State for Health, so his comments can be taken with suitable gravitas. A critical analysis of the paper shows that it makes a number of points that are really overtly political, but it outlines the trend of change of emphasis where the improvements expected through clinical governance will not only be an â€Å"ideal goal† but will become a statutory requirement. This clearly pre-empts the changes prescribed in the NHS Plan. The paper outlines new goals â€Å"in which financial control, service performance, and clinical quality are fully integrated at every level† are behind the major thrust of the piece. Careful reading of the paper strongly suggests that inherent in the restructuring plans is a change in emphasis onto expansion of professional roles and greater working flexibility between professions which is fundamental to our considerations here. (Gray C 2005). We also note that the â€Å"stage was being set† for the potential role change of healthcare professionals in general and the four main precepts of this paper impact on that belief, namely: Clinical governance is to be the main vehicle for continuously improving the quality of patient care and developing the capacity of the NHS in England to maintain high standards (including dealing with poor professional performance) It requires an organisation-wide transformation; clinical leadership and positive organisational cultures are particularly important Professional self regulation will be the key to dealing with the complex problems of poor performance among clinicians New approaches are needed to enable the recognition and replication of good clinical practice to ensure that lessons are reliably learned from failures in standards of care It is clearly significant that all of these points were implemented and indeed, expanded, when Donaldson was appointed to the office of Secretary of State for Health and they can be seen as both enhancing and reinforcing the points that we have presented relating to the guidance from the Nursing Midwifery Council about the expansion of professional roles. Because of their seminal importance in the examination of our subject, let us consider the background to these points further. We note that Donaldson was originally recruited from a business background and the record shows that he has chosen to apply a great many sound and proven business principles to both the structuring and the workings of the NHS. Many of his strategies and perhaps ideas, have a clear ancestry in the Cadbury Report (1992) which effectively analysed the overall impact of governance and issues of changing working practices and consequent responsibility in the business world. The report focused on the issues surrounding an expansion of responsibility and a consequent failure to take responsibility for one’s actions, frequently passing on the implied responsibility to another employee in the same company. It found this practice to be both counterproductive and inefficient and frequently would lead to defensive stances and attitudes being adopted. When problems arose, they were therefore far more difficult to actively solve. (Lakhani M 2005) Donaldson was instrumental in applying this strategy to a clinical setting within the working practices of the NHS. This particular paper takes the view that by promoting individual professional responsibility he would be encouraging a system that would allow:- NHS organisations to be accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. By implication this argument extends to the expansion and role realignment in general terms throughout the NHS. We shall consider the elements in this paper which are of relevance to these arguments. Staff self-esteem is of great value to an organisation. Frequently this is associated with increased responsibility and a firm professional footing. (Davies HTO et al. 2000). Donaldson and Scally clearly espouse the virtue of professional responsibility at all levels in an organisation and encourage staff to take, rather than to devolve responsibility for their actions and indeed seek to ideally provide a ambience that is conducive to expansion of responsibility which therefore generally benefits the whole organisation. Tools of change Although we are primarily considering the support worker in this dissertation we must first broaden the agenda in order to set our examination in an appropriate context. There have been a number of Government White Papers, consultative documents and advisory initiatives that have concerned the workings of the NHS. Some have greater practical significance than others. There appear to have been significantly more in the last decade than previously and anecdotal and observational evidence would seem to suggest that these too, are increasing at an exponential rate. One of the landmark plans in recent years has been the NHS Plan. It has been compared by some commentators as being on comparative magnitude as the original inception of the NHS in 1948 (Shortell SM et al 1998). It is quite possible that a cynical appraisal of the Plan would see it is little more than the result of political rhetoric and pre-emptive manoeuvring as a response to the perceived public disquiet about the state of the NHS. On the other extreme the optimist might view it as a positive plan for major improvement. (Moss et al 1995). Having the benefit of hindsight, there is no doubt that it has been the catalyst for a number of significant changes in the NHS, it is, of course, totally dependent upon your own particular viewpoint as to whether these changes are regarded as beneficial or otherwise. One has to be extremely careful in evaluating such comments as clearly it depends on the criteria chosen for evaluation as to whether the reform will appear to be positive or negative. (Bilsberry J. 1996) One only has to consider the debacle which ensued after the introduction of the Griffiths Report in the 1980s (Griffiths Report 1983). This was considered to be a major reform of the management structure of the NHS. There was general agreement that the management had become to unwieldy, detached and inefficient with too many layers of management. (Davies,C et al. 2000), The Griffiths Report was commissioned with the specific purpose of streamlining the management profile and was charged with the specific responsibility of improving both efficiency and accountability. The subsequent plan was unveiled and introduced piecemeal. In the words of the Government appointed reviewer of the episode :- These were a set of reforms that were designed to â€Å"streamline the administration â€Å" of the NHS. It involved a major change in emphasis in the way that the NHS was run, and in short, it was badly conceived, patchily implemented and introduced piecemeal. By any critical analysis it proved to be a complete disaster. (Davidmann 1988) It is not actually possible to pass judgement on whether the plan would have been successful or not as its method of introduction was generally seen to be its downfall. In essence, its introduction was not