Hospital restructuring in smaller urban Ontario settings: unwritten rules and uncertain relations

Important changes are underway in the management and provision of welfare service activities in advanced capitalist societies as governments scale back their responsibilities and commitments to social security and health care. In order to understand the processes by which the reform imperatives of the central state are implemented at the local level, it is necessary to account for particular organizational and place-based contingencies which influence decision making and strategic response. This paper presents a framework for understanding the context of executive decision making in the human services sector and uses the framework to illustrate issues of locally designed hospital restructuring in smaller urban centres in the province of Ontario, Canada. Specific experiences of the Chief Executive Officers of two non-metropolitan hospital settings are examined to explore the unwritten rules of hospital conduct and the relations of uncertainty that characterize efforts to restructure hospital services through formal arrangements with other independently governed hospitals and health care delivery organizations.     

Rural mental health and social geographies of caring

This paper contributes to an emerging geographical literature on the social geographies of caring. Drawing on recently undertaken empirical work in the Scottish Highlands, personal accounts about the provision of both formal and informal care for people with mental health problems are evaluated. The notion of ‘community care’ is critiqued, as too are claims about how rural and remote rural locations engender particular configurations of caring roles, practices and relations. It is shown that geographical distance, social proximity, stoic cultures and rural gossip networks all have a part to play in how caring occurs in such places. The paper concludes by suggesting areas of future research.     

Barriers to Co-Governance: Examining the "Chemistry" of Home-Care Networks in Germany, England, and Quebec

This article aims at studying the dynamics of organized home care and particular problems in the delivery of social services, analyzed against the background of the international recasting of welfare systems. Challenging an influential academic discourse on the advent of new forms of network governance thought to improve service provision, three jurisdictions—Germany, England, and Quebec—are compared with regard to how home-care networks are actually configured and the rationales which appear to shape the interaction between network members. The article argues that notwithstanding the extensive literature extolling the virtues of network governance or the possibility of reconciling different governance modes, home care operates through arrangements embracing conflicting rationales. Rather than providing for mutual adjustment and shared perspectives, contemporary home-care networks tend to produce tensions and outcome problems as a result of the "biased" interplay between various steering rationales within given institutional arrangements and different meta-governance regimes.     

The greying of resource communities in northern British Columbia: implications for health care delivery in already-underserviced communities

The delivery of 'rural' health care services has long confronted the geographic problems of distance, low user densities, low-order facilities and caregiver shortages. As a result, rural and remote communities across Canada have struggled with health care delivery. For rural and remote communities in resource hinterlands, population ageing driven by industrial restructuring presents a significant departure from past experience. Drawing on examples from northern British Columbia (BC), this paper examines this context of ageing in rural and remote locations with the purpose of highlighting impending challenges for health care service provision. In the first part of this paper, we provide a demographic overview of population change and ageing in northern BC. In the second part, we present data on the availability of services throughout the region to support seniors who age-in-place. Population ageing, in areas that have never dealt with this issue before, highlights not only important servicing questions but also important policy questions about how to provide for needs that the policy and community context are not presently equipped to meet.     

British voluntary hospitals, 1871-1938: the geography of provision and utilization

This article examines the distribution of beds, staff and in-patients in voluntary hospitals in England, Wales and Scotland between 1871 and 1938. The findings bear upon two theoretical debates; first, the concern of historians of social policy with the extent to which charity and mutual insurance delivered a satisfactory level of institutional care before the NHS, and second, the broader issue of whether the localism of voluntary sector provision tends to produce a geographically uneven service. We survey the chronology of voluntary hospital growth pointing to reasons for foundations. We then analyse the levels of beds, staff and in-patients per head of population in counties, county boroughs and large burghs. This evidence suggests that despite the expansion of the sector and the narrowing of differences between places, considerable variations in provision and utilization remained. We argue that these variations were likely to have had an impact on the health of individuals. We conclude by tracing the emergence in political and public discourse of the perception that geographical unevenness was a failing of the voluntary system.     

