Showing papers in "Health & Social Care in The Community in 2005"

'I daresay I might find it embarrassing': general practitioners' perspectives on discussing sexual health issues with lesbian and gay patients.

Abstract: The present paper explores general practitioners’ (GPs’) perspectives on the difficulties which they face when discussing sexual health issues with lesbian and gay patients in primary care consultations. It draws upon data obtained from a qualitative interview study with 22 GPs aged between 34 and 57 years who were practising in Sheffield, UK. Interviews were transcribed verbatim and the data were analysed thematically. The results indicate that (non-hetero)sexual orientation could form a barrier to talking about sexual health matters for almost half of this GP sample. Difficulties related primarily to ignorance of lesbian and gay lifestyles and sexual practices, and also included concerns about the appropriate language to use and assumptions about the nature of gay men’s relationships. Homophobic attitudes were also identified in a minority of the sample. Participants suggested improvements around improving communication about sexual health with lesbian and gay patients. These included training at undergraduate and postgraduate levels, taking a proactive role during consultations, not making assumptions about patients’ sexual orientation and having a non-discriminatory policy for their practice.

Families' experiences of caring for technology-dependent children: a temporal perspective.

Abstract: In the present study, families' experiences of caring for a technology-dependent child were examined from a temporal perspective. This involved exploring the multiple 'technological', 'social' and 'natural' rhythms and routines around which the families' lives were variously structured. A purposive sample of 36 families with technology-dependent children who used one or more medical devices on a daily basis was recruited. Devices included feeding pumps, suction machines, dialysis machines and ventilators. Using mainly qualitative methods, children, parents and siblings were interviewed to establish what the care routines involved and how these impacted on family members. The authors found that the rhythms and routines of care varied across the sample, depending on the type and number of devices used, the individual child's needs, and who provided technical care during the day and/or at night at home and in other settings. While the children's health and quality of life benefited from the technology, the time demands of the care routines and lack of compatibility with other social and institutional timeframes had some negative implications for the children and their families, limiting their participation in school, employment and social life in general. The need to use and oversee the use of some medical technologies at night also meant that many parents suffered regular disruption to their sleep. In conclusion, the authors argue that the care of technology-dependent children at home places considerable time demands on families. Families have little or no access to suitably trained carers who can provide technical care required in the home or away from the home to give parents and the whole family a break from caring where required. More trained carers and short-term care provision, better coordination of services and improvements in the design of devices would all help to reduce the negative effects of the care routines on families.

How place matters: unpacking technology and power in health and social care.

Abstract: The devolution of care into nontraditional community-based settings has led to a proliferation of sites for health and social care. Despite recent (re)formulations of 'evidence-based' approaches that stress the importance of optimizing interventions to best practice by taking into account the uniqueness of place, there is relatively little guidance in the literature and few attempts to systematically 'unpack' key dimensions of settings most relevant to policy, practice and research. In this paper, we explore how place matters for health and social care. In effect, we propose making place the lens through which to view practice, and not simply an interesting sideline focus. We focus specifically on (a) the emplacement of power relations in health and social care in and across settings; and (b) the pervasive (and often unrecognised) influence of technology on and in place (both 'mundane' and more visible 'high' technologies) as arguably among the most significant and pervasive (and often overlooked) dimensions of place pertinent to health and social care in both traditional (institutional) and nontraditional (community) settings. Drawing on diverse disciplinary literatures, we seek to make visible certain issues and bodies of work that health professionals may not be aware of, and which often remain inaccessible to practitioners and applied researchers on account of their density, complexity, and specialised terminology. In particular, drawing on the rich tradition of cultural studies, we advance the culture of place as a rubric for understanding the complex interrelationship between power, technology, culture, and place. Several fruitful avenues for place-sensitive research of health and social care practice (and its effects) are suggested.

Young adults’ (16–25 years) suggestions for providing developmentally appropriate diabetes services: a qualitative study