managed in any contemporary sense of the word, it was simply imposed and the chaos that ensued prompted the government to institute another report to glean what lessons it could form the whole affair. (Davidmann 1988). It is fair to comment that the majority of reforms that have been introduced since that time have been far more professionally managed and their introduction (whatever their eventual outcome) have generally been comparatively smooth and uneventful (Bennis et al 1999) The area of change management as a science and discipline is both extremely involved and complex. Changing the structure of a massive and established organisation such as the NHS is clearly difficult with established attitudes, working practices and inherent inertia. The lessons learned from the Griffiths Report appear to have been successfully applied to the introduction of the NHS Plan (Bryant 2005) In specific consideration of the NHS plan we should note that the specific stated aims of the plan were to:- Increase funding and reform Aim to redress geographical inequalities, Improve service standards, Extend patient choice. These aims have been, to some extent translated into reality. Let us examine each in detail. The increased funding was specifically delivered in the March 2000 budget settlement and has been honoured in successive budgets since. The Chancellor of the Exchequer stated that the money made available would ensure that the NHS would grow by one half in cash terms and by one third in real terms in just five years. Our examination of staffing levels (above) would seem to suggest that this trend has been successfully established. In addition, he promised a  £500 million â€Å"performance fund† for specific areas which were to be identified by separate investigation as being in particular need of assistance. (Halligan et al 2001) This certainly directly impinges upon our considerations of support staff and we shall return to this point later. The geographical inequalities and service standards are specifically addressed in the introduction of the National Service Frameworks which are mechanisms for specifically addressing inequalities and setting of both targets and goals of performance and excellence on a National rather than a local level, (Rouse et al 2001) and have been progressively rolled out across the country. These measures have been established in collaboration with assistance and guidance from bodies such as the National Institute for Clinical Excellence (NICE) which has a remit to examine both practices and facilities with the specific aim of achieving national standards. ( viz. NICE 2004) (NHS KSF 2004) It has made a number of recommendations which appear to have a firm evidence base. (Berwick D 2005) We should perhaps take this opportunity to note that the Institute, although undoubtedly set up in response to a worthy ideal, is already finding itself short of funding to do the job that it was originally conceived for. Spokesmen have already commented that it is short of money to achieve the research necessary to justify its continued activity (Shannon 2003) Patient choice is a far more complex issue that it might originally appear. Initial examination might suggest that to give patients the freedom to go where they wish to get their medical care is a fine objective, but closer examination of the issue would reveal that it has numerous pitfalls. In the specific terms of the NHS plan, it actually means that the patient’s primary healthcare team has a more wide-reaching choice of where they choose to refer the patient. (Wierzbicki et al 2001). A patient may consider any number of factors which may influence their choice of hospital including such factors as the general look of the buildings, the geographical site in relation to their friends and family and what they have read or heard anecdotally about the hospital. None of these factors have any major bearing on the treatment that they will receive. It may be that they will discover that the waiting list is shorter at hospital A than hospital B. what may well be less obvious to the patient is that hospital A may have a shorter waiting list because the local primary healthcare teams know that it has a number of serious shortcomings and so they tend to refer their patients to hospital B which consequently has a longer waiting list. Of course , we mustn’t ignore the possibility that hospital A is actually more efficient that hospital B or that hospital C provides a more comprehensive, courteous and efficient service with greater expertise than hospital D, but the primary healthcare teams are generally best placed to see the outcomes of their local hospitals and will generally know where their patients are served better in each individual circumstance. (after Donaldson L 2001) In the context of our examination here, all four of these aims have potential impact on our subject as each of these objectives are effectively resolved by expanding, and in some cases changing, the roles of staff within the NHS. Clearly the impact will vary between different disciplines and indeed, different geographical areas, but the overall objective of improving the efficiency and introduction of patient orientated goals has largely been met by the three expedients of: a) making more money available b) adopting progressive management strategies c) increasing staffing levels and redefining some roles within the NHS ( after Dixon et al 2003) It is perhaps useful to consider the whole of the NHS Plan as part of a reform continuum which has shaped the evolution of the NHS since its inception. We have already highlighted the Griffiths Reforms, but other landmark reforms that impact upon our considerations of change must include the Agenda for Change (2004) which is primarily staff and employment orientated and is concerned with a number of measures including staffing levels, staff role descriptions and staff pay levels. It has only recently been implemented (September 2005) and, for our purposes here, should be viewed in conjunction with another Government White Paper which is the complimentary NHS Knowledge and Skills Framework (KSF 2004). This particular paper targets the need for both recognising and rewarding specific speciality orientated enhancement of both skills and knowledge that are actually relevant to professional performance in both designated areas and in professional performance generally. Reading of the provisions reveals that the general provision of  £280 million over a three year period to â€Å"develop specific designated staff skills†. One of the proposed mechanisms is to set up individual learning accounts which will be worth  £150 per year. It is not yet clear what the impact will yet be on support staff in either specific or general terms. The impact of these reforms seems to be felt on many levels. There appears to be a move towards the redesignation of roles, flexible working, skill mix and the redesignation of professional boundaries. The NHS Plan itself calls for a number of changes to be made in