REEVALUATING THE ‘PROCOMPETITIVE’ EFFECTS OF HMOs: A SPATIAL EQUILIBRIUM APPROACH*

ABSTRACT. .The growth of health maintenance organizations (HMOs) commonly has been viewed as a “procompetitive” change in the structure of the health care delivery system. Because HMOs collect a prepaid fee from subscribers, they serve a dual role as insurers and providers of health care. While HMOs may have competed directly with conventional insurance plans, their effect in health care markets is potentially quite different. A multisector spatial equilibrium model, which incorporates the optimizing behavior of consumers, independent fee-for-service(FFS)providers, and a centralized HMO, is used to explore the effects of an exogenous shift in market structure away from FFS delivery toward the provision of seivices by the HMO. As more physicians are diverted from FFS practice to enter the HMO, both the HMO membership fee and prices in the FFS sector tend to rise. This pattern is consistent with empirical trends in the United States during the 1980s where, despite the rapid growth in HMOs and other forms of prepaid care, both FFS prices and HMO membership fees have risen sharply.     

Location or dis-location? Towards a conceptualization of people and place in the care-giving experience

Over the last two decades we have seen an increased interest in informal care within both political and academic communities in the UK. This has stemmed in large part from an increased emphasis on the home-space as the preferred site of care provision and a resultant increase in the complexity of the care-giving relationship. The explicitly spatial dimensions of this caring relationship, however, are vastly under-researched. This paper represents one attempt to redress the gap by examining the importance of place, and its conceptualization, in the care of frail older people. In doing so, the paper focuses, firstly, on the spatial manifestation of care at various scales, identifying some of the processes behind variations in the care-giving experience and, secondly, using the example of dementia care, it considers how Auge´'s concepts of anthropological place and non-space, when applied to domestic and institutional care settings, can facilitate a more nuanced understanding of the importance of people and place in the construction and delivery of care to frail older people.     

Progressive localism for an ethics of care: Local Area Co-ordination with people with learning disabilities

In the UK devolution to ‘new’ nations and localities is generating differences in the tone and substance of social care. In Scotland there is an apparent rejection of the ‘personalisation’ model dominant in England and other neoliberal welfare states; in its place, there is an emphasis on locally based co-produced care provision, involving local organisations, practitioners and individuals. The paper argues that this is an outcome of the open and deliberative nature of policy-making, and the further devolution of social care provision to local authorities in Scotland. Local scale networks and spaces of provision are generating a ‘progressive localism’, contesting the association between the local scale and financial austerity, drawing on a relational understanding of place. Non-commodified and locally-based provision expands the discourse of care from ‘caring for’ individuals to ‘caring about’ people and places, in what is termed an ‘ethics of care’. The paper uses the example of people with learning disabilities to examine a more broadly conceived ‘caring’ within local communities, offering possibilities for inclusion and belonging. The paper draws on interviews with key policy makers and place-based care practitioners, known as ‘Local Area Co-ordinators’.     

Women's paid work and moral economies of care

Female labour force participation has been increasing in recent decades, in part encouraged by state policies to raise the employment rate to encourage economic competitiveness and combat social exclusion. Social provision for care, however, has lagged behind this increase, creating practical and moral dilemmas for individuals and for society, facing parents with complex choices about how to combine work and care. In this paper, we draw on a qualitative study in London to explore the extent to which the large-scale entry of women into waged work is altering women's understandings of their duties and responsibilities to care for others. We conclude that their decisions are influenced by class position, entrenched gender inequalities in the labour market, varying abilities to pay for care and complex gendered understandings of caring responsibilities.     

Care,pay, love: commodification and the spaces of live-in care

This paper investigates uses of the concept of commodification in contemporary analyses of waged care. Drawing on theoretical work on commodification and discourse-analytical research on private live-in care in Switzerland, I explore how Swiss live-in care questions central discussions in the literature. Scholars have focused on the ways in which care is embroiled within market relations and the adverse effects of commodification on the character and quality of care. The paper outlines the two central discussions, identifies important limitations and explores the ways in which Swiss live-care contests their underlying assumptions. Swiss live-in care exhibits intricate processes of waging elder care. Live-in care services are offered and arranged on agency websites while taking place at elderly persons’ private households. Elder care thus becomes entangled in market relations both in virtual spaces and at home. Furthermore, live-in care workers do not distance themselves from their work but actively seek to improve their conditions of work. In so doing, they complicate the assumption that paying for care corrupts caregiving or turns it into a product for sale. Based on this evidence from Swiss live-in care, I propose that a careful use of commodification might best serve feminist interventions.     

