Colonists Essays - Stamp Act, Thirteen Colonies, Quartering Acts

Colonists Britain had a new policy when it came to it's colonies. All they had to do was inforce the laws they already had, not make new ones. George Greenville, Britains Prime Minister from 1763 to 1765, didn't realize this. To raise money for Britain after the expensive French and Indian war, they decided to tighten control on the colonies The Proclamation of 1763 was the first of five laws passed to accomplish this new goal. This "proclamation" reserved lands west of the Appalachian Mtns. for use of the Indians. The frontiersmen were the first to get angry at the new land law because they wanted to settle in the unexplored west. Then in 1764 the British parliament passed the Colonial Currency Act. This act took away the right of any colony to issue its own paper money. This lead to increased poverty and hardship after the French and Indian war. The people opposed it because if more money was in circulation the economy would of been better. The Sugar Act in 1764, put a tax on sug ar, molasses, wines, and other foreign products. This upset one Samuel Adams. After having lived in the colonies some years and being a successful merchant, He felt that the law was particularly unfair for merchants, as they were the most taxed. This also increased fear among the colonists that they would lose the right to determine taxes among their own colonies. Later in the next year of 1765, the Stamp Act was decreed. Special stamps were now required on newspapers, playing cards, business papers, and other legal documents. This law hurt the common man, but most the wealthy. John Adams, a well respected Virginian, wrote a partition to the king of Britain to repeal the act. Daniel Dulainy led protest with the people using effigies and all. They were afraid that there would be an increase of external taxes and the colonies would lose the right of thier own taxation. The Quartering Act in 1765, colonists had to give British troops places to live, some supplies, and part of their salaries. The New York assembly opposed this because it was an infringement on the rights of "British Citizens" and represented a removal of colonial self government. It is now apparent with these new laws the citizens of the 13 colonies felt violated and used. They did not feel they were properly represented in parliament nor that the king should have any right to oppose restrictions on them each time a new law was passed, more resentment and anger would increase thus was born the American Revolution.

Time Transfixed essays

Time Transfixed essays RENE MARGRITTE, TIME TRANSFIXED, 1938 Time transfixed by Rene Margritte is a surrealistic painting. By watching the painting We see a very sharp and clear painting with dark colors close to the red. The painting look so real that fools the eye and the observer has the impression that it is a computer graphic and not a real painting. The composition its ruled by straight diagonal lines. But there are some vertical lines to break the monotony and to relax our eye. Our vision goes straight to the fireplace because its the only object on white and attracts our attention. It is a strange composition. There is a fireplace and a train coming through it. Its the train that travels through the time. But why come through the fireplace? That because is surrealistic. On the top of the fireplace are two candles. The candles are not lit. But the painting is illuminated by natural light coming from the right. The candles symbolize the knowledge. In meddle of two candles is a black watch showing 1 oclock. The watch symbolizes time and the mystery of time! On the back is a mirror. It reflects only the shape of the candle and the watch and nothing else. There is void space on the mirror. Thats because the mirror symbolizes the mystery of the Universe and our ignorance for the mysteries that Universe hides and the forth dimension TIME. By seeing the painting the observers has the impression that there is void space in the room too. The mirror and the fireplace, which looks like an empty box, give that impression. We dont know if there is void space in the room b ecause we see only a part of it. There are also implied lines. Its the painting line that goes from the left to the inside right and the light line that goes from right to inside left. Those lines meet together at an another horizontal line, which passes through the train and the watch. These lines give more focus to the train and ...