Abstract: Managing the multiple demands of a chronic condition whilst negotiating the developmental tasks of adolescence and young adulthood is a process that is neither well described nor understood, particularly in relation to providing developmentally appropriate health care for young people. The importance of this issue is starting to be reflected within the literature, and although research into models of service delivery is emerging, a lack of user involvement in service development is apparent. This qualitative, user involvement study aimed to describe and understand the considered opinions of 19 young adults with diabetes who were receiving secondary care services about the provision of diabetes services for young people. The findings, gathered using semistructured interview and focus group methods, have potentially wide-reaching implications across primary and secondary health care, and across agencies providing services to children and young people, in terms of facilitating a person's transition through adolescence and into young adult life. Participants suggested key issues to address when developing services for young people, including staff consistency, civility, clinic structures which help a person navigate the health care system, provision of age-specific information, and support in relation to a range of health, emotional, social and developmental needs. Health care professionals can help young people to meet the expectations upon them as autonomous service users by modelling appropriate relationships, helping them to acquire skills and knowledge, and overcome barriers to them becoming active participants in their health care and achieving social participation in a fuller sense. It is somewhat arbitrary to delineate between adolescence and young adulthood in terms of age alone, but in this paper, 'adolescence' refers to the period between 11 and 15 years of age, and 'young adulthood' between 16 and 25 years of age. The phrase 'young people' will also be used to refer to people between 11 and 25 years.

Keeping warm and staying well: findings from the qualitative arm of the Warm Homes Project

Abstract: This paper presents findings from the qualitative arm of the Warm Homes Project, a programme of research concerned with the nature of fuel poverty, its alleviation and its relationship to family health. Much of the research into fuel poverty, which results from various combinations of low income and fuel inefficiency, has drawn upon quantitative paradigms. Experiences of, and coping with, fuel poverty have not been well explored. Data for the present study were obtained through qualitative interviews with household members about the above issues. The findings suggest that the expectations of those in fuel poverty about staying warm, and their beliefs about the relationship between warmth and health, vary considerably. Fuel poverty often had wider ramifications, impacting on quality of life in complex ways. The respondents took steps to alleviate cold, but their strategies varied. Coping was affected by informational limitations as well as cost constraints. Measures designed to alleviate fuel poverty should take into account its wider social meaning within the lives of household members.

Living with motor neurone disease: lives, experiences of services and suggestions for change.

Abstract: Palliative care involves the complete, holistic care of people with progressive illness and their families. People living with motor neurone disease (MND) require a range of multidisciplinary palliative care services. However, there are significant gaps in our understanding of these people's lives, experiences of services and their suggestions for service change. The present study addressed the following questions: (1) What are the lived experiences of people living with MND? (2) What are people's experiences of services? and (3) Can improvements to care be identified? A qualitative research design was adopted using semi-structured interviews. The topic guide was developed from existing literature. The study was based in three boroughs in London, UK. People living with MND and professionals were drawn from a database at King's College Hospital, and additionally, through 'snowball' sampling. Nine people with MND, five carers/family members and 15 professionals took part in the interviews. These interviews were audio-taped, transcribed and checked for accuracy against the original recordings. Themes within the interviews were coded and grouped. The analysis was facilitated with the NVIVO computer software package. The findings are presented within three substantive groups: (1) the impact of MND on people's lives (the physical impacts of the illness, including increasing disability; social issues, including restrictions on social activities; and adjustments to people's lives, including methods of coping with the illness); (2) experiences of services (accessing service entitlements, information sources, professionals' attitudes and approaches, and professionals' knowledge and understanding of MND); and (3) suggestions for service change (better information and communication, including information on service entitlements; improved knowledge amongst professionals about MND; and some suggestions for service restructuring). This study brings a fresh approach to understanding the impacts of MND and the ways in which services can be improved to meet people's needs. The paper concludes with methodological considerations, the implications of the findings for practitioners and policy makers, and suggestions for further research.

The last 3 months of life: care, transitions and the place of death of older people

Abstract: Many older people die in hospitals, whereas research indicates that they would prefer to die at home. Little is known about the factors associated with place of death. The aim of the present study was to investigate the care received by older people in the last 3 months of their life, the transitions in care and the predictors of place of death. In this population-based study, interviews were held with 270 proxy respondents to obtain data on 342 deceased participants (79% response rate) in the Longitudinal Aging Study Amsterdam. In the last 3 months of life, the utilisation of formal care increased. Half of the community-dwelling older people and their families were confronted with transitions to institutional care, in most cases to hospitals. Women relied less often on informal care only, and were more dependent than men on institutional care. For people who only received informal care, the odds of dying in a hospital were 3.68 times the odds for those who received a combination of formal and informal home care. The chance of dying in a hospital was also related to the geographical region. The authors argue that future research is needed into the association that they found in the present study, i.e. that decedents who received both formal and informal care were more likely to die at home. In view of the differences found in geographical region in relation to place of death, further investigation of regional differences in the availability and accessibility of care is indicated.

Enabling frail older people with a communication difficulty to express their views: the use of Talking Mats as an interview tool.