“It's not like your home”: Homeless Encampments,Housing Projects,and the Struggle over Domestic Space

Based on an analysis of housing projects and homeless encampments in Fresno, California, this paper argues that both anti‐homeless policing and housing provision mutually constrain homeless people's expressions of home, such that struggles over domestic space have become integral to the contemporary politics of US homelessness. In particular, this article asserts that contemporary homelessness policy is marked by a clash between competing visions of home. While housing projects in Fresno are based on a model of privatized and surveilled apartments, people who lived in local encampments often asserted alternative notions of home grounded in community rather than family, mutual care rather than institutional care, and appropriation rather than consumption. Meanwhile, local officials viewed such alternative domestic spaces as non‐homes worthy of destruction. Rather than valorizing domestic struggles above public or institutional struggles, this article seeks to move beyond geographic binaries to more holistically approach the politics of US homelessness.     

Including people with learning difficulties in cultural and heritage sites

This paper examines the processes involved in a participatory inclusive research project in Liverpool and Merseyside, UK. The project involved 25 people with learning difficulties – the Heritage Forum – visiting 13 cultural and heritage sites on more than 50 occasions across a 15‐month period. The research provides a much needed resource at a time when there is a lack of provision for, and research into, the intellectual accessibility of cultural and heritage sites in the UK and globally. This paper details the research approach taken by the Heritage Forum, providing a flexible protocol about ways of working with groups and individuals with learning difficulties. It also reports on the Heritage Forum’s general findings about the cultural and heritage sites, providing some initial guidance about how to best include this diverse population.     

Iranian Studies in the United Kingdom in the Twentieth Century

This essay provides a general introductory survey of Iranian and Iran-related studies in the United Kingdom in the twentieth century (including languages, literature, and the arts), with a very brief preliminary foray into earlier Iran-related scholarship and wide-ranging imaginations of Iran in Britain and Ireland, as well as some concluding remarks on contemporary knowledge production about Britain in Iran. Among other themes covered in the essay are the varied contributions of non-Britons and non-Irish to Iran-related scholarship and imaginations in the United Kingdom, underscoring the overall transnational production, dissemination, reception, and utilization of knowledge (history, geography, archaeology, cultures, ethnography and anthropology, art and architecture, Iran-related Persian-language literatures and poetry, etc.). In particular, the essay highlights the contributions made by individuals from, and institutions in, the Indian subcontinent to “British” scholarship and knowledge about Iran.     

An historical geography of liberty: Lancashire and the Inebriates Acts

This paper examines the Inebriates Acts of 1879 and 1898 which facilitated the formal provision of institutional care for inebriates. The Acts' permissive character produced an uneven geography of provision of institutions that meant that inebriate treatment varied markedly across the counties and county boroughs of England and Wales. The vast majority of those committed under the Acts were women. Using two exemplary case studies from Lancashire, a private retreat created under the 1879 Act and a council run reformatory created under the 1898 Act, the paper considers how debates about liberty and control shaped the regulation of problem drunkards. It shows that geography was as important as class, religion, and gender in determining who was subjected to regulation. The paper argues that the failure to reform inebriates helped the recoding of inebriety within a broader discourse of mental deficiency that encouraged the permanent segregation of problem populations.     

The impact of centralisation upon geographical variations in the provision of aged care services: a comparison of outcomes in Melbourne and Adelaide

This paper examines the extent to which centralisation affects service delivery through a comparison of geographical variations in community-based services for the aged in the cities of Melbourne and Adelaide. The first part outlines the administrative structures in the two cities. This is followed by a comparison of geographical variations in the provision of meals-on-wheels services and residential accommodation within the cities. The final part considers the implications of the results for our understanding of the influence of centralisation upon service provision in Australian cities.     

