Discretion used to be considered a feature of individuals, but growing literature shows that it has collective features as well. To develop an understanding of the individual and cooperative work of inspectors in using discretion and the discretionary room granted to them, we compared two inspectorates: the Care Quality Commission (CQC) in England and the Joint Inspectorate for Youth (JIY) in the Netherlands. Our analysis reveals that inspectors engage with colleagues, managers, and stakeholders to include other perspectives, gain mandate, and broaden their repertoire. At the CQC, inspectors use their discretion collectively; on their own initiative, they involve others in balancing and interpreting rules to reach judgments. At the JIY, teamwork is central and regulatory teams are granted collective discretionary room. We argue that collective work permits both responsiveness and consistency. In studying the judgments of inspectors and other street-level bureaucrats, it is vital to look at collective work and how it combines consistency and responsiveness.

BackgroundUsers of care services are increasingly participating in inspections of the quality of care. In practice, incorporating service users’ views is difficult, as users may have other views on good care than inspectors and thus give information that does not fit the inspectors’ assessment criteria. This study compared the views on good care of young care users (adolescents) and inspectors, seeking to understand what the differences and similarities mean to incorporating the users’ views in inspections.MethodsWe conducted a single-case study combining document analysis with a meeting with inspectors. The selected case came from a Dutch inspectorate and involved a thematic inspection of care for children growing up poor.ResultsInspectors and adolescents agree on the importance of timely care, creating opportunities for personal development, and a respectful relationship. The views on quality of care differ with regard to sharing information, creating solutions, and the right moment to offer help. We identified three ways inspectors deal with the differences: 1) prioritize their own views, 2) pass the problem onto others to solve, and 3) separate the differing perspectives. With similar viewpoints, inspectors use the adolescents’ views to support their assessments. When viewpoints conflict, information from adolescents does not affect the inspectors’ judgments. Explanations are related to the vulnerability of the adolescents involved, the inspectorate’s organizational rules and routines and the external regulatory context.ConclusionsService user involvement in inspections potentially impacts the quality of care. Yet, conflicts between the views of service users and inspectors are not easily overcome in the regulatory context.

BackgroundSchools are regarded as an important setting for the prevention of overweight. This study presents a nationally representative picture of the obesogenity of the school environment, the awareness of schools regarding overweight, and actions taken by the schools aiming at overweight prevention. In addition, differences between school levels were studied.MethodsIn 2006-2007, questionnaires were sent to all Dutch secondary schools (age group 12-18 years). Prevalences of the outcome variables were calculated for the schools in total and by school level. The association between school level and outcome variables were analysed by a log linear regression.ResultsUnhealthy foods and drinks are widely available at secondary schools. One third of the schools indicated that overweight has increased among students and half of the schools agreed that schools were (co)responsible for the prevention of overweight. Only 3% of the schools have a policy on overweight prevention. Small differences were observed between vocational education schools and higher education schools. The presence of vending machines did not differ by school level, but at vocational education schools, the content of the vending machines was less healthy.ConclusionThis study describes the current situation at schools which is essential for the development and evaluation of future overweight prevention policies and interventions. In general, secondary schools are not actively involved in overweight prevention and the nutritional environment at most schools could be improved. The small differences between school levels do not give reason for a differential approach for a certain school level for overweight prevention.

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Background: In the regulation of healthcare, the subject of patient and family involvement figures increasingly prominently on the agenda. However, the literature on involving patients and families in regulation is still in its infancy. A systematic analysis of how patient and family involvement in regulation is accomplished across different health systems is lacking. We provide such an overview by mapping and classifying methods of patient and family involvement in regulatory practice in four countries; Norway, England, the Netherlands, and Australia. We thus provide a knowledge base that enables discussions about possible types of involvement, and advantages and difficulties of involvement encountered in practice. Methods: The research design was a multiple case study of patient and family involvement in regulation in four countries. The authors collected 1) academic literature if available and 2) documents of regulators that describe user involvement. Based on the data collected, the authors from each country completed a pre-agreed template to describe the involvement methods. The following information was extracted and included where available: 1) Method of involvement, 2) Type of regulatory activity, 3) Purpose of involvement, 4) Who is involved and 5) Lessons learnt. Results: Our mapping of involvement strategies showed a range of methods being used in regulation, which we classified into four categories: individual proactive, individual reactive, collective proactive, and collective reactive methods. Reported advantages included: increased quality of regulation, increased legitimacy, perceived justice for those affected, and empowerment. Difficulties were also reported concerning: how to incorporate the input of users in decisions, the fact that not all users want to be involved, time and costs required, organizational procedures standing in the way of involvement, and dealing with emotions.

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Inspectorates have been criticized for assessing compliance with the rules rather than outcomes for children. In the Netherlands, inspectorates have developed a ‘journey tool’ to reconstruct children's travels through all the organizations providing care. Using document analysis and semi‐structured interviews, we evaluated how inspectors use this tool in practice. We applied an ontological theoretical framework to the coordination of care to analyse 24 journeys through care organizations, including a selection of six journeys in further detail. Our analysis shows that up until now, inspectors used only one form of coordination, the creation of a hierarchy, resulting in one problem definition. However, in complex care practices, children have multiple and often incompatible problems so that one coherent problem definition cannot be made. We show that ‘patchwork’, a form of coordination that allows discrepancies enables inspectors to reflect on complex care practices and evaluate options to improve outcomes for children.