Abstract: The aim of the present study was to obtain the views of frail older people with communication impairments using an innovative interviewing method, Talking Mats. People with a communication disability are often omitted from qualitative research studies since they cannot respond to the more traditional methods of interviewing. However, their views are important and they may, in fact, have additional insights because of their communication situation. The 10 participants in this study were frail older people with a range of communication difficulties with causes including stroke, dementia and hearing loss. They had all recently (within 6 months) moved into care homes. Each participant was interviewed using Talking Mats to obtain their views on four aspects of their life: activities, people, environment and self. The findings are presented in a visual way, and the four life themes are discussed with reference to the different participants. Many insights were gained, such as the participants' views of the activities which they like and dislike, and the views of some of the people in the study about their nursing home environment. The advantages of the Talking Mats as an interview method for research, practice and policy in the care of frail older people are described. The study concludes that Talking Mats is a useful and enjoyable method of allowing frail older people with a communication disability to express views which they have difficulty conveying otherwise.

Involving older people in research: methodological issues.

Abstract: The policy imperative to increase public participation in health and social care research, planning and service delivery raises significant questions about optimum approaches, methods and the extent to which this policy can influence change in practice. This paper highlights the key policy literature on user involvement and participatory research methods to establish the context for a partnership research project exploring perceptions of risk in relation to falls from the perspectives of older people, carers, and health and social care professionals. The paper reports the methods used in developing user involvement in the research at a number of levels, including project management, and a consumer panel working alongside the research team and influencing the dissemination in local falls prevention strategies. The authors draw out the issues related to the context and method of involvement, and discuss the impact on research quality and local service development in health and social care.

Exploring the 'fit' between people and providers: refugee health needs and health care services in Mt Roskill, Auckland, New Zealand

Abstract: The needs of refugees and the struggles on the part of service providers to address this diverse population have received limited attention within the academic literature. This paper profiles Hauora o Puketapapa/Roskill Union and Community Health Centre (HoP), which is a non-profit, community owned and operated health clinic designed to deliver accessible, affordable and appropriate primary health care services to low-income groups in the Mt Roskill area of Auckland, New Zealand. The clinic's locality has undergone considerable demographic change over recent years with the arrival of refugees from diverse backgrounds. This situation has resulted in new sets of health needs and expectations which need to be addressed. The study took place in 2002-2003 and employed qualitative methods. In-depth interviews with community representatives, clinic users and health service staff members revealed that refugees face considerable barriers in accessing and utilising health services. Similarly, we found that health practitioners face the daunting task of endeavouring to meet these needs in an effective and culturally appropriate manner within a limited funding environment. We conclude that, despite these challenges, HoP has successfully established itself as a well-regarded place of primary health care. In so doing, it has strengthened the capacity of the local community to respond to the changing policy environment. However, long-term sustainability issues remain unless resourcing issues are adequately addressed.

‘Implementation deficit’ and ‘street‐level bureaucracy’: policy, practice and change in the development of community nursing issues

Abstract: The present paper examines the mechanisms by which health and social care policies put forward by the Government may be translated into community nursing practice. Data from a research project on community nurse case managers were re-examined in the light of two classic theories often cited by policy analysts (i.e. implementation theory and ‘street-level bureaucracy’). It was found that the extent to which nurses adopted the case management role, and the model of choice, depended on four major interrelated variables, namely: (1) the clarity of policy guidance; (2) the extent to which it coincided with professional (nursing) values; (3) local practices and policies; and (4) the personal vision of the community nurse. It is argued that this framework may have wider relevance, and this was tested out in two ways. First, major change in one of these variables (Government policy) over time was analysed for its effect on case management practice via the remaining variables. Secondly, an unrelated, but policy-initiated, nursing issue (nurse prescribing) was briefly examined in the light of the framework. It is suggested that this framework may be of some use when considering the likely practice response to policy-related changes in community nursing.

'Working at the margins' or 'leading from behind'? A Canadian study of hospital-community collaboration.