Probability Assignment Speech or Presentation Example | Topics and Well Written Essays - 500 words

Probability Assignment - Speech or Presentation Example Since the committee consists of 3 members, there are 3! possible permutations of any committee. Thus, we need to divide the number of permutations by 6 to get the number of combinations: When a coin is tossed once, there are two outcomes. It can turn up a head or a tail. When 10 coins are tossed simultaneously, the total number of outcomes = 210. In this event, if the third coin were to turn up a head, then the number of possibilities for the third coin is only 1 as the outcome is fixed as head. Therefore, the remaining 9 coins can turn up either a head or a tail equals 29. The first envelope can be posted in any of the 3 mailboxes. Hence, there are 3 choices for it. Similarly, each of the other four envelopes can be posted in any of the 3 mailboxes. Therefore, the total number of ways these 5 envelopes can be posted in the 3 mailboxes is 3*3*3*3*3 =

Schools can Help Prevent Childhood Obesity Essay

Schools can Help Prevent Childhood Obesity - Essay Example School cafeterias are obliged to offer healthy food choices. This is the underlying principle of the National School Lunch Program (NSLP), started in 1946. The federal school lunch and breakfast program caters to twenty-nine million school children daily and aims to provide nutritionally balanced meals at a cost of seven million a year to taxpayers (Fried and Simon, 1492). 99% of all public schools and 83% of private schools participate in the program which reimburses the cost of the breakfast and lunch and provides commodity supplies (Leviton, 43). The US Department of Agriculture (USDA) provides dietary guidelines and nutritional standards for schools in implementing the NSLP. Based on recommendations made by the Institute of Medicine of the National Academies, the NSLP aims to â€Å"enhance the diet and health of school children, and help mitigate the childhood obesity trend† (USDA web site). Schools are required to increase the availability of fruits, vegetables, whole gra ins and low-fat milk and reduce the levels of sodium and saturated fats. The ‘Farm to School’ program attempts to bring fresh, locally produced food into school cafeterias and introduce children to farms, gardening, and cooking. In theory, all schools under the NSLP provide balanced nutritional meals. However, the reality is different: a 2009 study published in the Journal of the American Dietetic Association found that 94 percent of school lunches failed to meet the USDA’s regulatory standards regarding the sodium or total fat standards. Dana Woldow, a mother who is a volunteer in her children’s school nutrition committee, says, â€Å"In the school cafeteria you could buy soda, potato chips, snack cakes, corndogs, French fries, apple turnovers, ice cream --you know, carnival food† (Christensen). This is largely because frozen and processed foods are cheaper than fresh or organic produce and the NSLP is under-funded. Schools also procure pre-cooked food as they do not have kitchens. It is clear that there is much room for improvement in school cafeteria’s ability to provide a nutritious diet for all students. The healthy food offerings in school cafeterias are significantly off-set by the availability of ‘competitive food.’ This term refers to foods of little nutritional value which compete with the NSLP funded school breakfast and

Introduction about Drones and Seattle Police's Drones Essay

Introduction about Drones and Seattle Police's Drones - Essay Example The ones used for attacking enemy lines have recently been a part of war on terrorism where they are used to figure out enemies on the ground and then they are used to eliminate these enemies. The ones used for surveillance purposes have been used both domestically and internationally for security purposes. For example: recently the state of Seattle purchased two drones each costing a total of $41,000 (Clarridge, 2012). These drones are under the testing phase and are controlled by the police department of Seattle. These drones have been adopted by the police department for the purpose of surveillance and these drones have cameras along with infrared eye attached to it. There are various benefits of using drones, these include: they are in expensive, they save lives and they provide a competitive advantage to the side that is using them (Benjamin 18). Clarridge, Christine. "Police Department demonstrates new drone, to help allay concerns | Local News | The Seattle Times." The Seattle Times | News, sports, weather, events in the Northwest. N.p., 27 Apr. 2012. Web. 13 Mar. 2013.