Medical versus social work-places: constructing and compensating the personal support worker across health care settings in Ontario,Canada

This article explores the role of place in explaining variation in caregiver compensation. Using the labour category of Personal Support Worker (PSW) in Ontario, Canada, it contrasts wage rates across three health care settings: hospitals, long-term care facilities and private homes. An evaluation of current literature from disciplines spanning geography, gender studies, political science and sociology is combined with a critical analysis of policy documents and wage data to reveal that, despite holding similar qualifications and performing comparable job duties, hospital-based workers receive higher wages than home-based workers. I theorize that this wage disparity is partially attributable to the historical privileging of hospital settings in Canada, based on a medical-social continuum of health care valuation. Given that the hospital is constructed as a highly medical place, whereas the home is considered to be a social place, caregiving work enjoys greater financing protection in the former. I argue that these constructions stem from deeply gendered historical roots which view the marketplace as a male-dominated setting for productive waged labour, and the home as a female-dominated setting for unpaid social pursuits. Thus, when personal support services shift from public institutions into private homes, these activities become invisible to the state, and their provision beyond its purview. I conclude that the medical versus social nature of the duties performed by PSWs has become secondary to the medical versus social nature of the setting in which these activities take place. This has translated into lower wages for home-based PSWs, effectively resulting in wage discrimination.     

Sceattas in Anglo-Saxon Graves

ANGLO-SAXON SILVER PENNIES (sceattas) are rare as gravegoods, but their provision was a regular element of burial practice in a small minority of later 7th-century-furnished inhumations and later burials. Although the number both of coins and burials is very small, they show patterns of deposition and treatment that have both a cultural and a broader chronological significance. This sample provides a window on social and symbolic attitudes to the coinages as elements of the broader material culture of contemporary society, and constitutes important corroborating evidence that the Primary Phase issues embodied a new degree of monetisation in 7th-century England.     

Out from the (Green) shadow? Neoliberal hegemony through the market logic of shared urban environmental governance

Recent work in critical geography describes the neoliberalization of urban social service provision through a transition from state provision to civil sector delivery. The concept of a ‘shadow state’ is deployed by some social theorists to describe this process by which nonprofits with government contracts increasingly adopt a state-oriented agenda for the execution of social entitlement programs. Possible linkages between the neoliberalization of urban environmental service provision and a shadow state are lacking by comparison. I, therefore, use qualitative data concerning three organizations in Milwaukee, Wisconsin to demonstrate that civil sector groups are stepping up as local government diminishes its markets for municipal environmental labor. However, the diverse compositions of these shared governances potentially complicate the efficacy of a shadow state thesis for describing environmental provision in inner-city Milwaukee. Instead, I argue that a Gramscian interpretation of shared governance better accounts for the neoliberalization of environmental service provision as government agencies and civil sector groups relate to one another through hegemonic market logic. I argue that this provides a more nuanced picture of how governance concerning the urban environment is constructed by the government, market, and civil sectors to further shape human social reproduction.     

Gendering pastoral power: masculinity,affective labour and competitive bonds of solidarity among Filipino migrant men in Saudi Arabia

This article draws on Foucault’s concept of pastoral power to understand Filipino men’s care work and the making of migrant masculinities in Saudi Arabia. Feminist scholars have indicated the gendered nature of pastoral power and emphasized what Young refers to as the ‘logic of masculinist protection’ that characterizes the contemporary security state. However, the notion of pastoral power invites further consideration of the taken for granted cultural assumptions about the way that hegemonic masculinity and forms of homosociality are characterized mainly by aggression, competition and dominance. Men’s talk about and practical involvement in assisting fellow migrants in diasporic settings foregrounds the way that an ethics of care runs up against and is entangled with the competitive bonds of masculine solidarities. While markers of material success are privileged in measuring migrant men’s accomplishments in country of origin, practices of care become central to men’s achievement of symbolic power and social legitimacy especially among their peers in the diaspora. That spatialization is also linked to temporally shifting models of masculinity and normative expectations about men over the life course.