Abstract: Collaboration between hospitals and community organisations has been promoted over the past 20 years by various levels of government, hospital associations, health promotion advocates, and others at the state/province, national and international levels as a way to improve the ‘efficiency of the system’, reduce duplication, enhance effectiveness and service coordination, improve continuity of care, and enhance community capacity to address complex issues. Nevertheless, and despite a growing literature on interagency collaboration, systematic documentation and empirical analysis of hospital−community collaboration (HCC) is almost completely lacking in the literature, particularly as regards collaborations that address the determinants of health beyond the hospital walls. In this paper, we describe the methodology and key findings from a research study of HCC. The Hospital Involvement in Community Action (HICA) study undertook detailed qualitative case studies (in four urban, suburban, rural and northern locations) and a telephone survey (of 139 community organisations in a large urban centre) in order to learn about the range of collaborations and working relationships that exist between hospitals and community agencies in the province of Ontario (Canada), and the factors that influenced (enabled and/or hindered) HCC. Particular attention was paid to barriers and enablers at three nested levels of context (policy, hospital and community) and, drawing primarily on the qualitative case studies, it is this aspect that is the focus of this paper. That such collaborations continue to be widespread despite a generally unfavourable policy environment and hospital institutional culture that poses significant barriers, suggests that the extent to which HCC flourishes (or exists at all) crucially depends on the presence and ongoing enthusiasm/commitment of one or more ‘champions’ within the hospital, and the commitment of both parties to overcome the marked cultural differences between hospital and community. We conclude with a discussion of implications for policy and practice.

Parenting support in the context of poverty: a meta-synthesis of the qualitative evidence.

Abstract: From the outset, providing support for parents has been a key feature of New Labour's policy agenda, but ‘good’ parenting, and child health and well-being are often undermined by the stresses associated with poverty Moreover, there may be a gap between policy aims, and the perceptions and motivations of those intended to benefit Drawing on a systematic review of qualitative studies of low-income parents, the present paper explores their experiences of informal and formal support networks, considering their strengths and weaknesses in the context of poverty Traditional systematic review methods were used to locate and critically appraise 12 UK qualitative studies, which took as their focus parents’ subjective experiences of caring for children in impoverished circumstances Meta-ethnographic methods were then used to produce a qualitative meta-synthesis of findings Exploring the similarities and differences in parents’ accounts across studies identified positive and negative aspects of social support as a resource for poor parents The review suggests that naturally occurring support systems do provide both material and emotional help to parents, but that such support has certain inherent drawbacks It is not universally available and, in some circumstances, carries negative associations for poor families Low-income lone mothers in particular enjoy smaller support networks, and are more reliant on mutual support than those in two-parent families Paradoxically, it is the most socially isolated women who are least willing to seek professional help Overall, low-income parents’ experiences of formal health and social welfare agencies are mixed, and not invariably positive In conclusion, this paper suggests that formal support services have the potential to fill gaps in informal support systems for poor families, but only if these are provided in ways which are sensitive to their needs Therefore, parents’ perspectives are essential to informing service design, development and evaluation in health and social care

Intellectual disability, challenging behaviour and cost in care accommodation: what are the links?

Abstract: The paper examines the links between degree of intellectual disability, challenging behaviour, service utilisation and cost for a group of people with intellectual disabilities living in care accommodation in England. A cross-sectional survey was conducted of people with intellectual disabilities, identified via provider organisations, with supplementary collection of costs data. Multivariate analyses of cost variations were carried out for 930 adults with intellectual disabilities. There were strong, nonlinear, interdependent links between degree of intellectual disability, behaviour, service use and costs. Higher costs were associated with more severe intellectual disabilities and more challenging behaviour. Sector and scale of residence also influenced cost in quite complex ways. Access to and use of services by people with intellectual disabilities were not always appropriately linked to perceived or actual needs. Policy makers and local commissioning agencies need to explore the sources of cost variation between individuals, sectors and types of accommodation in order to achieve national policy objectives on quality, choice, independence and inclusion.

The mental health of looked after children: matching response to need

Abstract: Previous research has established high rates of mental health need in looked after children. The study described in this paper aimed to explore in more depth the mental health problems of looked after children and to examine the service response to those needs in two English local authorities. The study utilised a purposive sample of 80 looked after children which was biased towards those with high needs but which reflected the characteristics of looked after children in the two areas with regard to age, gender and type of placement. Key data on children and young people were collected from social services’ case files and a set of indicators of mental health need was designed by the research team in order to distinguish different types and levels of mental health problems. High levels of mental health need in the study group were associated with placement disruption. Educational difficulties were also apparent in the group with the highest levels of mental health need. Longer-term input from child and adolescent mental health services (CAMHS) professionals did not appear to be targeted on the group with the highest level of mental health needs. The researchers conclude that longer-term CAMHS interventions could be usefully focused on looked after children who have experienced high levels of placement disruption. As the professional group most likely to be providing substantial intervention to looked after children and their carers, social workers require relevant training in identifying and responding to mental health needs. CAMHS professionals could develop and strengthen their consultative roles with front-line carers, social workers and schools.