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

Essay --

In the period 1865-1900, technology, government policy, and economic conditions all greatly changed American agriculture at the expense of the farmers. New farming machinery had a large role in the late 19th century, giving farmers the opportunity to produce a surplus of crops. The railroads also had a large influence on agriculture. Although they were able to quickly transport goods, the railroads were also used to charge the farmers large fees. The booming industry also changed American agriculture, creating a multitude of monopolies which the farmers simply could not compete. Economically, the monetary policy along with the steadily dropping prices of agricultural produce led farmers further into debt, eventually producing outcomes such as the crop-lien system and sharecropping. All of these tie into government policy which favored the large and wealthy industries and monopolies over the farmers. Farmers began to cultivate vast areas of crops such as wheat, cotton, and corn. A picture of The Wheat Harvest in 1880 shows men on tractors and over a large amount of horses pulling the tractor along the long and wide fields of wheat. As farmers started to accumulate their goods, they needed to be able to transfer the goods across states. Some farmers chose to use cattle trails to transport their goods while others were forced to choose, and pay for, the ever-growing railroad system. Maps provided show the difference in the amount of railroads and cattle trails within the Unites States from 1870 to 1890. Eastern States such as New Jersey, Tennessee, Virginia and many others were filled with existing railroads prior to 1870, as Colonel John Stevens started out his railroad revolutionizing movement in New Jersey in 1815. By 1890 there ... ...e greatly needed and then how they got across to states that would take weeks and months to get to by cattle or wagon. It also showed a time when the economy fell and desperately tried to climb back up. To sum it up, throughout the period 1865-1900, technology, government policy, and economic conditions all changed agriculture in America but at the expense of the farmers. New farming machinery gave frames the ability to produce more crops. Railroads quickly transported goods but also forced farmers to pay hefty fees. The booming industry also changed American agriculture, creating monopolies which the farmers could not compete with. Economically, the monetary policy along with the steadily dropping prices of agricultural produce led farmers further into debt. And, finally, the government policies favored large and wealthy industries and monopolies over the farmers.

Reflect on the importance of a child centred approach in the Early Years Essay

A – Reflect on the importance of a child centred approach in the Early Years A child centred approach in early years settings is important as it makes sure the children’s needs are met fully and it helps them reach their full potential. Children reflect their interests through their learning and different experiences. It is important for practitioners to encourage this so they can find out what the children are interested in and then later use the information when planning activities. Having a show and tell gives practitioners a chance to find out about what the children like and enjoy. They are also showing the children that they are interested in what they get up to when they are not at school. (Also relates to C) Another way of finding out more about the children is by getting them to take a toy home for a period of time then getting them write a diary of activities they did with the toy. Knowing what the children like can also help the practitioner improve their tea ching methods. For example, if they know some of the children like the police, they can turn the home corner into a police station. This would encourage the children to take part in more activities because they would enjoy what they are doing. (C) It is important to have different ability groups in an Early Years setting because it can help the children reach their full potential as they would be going at a pace that is suitable for them and not for someone else. This also gives the children the chance to help each other in the group because they would be at the same stages and most likely get caught out at the same sections. According to Vygotsky, â€Å"By letting students of similar but differing abilities work in groups, they can help each other: often a lot more effectively than a teacher would be able to.† (Urbano, 12/07/12, Scaffolding and Peer-learning: Thinking about Vygotsky’s â€Å"Zone of Proximal Development†) Performing observations can also help children reach the ir full potential because practitioners can see if the children are at the expected development stages for their age, and if they are not, they can support the children in the specific areas they need help with. It is important to work in partnership with parents because â€Å"parents have the most knowledge and understanding of their child† (Beaver et al, 2008, pg 27) so practitioners can learn from them about how best to help the children and encourage them to improve their abilities. The planning cycle is a useful guide for helping practitioners look at the different types of development in a child. Using the cycle can  help practitioners respond to the children’s needs because they can work out what needs to be observed, then after the observations they can analyse their findings and make plans that would benefit the child. When the plan has been put into motion another assessment can be done on the child to see if there have been any improvements. The cycle can be repeated to continue helping the child.