working practices, both general (conceptual) and specific. It also calls for a change in the actual roles of some healthcare professionals, including support staff. It goes into great detail about the need for some of these changes need to be established but it also has to be observed that there is actually very little detail in the Plan as to how these changes are either to be introduced or managed. It refers to the changes in general terms, there is actually very little detail relating to what it expects these changes to actually be in reality. (Krogstad et al 2002) If one were to produce an analysis of the pre-2000 structure of the NHS one could conclude that it had three major problems which were not consistent with the function, structure and organisation of a typical 21st century industry a lack of national standards old-fashioned demarcations between staff and barriers between services a lack of clear incentives and levers to improve performance over-centralisation and disempowered patients. (Nickols 2004) One observation that is also relevant to our considerations here is the phrase â€Å"seamless interface† appears very frequently throughout the document. Although it is primarily applied to the interface between primary and secondary care, it is also, both explicitly and by implication, applied to the interface between different groups of professionals within both aspects of the service. (Rudd et al 1997) In direct consideration of our subject, we can take this to mean that there is a requirement for seamless interaction between all factions of the operating theatre staff and between them and the other professionals in the hospital. (Dixon et al 2003) Other significant milestones in the changes in the role of support staff were the introduction of the National Service Framework. These are a series of recommendations, stipulations and targets which are designed to raise the performance to the level of the best across the nation rather than to have pockets of excellence surrounded by a sea of mediocrity (White M 2005). The issues surrounding the National Service Frameworks are huge, as they collectively cover most of the major therapeutic areas in medicine. The reason for their inclusion in this particular consideration, is because of their collective impact on the role of the support staff, who have to expand their role and skills in order to comply with their requirements. It is completely impractical to consider all of the implications of the National Service Frameworks so, as a representative â€Å"sample† we will consider just one, the National Service Framework for the elderly. In distinct contrast to our comments in relation to the Griffiths Report earlier in this piece, the introduction of the National Service Frameworks could be considered nothing short of exemplary. There have been consultation periods, pre-implementation pilots and possibly most importantly, a well publicised and staged National roll-out programme which was designed to implement each of the strategies in a graded and controlled fashion with the intention of trying to ensure smooth implementation across the country. (Nickols F.2004). If we consider as an exploratory example, a small portion of the National Service Framework for the elderly Standard Two, this states that it should ensure that: Ensure that older people are treated as individuals and that they receive appropriate and timely packages of care which meet their needs as individuals, regardless of health and social services boundaries. One could perhaps reasonably hope that such aspirations would have been unnecessary, but behind the actual words are a number of other concepts that are central to our consideration to the expanding role of the support staff. The concept of â€Å"Person Centred Care† is a central precept of the Standard Two. It is described with the intention of trying to allow the elderly to feel entitled to be treated as individuals and also to allow them to retain responsibility for their own choices for their own care. The expansions of the roles of the support staff comes primarily in the adoption of the main tenet of the concept of Person Centred Care and that is the introduction of the Single Assessment Process (SAP). This recognises that there are effectively a great number of support agencies that potential can be involved to look after the needs of the elderly, both in hospital and after discharge. Prior to the introduction of the National Service Framework, it was common practice for each agency to separately make contact with the patient and make their own assessment in terms of their own distinct considerations. We shall discuss this point later in the context of insularity of specialities. The end result of this process was the fact that, very commonly, the same (or similar) facts are repeatedly elicited on different occasions with all the implications that this type of duplication has on inefficient working and waste of resources. (Fatchett A. 1998). The SAP is designed so that any member of the health care team can assemble the information in such a way and in such a format that it will be of use to the other members of the team, or for that matter any of the agencies who might have a legitimate need for the information. This particular role expansion is designed to assist in reducing the amount of red tape that appears to be an inevitable encumbrance of many of the measures that are designed to assist the elderly patient, and only appears to finish up by hampering them. (Gott M 2000). The adoption of the Single Assessment Process is no more than one example, perhaps not so much of an expansion of the role, but a realignment of the role of support staff. It is still a fairly new concept and is central to the aims of the National Service Framework that the needs and wishes of the patient should be at the heart of the whole process. Because it is new, the extent to which it can accommodate these aims and aspirations alongside the day to day practicalities of service provision still has yet to be fully assessed. (Mannion R et al 2005) In some ways, this new role expansion can be viewed in parallel with the concepts of seamless interfacing and multidisciplinary team working which we have examined elsewhere in this dissertation. Given the fact that the Single Assessment Process has only been operational since April 2004, but the move towards multidisciplinary team working and the concept of the seamless interface has been apparent and espoused for some years (Mason et al 2003). The latter were effectively translated into reality without major upheaval, one can be reasonably confident that the same will eventually be said for both the Single Assessment Process and its implications for both staff and patients. We have described this particular example of role expansion more as a realignment because, at first sight, its implications are quite subtle when compared to other examples that we shall be considering, but equally they are quite fundamental, as they impinge upon the role