Dementia care provision in rural Scotland: service users' and carers' experiences.

Abstract: There has been global neglect of service users' and carers' experiences of dementia care provision in rural areas. The present paper draws on a qualitative study of service provision for people with dementia and their carers in remote and rural Scotland. It draws on interviews with 15 people with dementia and 16 carers to explore their views about health and social dementia care service provision in rural Scotland. A further 14 carers of people with dementia participated in one of three focus groups. The paper discusses perceived gaps in services as well as positive aspects of dementia service provision which service users attribute to living in a rural area. The important issues this raises for the development of dementia care provision in rural areas are briefly discussed.

According to need? Predicting the amount of municipal home help allocated to elderly recipients in an urban area of Sweden.

Abstract: Given the cutbacks which have been carried out in the Swedish welfare state despite the unchanged official policy of allocation of home help services according to needs, it is essential to evaluate the factors which guide the allocation of home help today. Whereas numerous studies have identified factors which predict entry into the home help system, the present paper concentrates on predictors of the amount of home help amongst those allocated assistance. Data were obtained from the population-based care and services section of the 2002 Swedish National Study of Aging and Care-Kungsholmen (SNAC-K). All home help recipients (> or = 65 years of age) living in an inner city district of Stockholm (Kungsholmen) were analysed with ordinary least squares regressions to identify predictors of the number of hours of home help (n = 943). Need indicators, i.e. dependency in activities of daily living (ADLs) and instrumental ADLs (IADLs), and cognitive impairment (Berger scale) were the strongest predictors of more hours of home help. The addition of sociodemographic (i.e. age, gender and income), environmental (i.e. informal care, housing adaptations and housing accessibility) and structural (i.e. variations in allocation decisions between one care manager and another) factors contributed only marginally to the explained variance. Hours of help entitlement increased slightly with greater age. Co-residing individuals were allocated significantly fewer home help hours than those living alone. Income and regular access to informal care were not significant predictors. The fact that services are provided according to need criteria does not necessarily mean that the provided services are adequate to meet needs. On the macro level, social policy decisions and available economic and manpower resources determine the allotment of municipal home help. However, this study in an urban sample suggests that, within the available resources, the amount of home help allocated is guided mainly by need indicators amongst those given assistance.

A qualitative study exploring the experiences and views of mothers, health visitors and family support centre workers on the challenges and difficulties of parenting.

Abstract: Successive policy documents have referred to the need to support parents as an approach to reducing social exclusion, behaviour problems among young people and crime rates. Much of the rhetoric focuses on professional intervention, and there is less attention paid to the views and experiences of parents themselves. The present study explores the experiences and views of mothers, health visitors and family support centre workers who work with parents on the challenges and difficulties of parenting children under the age of 6 years. It provides an appreciation of their views on effective parenting and how parents can be helped to feel more effective in the parenting role. Focus groups, which were exploratory and interactive in form, were conducted across three primary care trusts in Hertfordshire, UK. Three samples were purposively selected in order to examine the range and diversity of experiences and views about parenting, and included the parents of children up to the age of 6 years, health visitors and family support centre workers. The mothers were those waiting to attend a parenting programme, and included first-time mothers and those with more than one child. The health visitors and family support workers had a range of experience in working with parents and children, and included those who were facilitating parenting programmes and those who were not. A number of themes emerged surrounding the challenges and difficulties of parenting and effective parenting, including expectations of others, establishing routines, play, behavioural issues and discipline, empathy, and communication. Similar themes emerged from all groups; however, there were qualitative differences between parents and professionals in the way in which these issues were expressed. Key statements from the parent focus groups have been developed into self-efficacy statements, which will be used as input to the development of a tool to measure the effectiveness of parenting programmes.

Multi-agency working in services for disabled children: what impact does it have on professionals?

Abstract: Whilst agencies in many sectors have been encouraged to work together to better meet the needs of service users, multi-agency working is now a central feature of government policy. In relation to children's services, the National Service Framework, the English green paper, 'Every Child Matters' (DfES, 2003) and the Children Bill (DfES 2004) give a high priority to an integrated approach to service provision. This paper focuses on multi-agency working for disabled children with complex health-care needs, a group of children who, perhaps even more than most, require the many professionals who support them and their families, to work more closely together. Drawing on the findings from a 3-year qualitative research study, this paper examines the impact of working in a multi-agency service on professionals. Interviews with 115 professionals concluded that staff were overwhelmingly positive about working as part of a multi-agency service. They reported improvements to their working lives in areas such as professional development, communication, collaboration with colleagues, and relationships with families with disabled children. However, whilst professionals felt that they were able to offer families a more efficient service, there was concern that the overall impact of multi-agency working on disabled children and their families would be limited.