Term limits debate essays

Term limits debate essays The speaker will yield to no questions...... through out history the reasons for presidential and congressional term limits have been seen in the governments around the world. On every continent a ruler can be found, who is tyrannical and dictatorial. every government that does not have term limits runs the risk of having a corrupt and power hungry official abuse the power they have to rule. Term limits are the only way for a government to ensure the influx of new ideas and thoughts and to prevent one individual from becoming to powerful. In the authoritarian government established in Iraq by Saddam Hussein the usefulness of term limits can be seen quite clearly. After a military coup in 1968 , Hussein established himself as the head of a revolutionary command council with absolute authority over the country. Through out his rule Saddam Hussein has lead his country into many bloody and costly wars with the countries surrounding Iraq. Through his stubborn ideas and unrelenting policies he has inflicted much damage on his country. He represses and has led violent persecutions on religious minorities. Even his close circle of family and friends began to doubt his policies. B/c of this he had many of them arrested, exiled and some even killed....especially those he thought were after his rule. This shows his irrational need for power. If presidential term limits had been in place his power would have been restricted by those limits instead of allowing his hunger for power to grow into a bloody 20 year regime. Fidel Castros regime in cuba is also an example of circumstances that could have benefited from term limits. After gaining power by a military coup, castro became prime minister. In 1961 he cancelled the romised elections and suspended Cubas constitution. A constitution that he argued for in court only a few years before. Castro ruled cuba with complete disregard for the constitution from 1940 to 1976. The nation...

On the Road essays

On the Road essays World War II marked a wide dividing line between the old and the new in American society and the nations literature(The World Book Encyclopedia 427) . When world War II ended there was a pent up desire that had been postponed due to the war. Post war America brought about a time when it seemed that every young man was doing the same thing, getting a job, settling down and starting a family. America was becoming a nation of consumers. One group that was against conforming to this dull American lifestyle was referred to as Beatniks. The Beats or Beatniks condemned middle class American life as morally bankrupt. They praised individualism as the highest human goal(The World Book Encyclopedia 428). This perspective was present in poetry and literature through out the beat movement. One of the most important works produced during the beat movement was Jack Kerouacs On The Road. In the novel Jack Kerouacs alter ego Sal Paradise represents the American man who realizes he doesnt want to co nform to societies pressures but still hasnt realized what it is exactly he wants to do. He is a man who has very little direction and is very much lost in the world as he knows it. Kerouac seems to be constantly trying to escape. In examining the novel one might wonder what is Kerouac escaping and by what means does he do so? Kerouac used two means of escape through out the novel and through out his life. His first means of escape was his constant travel. He traveled from east to west, New York to San Francisco and stopped everywhere in between. He made this trip over and over, constantly on the road. The simple title of the novel exemplifies Kerouacs ongoing need to travel. When he and his friends got tried of traveling east to west they traveled north to south, driving all the way down to Mexico City. His travels gave him the opportunity to be an outsider with no worries. He was abl...

Starbucks Company. Audit Report Essay Example | Topics and Well Written Essays - 4000 words

Starbucks Company. Audit Report - Essay Example In this report, the focus is on ethical dilemmas in Starbucks Company. As at October 2011, Starbucks has 149, 000 employees, operating over 17, 000 Coffee Shops globally, spread in approximately 40 countries (Hoovers, 2011, p.1). Out of the outlets, The United States accounts for most of the outlets, meaning that the country forms the base of the company’s operations (Hoovers, 2011, p.1). The relative importance of the ethical dilemmas and the ways, in which the company deals with the dilemmas, shows its strength. Mostly, ethical organisations achieve success in their business undertaking and corporate citizenship. The combined factors have led to the success in Starbucks Company. Despite the improvements, which the company has made on its corporate ethics, there are various ethical dilemmas that it faces. 2.0 Ethical Dilemmas in the Company In essence, the ethical dilemmas of the company could be understood well using the stakeholder’s analysis to unveil the truth. Literally, stakeholder’s analysis is the detailed consideration of the people within, or outside the company whose influence in the business operation is significant. According to Crane and Matten (2010:62) â€Å"a stakeholder is a individual or a group which is either is harmed by or benefits from, the corporation; or whose rights can be violated or have to be respected by the corporation† ... The stakeholders, both internal and external are regarded as important since they contribute to the development of the company. In fact, the company has full influence on the stakeholders to maintain their public image. The chairman refers to the stakeholders of the company as skilled work-force in coffee industry. As an International company, the stakeholders embrace diversity of intellect, race, colour, taste, and religion without any form of discrimination, or prejudice. As any other company, Starbucks face a lot of ethical challenges during their operations. Those challenges either impact negatively or positively on the stakeholders and the communities of operation. Some of the ethical dilemmas facing the company include protection of private information, intellectual property, diversity and conflict of interest. The issues have been ranked according to their impact on the stakeholders. Rank Issue Stakeholder Why this issue has been ranked in this position 1 Data from customers C ustomers They are the most important Stakeholders. 2 Intellectual property Employees They make the organistion operate daily. 3 Diversity Employees They make the organistion operate daily. 4 Conflict of Interest Suppliers They supply necessities to the organisation. 2.1 Customers - Private Information being Held on Customers One of the ethical dilemmas that the company faced was the need to protect the information received from the clients concerning the business ethics and adherence to compliance requirements. Since data were collected from, the customers could threaten personal security, there was need to protect the identity and security of the person disclosing the data. Indeed, the information might threaten a person’s safety if confidentiality of the data is