Carers and the digital divide: factors affecting Internet use among carers in the UK.

Abstract: This paper presents data from a cross-sectional survey of 3014 adult carers, examining use of the Internet and factors associated with it. Carers recruited from the databases of three local authorities and other carer organisations within their geographical boundaries and that of Carers UK, a national carers organisation, were sent a postal questionnaire (response rate: 40%). A comparison of our data with national data on carers suggests some under-representation of men and younger adult carers and some over-representation of those who had been caring for long periods and those with substantial caring responsibilities. Two measures of Internet use were used and are presented in this analysis: previous use (ever used vs never previously used) and frequency (less than once a week vs once a week or more). Bivariate analyses identified patterns of Internet use and socio-demographic and socio-economic factors and caring circumstances associated with them. Factors significantly associated with each measure of Internet use were entered into direct logistic regression analyses to identify factors significantly associated with each measure. Half (50%) of all carers had previously used the Internet. Of this group, 61% had used it once a week or more frequently. Factors significantly associated with having previously used the Internet were carer's age, employment status, housing tenure and number of hours per week they spent caring. Frequency of Internet use was significantly associated with carer's age, sex, employment status and number of hours spent caring. Our study suggests that a significant number of carers may not currently be Internet users and that age, gender, socio-economic status and caring responsibilities shape Internet use in particular ways. Given the targets set by government for the development of online services, it is important to address the digital divide among carers and to continue to develop other services and information systems to meet the needs of those who do not access the Internet.

Using pooled budgets to integrate health and welfare services: a comparison of experiments in England and Sweden.

Abstract: The lack of collaboration between health, social and other welfare services is believed to impair efficiency and reduce effectiveness in addressing the complex problems of patients. Differences in funding streams, political accountabilities, organisational structures and professional cultures are all alleged to contribute to barriers between services. Drawing on their respective evaluations, this paper describes experiments in England and Sweden that use pooled budgets between services to improve interagency and interprofessional collaboration and presents evidence on their impact. Despite differences in the funding and organisation of health and welfare services in each country, some similar conclusions are reached. Among senior managers and politicians, budget pooling broadened their awareness of interdependencies with other agencies and professionals in promoting patients’ welfare. However, these broadened perspectives were not immediately shared by professionals working at the front line, with whom patients had immediate contact. Moreover, neither experiment yielded unequivocal evidence of improved cost-effectiveness or of the benefits of budget pooling on the outcomes for service users. These experiments also raise questions about the equity and accountability of welfare services because in both countries only a limited range of services has been integrated under the umbrella of the pooled budgets.

The challenges associated with providing community care for people with complex needs in rural areas: a qualitative investigation.

Abstract: The aim of the present study was to explore the experiences of recipients and providers of community care in rural areas in Northern Ireland. Additionally, the authors sought to examine the impact of location, housing and environmental factors on the delivery of community care to older people with complex needs. Individual, semistructured interviews were held with service users (n = 17) and family carers (n = 14). Individual and focus group interviews were conducted with care assistants, health and social care professionals, and senior managers from a large health and social care trust and health and social services board in Northern Ireland. The importance of enabling older people to remain in their own homes and communities was emphasised by all participants. The main challenges associated with care provision in rural areas included: difficulties recruiting care assistants; lack of choice of care assistants; isolation; travel and distance between clients and their care assistants; and poor housing conditions. There was a general consensus among participants that the effectiveness of rural community care was perceived to be reliant upon the goodwill of the community. Additionally, changing demographic trends and the predicted shortfall in the number of formal and informal carers were considered key issues for service planners. A number of creative strategies could be used to address many of the limitations associated with rural isolation. These should involve capitalising on available community networks. However, planners should also acknowledge that additional resources are required to maintain older people in rural communities.

Social support in the healthcare setting: the role of volunteers

Abstract: The participation of volunteers in the National Health Service (NHS) has been actively promoted during recent years, particularly within community and primary healthcare services (National Health Service 1996, 1998). As a consequence, volunteers currently make a significant contribution to health and social care within the UK. Concerning this contribution, the literature often portrays the volunteers' role as one of providing social support. In the present paper, the authors attempt to explore this role in more detail, drawing on interview data from studies of two separate volunteer programmes. One of these considered the role of volunteers supporting older hospitalised patients (Davies et al. 2001), and the other was based within general practice (Faulkner 2003, 2004). The social support provided by these programmes is considered from the perspective of four broad support mechanisms described by Langford et al. (1997), namely: emotional support; informational support; appraisal support; and instrumental support. Secondary analysis examines the potential contribution of volunteers to patient well-being.

Housing and dementia care - a scoping review of the literature.

Abstract: This paper reports the findings of a scoping study designed to describe the evidence base with regard to housing provision for elderly people with dementia with the aim of identifying gaps in existing knowledge. This report from the scoping study findings covers studies of housing and accommodation in relation to dementia that have been published in the UK since the early 1980s, although we draw on limited aspects of overseas research to illuminate issues missing from the UK research agenda. The results reveal a significant number of research gaps in the UK context, most notably in relation to end-of-life care for people with dementia and the effectiveness of integrated and segregated facilities. UK policy regarding the development of extra-care housing also neglects the long-term future of people with dementia. A more robust evidence base will be required, combining a variety of methodological approaches, if UK dementia research is to contribute to future housing policy developments.

The impact of ‘statutory duties’ on mental health social workers in the UK

Abstract: In the UK, applications for involuntary admission to psychiatric units are made mainly by specially trained approved social workers (ASWs). Proposed changes in the legislation will permit other professionals to undertake these statutory duties. This study aimed to examine how ASW status impacts upon work pattern and workload stresses by comparing ASWs with other mental health social workers who did not carry statutory responsibilities. A multimethod design was adopted that included a cross-sectional national survey of mental health social workers (n=237, including 162 ASWs), and a telephone survey of mental health service managers (n=60). Data were collected using a semistructured questionnaire and diary, the content of which was derived from focus-group work and standard measures. Features of job content, working patterns and conditions were described and their association with stress, burnout and job satisfaction examined. ASWs were older and had been qualified longer than non-ASWs. The working patterns and conditions of the two groups did not differ, although ASWs did more hours on duty. ASWs received less support at work, particularly from supervisors and their role afforded less decision latitude than that of non-ASWs. ASW status was related to an elevated GHQ score, particularly among males. Emotional exhaustion was very high (over two-thirds in both groups) but ASWs and non-ASWs did not differ in this or any other feature of burnout, only 8% of the sample were actually 'burnt-out', being more common among ASWs. ASWs were more dissatisfied and were more likely than non-ASWs to want to leave their job. Given that ASW status increased stress and job dissatisfaction, especially for men, and was related to a desire to leave one's current job, it seems likely that extending statutory duties to other professionals will increase levels of stress, burnout and dissatisfaction in these groups also. In turn, this might have consequences for staff recruitment and retention.

Gatekeepers in sickness insurance: a systematic review of the literature on practices of social insurance officers.

Abstract: Decisions concerning entitlement to sickness benefits have a substantial impact on the lives of individuals and on society. In most countries, such decisions are made by staff of private or public insurance organisations. The work performed by these professionals is debated, hence more knowledge is needed on this subject. The aim of the present study was to review scientific studies of the practices of social insurance officers (SIOs) published in English, Danish, Norwegian and Swedish. Studies were searched for in literature databases, in reference lists, and through personal contacts. Analyses were made of type of study, areas investigated, research questions, theories used, and the results. Sixteen studies were included. SIOs and several other actors are responsible for applying measures to minimise sick-leave and promote return to work (RTW). The studies focusing on coordination of such measures revealed that SIOs felt unsure about how to handle their contacts with clients and other actors. One study indicated that the SIOs, partly due to lack of time, accepted the recommendations of physicians instead of making their own judgments about granting sickness benefits. While all SIOs must make decisions concerning entitlement to sickness benefits on a daily basis, few of the reviewed studies scrutinised the actual granting of sickness compensation. The studies were also deficient in that they investigated the decision latitude of the SIOs from a very limited perspective, mainly on an individual level and often primarily in relation to colleagues and/or clients rather than to the laws and regulations of the sickness insurance. The concepts and framework in this area of research need to be developed to facilitate elucidation of the interaction between different actors in local spheres, professionals in different disciplines, and between welfare staff and individual citizens.

The feasibility and acceptability of a specialist health and social care team for the promotion of health and independence in 'at risk' older adults.