Extended Self and Consumerism Essay Example | Topics and Well Written Essays - 1500 words

Extended Self and Consumerism - Essay Example For example, some of us are focused on personal comfort and buy cars; some other people want to collect money or some trifles to satisfy their aesthetic desires, needs and wants. It is possible to claim that Oscar Wilde's main characters were often considered about their appearance to the greatest extent. These ideas are relevant to the modern context, because they underline that people appreciate their appearance and buy the objects of art, luxury or jewelry just to look good. In other words, people create their own images by means of different products and objects. To correlate the principles of consumerism with our daily behaviors in the market, it is necessary to have a strong theoretical background and up-to-date empirical material. The works by Belk (1988) and Goffman (1990) are illustrated by blogs of the consumers in the Internet. Consumerism and Blogs Belk claims that "if involuntary loss of possessions causes a loss of self, one of the primary reactions following such loss should be an attempt at self-restoration. This phenomenon has been observed in psychoanalysis and has led to the hypothesis that, along with body loss, object loss is the fountainhead of creativity" (Belk, 1988). Therefore, we can claim that the things we own reflect our inner stability. We are well-balanced personalities in case we feel all right and feel our ability to buy a thing or object we want. It sounds like individuals are not complicated individuals. We do not need much, but we want much. Now, when there is a perfect opportunity to share your aspirations with the global community, we are pleasantly sharing this opportunity and use this chance perfectly. When we buy pets, very often we subconsciously chose those breeds, which will look like us. We extend our selves in our dogs; we want to become their masters and parents at the same time. In one blog post there was a commentary about a similar nature of a dog and a master of a dog: "We spend money on our dogs,  pampering them with fancy collars and toys.   Investing in our pets has become a part of being a pet owner, and it speaks of our morals as pet owners.   If someone refuses to take their sick pet to the vet it’s similar to declining to take a child to the doctor" (The Extended Self). From this perspective pets are associated with our desire to nourish ourselves, or extended part of us as much as we want.    On the basis of several blog posts by Chinese consumers we will talk about correlation between the extended self and intentions of buyers to get some products or goods. A purpose of modern blogs can be considered as a means for consumer culture promotion. Cyberspace is a modern plane for promotion of desires and interests of the customers in some goods. Blog is a unique means for self-expression online. It is a kind of a modern diary, which can include up-to-date photos and music. Incomes and urban consumer culture is being developed at a full pace in China. Of course, it is mo re natural of women to update their information about blogs if they talk about their purchases. Thus, "Jessie† updates the world on her blog about new additions to her private closet, and discusses her favorite possessions ranging from a pair of Converse shoes to Abercrombie shirts. She writes about what she already has and laments what she could not afford to have" (Xin Zhao, Belk 2007). On the one hand, this girl does not have any problems and she can