Abstract: Population ageing, escalating costs in pensions, health-care and long-term care have prompted a new policy agenda for active ageing and quality of life in old age across the European Union and other developed countries. In England, the National Service Framework for Older People (NSF OP) explicitly demands for the first time that the NHS and local authorities, in partnership, agree programmes to promote health ageing and to prevent disease in older people. These programmes are expected to improve access for older people to mainstream health promotion services and also to develop multiagency initiatives to promote health, independence and well-being in old age. This paper describes the evaluation of one interagency project team established to test out mechanisms for addressing health promotion for older people through primary care. A mixed methodology was used to understand the processes of service development, the impact of the team's intervention, and the primary and secondary outcomes for older people. The project demonstrated that multi-agency partnerships have the potential to improve the quality of the lives of older people deemed 'at risk' by their general practitioners, particularly through income generation but also in the identification of medical problems such as unrecognised hypertension, hearing loss and visual loss. It also offered some key learning points for other multi-agency groups developing similar services.

Exploring risk perception and behaviour of homeless injecting drug users diagnosed with hepatitis C.

Abstract: Injecting drug users (IDUs) are at the greatest risk of hepatitis C infection by using any item of injecting equipment that has come into contact with contaminated blood. Alongside this, homeless IDUs have been identified as being at increased risk of harm in their illicit drug taking behaviour. This study interviewed 17 hepatitis C positive homeless IDUs about their injecting practices. In-depth interviews explored the impact of a positive hepatitis C diagnosis on their injecting and identified their risk behaviours and perceptions. The interviews were tape-recorded, transcribed and analysed using the framework approach. Homeless IDUs engaged in both high risk and unhygienic injecting practices, such as using drugs outside and in public places, sharing injecting equipment and re-using cleaned needles. Excessive needle reuse whilst in prison was also identified. However, the findings were not universally bleak as a positive diagnosis of hepatitis C did lead to some behaviour change towards safer injecting and some adopted other lifestyle and behaviour changes. It was, however, common for homeless people to devolve responsibility for preventing hepatitis C transmission to their peers, especially when injecting with others. Knowledge regarding possible transmission through injecting paraphernalia appeared to make users more careful to reduce it through these routes. Placing a continuous emphasis on health promotion is therefore important in educating IDUs about the hepatitis C transmission risks associated with injecting drug use. Information regarding safer and hygienic use, including accurate information regarding the most effective methods to clean used equipment, must be re-enforced by people working with homeless injecting drug users.

Fixing the system? The experience of service users of the quasi-market in disability services in Australia.

Abstract: A qualitative study involving semi-structured interviews with 31 people with disabilities and 32 carers in the state of Queensland, Australia, found that their experience of supportive service delivery had not improved despite reforms of the service delivery system driven by a version of the quasi-market model. Instead of delivering increased consumer choice and improved efficiency in service delivery, service users experienced inadequate service supply, service cutbacks, and an increased emphasis on cost subsidisation and assessment processes. Additionally, few consumers felt that individualised funding arrangements had personally delivered the benefits which the quasi-market model and associated policy paradigm had indicated that they should receive. For many consumers, the notion of consumer 'choice' around service provision was fictitious and they felt that any efficiency gains were at the agency level, largely at the consumers' cost. It is concluded that there appears to be no particular benefit to service users of quasi-market reforms, particularly in policy contexts where service delivery systems are historically under-funded.

Desired outcomes for children and young people with complex health care needs, and children who do not use speech for communication

Abstract: Within recent policies and initiatives, there is a growing emphasis on outcomes-focused practice and user-defined outcomes to ensure that the children and families most at risk of social exclusion have every opportunity to build successful and independent lives However, we still know little about what children and young people with disabilities consider constitutes a good quality of life The present paper reports the findings of a qualitative research project that aimed to identify the desires and aspirations of children and young people with complex health care needs (CHNs), as well as those who do not use speech for communication (NS) and their parents Fifty families participated in this study; 26 families had a child with CHNs and 24 had a child with NS Semistructured interviews were carried out with 50 parents, 18 children and 17 other informants (teachers and other non-parent carers who knew the child well) A range of visual or non-verbal techniques were used to facilitate interviews with children The research found that, while children and their parents aspired to the same sort of outcomes as those of non-disabled children, such as to have friends, interests and future independence, the specific meaning they attached to certain outcomes and the way they prioritised aspirations differed These findings have implications for the ways in which outcomes are defined and measured, and the role of services in achieving these outcomes