Ailsa Cameron

Identity in the fourth age: perseverance, adaptation and maintaining dignity

ABSTRACT The fourth age remains a poorly understood phenomenon and there is a lack of understanding of the perceptions of those who might be considered to be living in it. This article draws on findings from a study of dignity in later life which examined the day-to-day experiences of participants who were in need of support and care because of failing health. It discusses their accounts of the changes to their sense of self and their identity that came about as a result of their ageing and health problems and looks also at the ways in which the support and care they received helped to shape their adjustment to those changes. The accounts given by participants reveal a great deal about the physical, mental and emotional effort entailed in maintaining a sense of self and highlight the essential role played by social relationships in the maintenance of identity. These findings are analysed by reference to emerging theories of the fourth age.

Reshaping the NHS workforce

Education and debate p 1067 The staffing problems of the NHS continue to make headlines.1 Junior doctors are threatening to strike, consultants are voicing their frustration, and nurses are voting with their feet.2 Though their concerns are less visible, physiotherapists, radiographers, occupational therapists and other members of the professions allied to medicine are also facing major challenges.3 The problems have been well rehearsed but solutions seem as far away as ever.If the healthcare needs of this new millennium are to be met, more radical approaches to collaborative working will need to be explored. By its very nature the healthcare labour force is an interdependent one. The different occupational groups did not develop in isolation from each other but as part of a complex and interdependent system capable of carrying out the many activities that make up a modern health service. Yet despite this obvious reciprocity, the different elements of the NHS labour force are still planned and managed in isolation. This continuing fragmentation has a major impact on the quality of patient care and on the wellbeing of health workers themselves.4 Since the 1970s there have been irresistible pressures towards collaborative working across traditional boundaries. More health workers are now organised into multiprofessional teams, and many nurses and those in the professions allied to medicine …

Impermeable boundaries? Developments in professional and inter-professional practice

The nature of the professional task in welfare services is constantly changing. These changes are not confined to Britain but are widespread across the developed world and include initiatives to develop new professional roles and redesign existing services. Central to these initiatives is an assumption that the professions, and the individual professionals involved, will be willing and able to adapt their professional practice. The challenges inevitably posed by these developments appear to have been played down, particularly in respect of the role played by the boundaries between professions. This article considers the nature of boundaries before exploring these service developments as a means to highlight the issues they raise. The article contends that for these developments to work we need to move beyond the current focus on the role of education, training and regulation which structure professional boundaries to appreciate the ‘human and social aspects’ of these changes in order to understand how individual professionals perceive and experience the boundaries between professional groups.

Evidence based policy making and the 'art' of commissioning - how English healthcare commissioners access and use information and academic research in 'real life' decision-making: an empirical qualitative study.

BackgroundPolicymakers such as English healthcare commissioners are encouraged to adopt ‘evidence-based policy-making’, with ‘evidence’ defined by researchers as academic research. To learn how academic research can influence policy, researchers need to know more about commissioning, commissioners’ information seeking behaviour and the role of research in their decisions.MethodsIn case studies of four commissioning organisations, we interviewed 52 people including clinical and managerial commissioners, observed 14 commissioning meetings and collected documentation e.g. meeting minutes and reports. Using constant comparison, data were coded, summarised and analysed to facilitate cross case comparison.ResultsThe ‘art of commissioning’ entails juggling competing agendas, priorities, power relationships, demands and personal inclinations to build a persuasive, compelling case. Policymakers sought information to identify options, navigate ways through, justify decisions and convince others to approve and/or follow the suggested course. ‘Evidence-based policy-making’ usually meant pragmatic selection of ‘evidence’ such as best practice guidance, clinicians’ and users’ views of services and innovations from elsewhere. Inconclusive or negative research was unhelpful in developing policymaking plans and did not inform disinvestment decisions. Information was exchanged through conversations and stories, which were fast, flexible and suited the rapidly changing world of policymaking. Local data often trumped national or research-based evidence. Local evaluations were more useful than academic research.DiscussionCommissioners are highly pragmatic and will only use information that helps them create a compelling case for action.Therefore, researchers need to start producing more useful information.ConclusionsTo influence policymakers’ decisions, researchers need to 1) learn more about local policymakers’ priorities 2) develop relationships of mutual benefit 3) use verbal instead of writtencommunication 4) work with intermediaries such as public health consultants and 5) co-produce local evaluations.

The contribution of housing support workers to joined-up services.

This paper explores the role of the “housing support” worker and considers the contribution the role can make to the modernization of welfare services. Although the role is inextricably linked to a growing appreciation of the relationship between housing and wellbeing the paper also considers a range of other drivers that may have had an impact on the emergence of the role. The housing support worker role may, for example, be seen as a response to developments within the social work profession as well as to wider debates about how to support adults with complex needs. The development of roles, such as the housing support worker, that work across organizational boundaries are not without their challenges. This paper explores the drivers behind the development of the housing support role and then, using data from the Supporting People Health Pilots programme evaluation, considers issues about the preparation and support required for those working in these roles to ensure that their potential contribution is maximized.

From pillar to post: homeless women's experiences of social care.

This paper reports findings from a longitudinal study of homeless women. Thirty-eight women were recruited with a retention rate of 58% over three rounds of interviews. Interviews explored specific events in womens lives, their current living arrangements and how their experiences and needs, including for social care, changed over time. Data were analysed thematically using a priori codes. Women reported a range of complex issues, consistent with experiences of deep social exclusion and received support from both statutory and voluntary agencies. Although women appreciated the support they received, many reported that services were fragmented and rarely personalised to their needs.

What do external consultants from private and not-for-profit companies offer healthcare commissioners? A qualitative study of knowledge exchange.

Objectives The use of external consultants from private and not-for-profit providers in the National Health Service (NHS) is intended to improve the quality of commissioning. The aim of this study was to learn about the support offered to healthcare commissioners, how external consultants and their clients work together and the perceived impact on the quality of commissioning. Setting NHS commissioning organisations and private and not-for-profit providers. Design Mixed methods case study of eight cases. Data collection 92 interviews with external consultants (n=36), their clients (n=47) and others (n=9). Observation of 25 training events and meetings. Documentation, for example, meeting minutes and reports. Analysis Constant comparison. Data were coded, summarised and analysed by the research team with a coding framework to facilitate cross-case comparison. Results In the four contracts presented here, external providers offered technical solutions (eg, software tools), outsourcing and expertise including project management, data interpretation and brokering relationships with experts. In assessing perceived impact on quality of commissioning, two contracts had limited value, one had short-term benefits and one provided short and longer term benefits. Contracts with commissioners actively learning, embedding and applying new skills were more valued. Other elements of success were: (1) addressing clearly agreed problems of relevance to managerial and operational staff (2) solutions co-produced at all organisational levels (3) external consultants working directly with clients to interpret data outputs to inform locally contextualised commissioning strategies. Without explicit knowledge exchange strategies, outsourcing commissioning to external providers resulted in the NHS clients becoming dependent. Conclusions NHS commissioning will be disadvantaged if commissioners both fail to learn in the short term from the knowledge of external providers and in the longer term lose local skills. Knowledge exchange mechanisms are a vital component of commissioning and should be embedded in external provider contracts.

The Changing Policy Context of Occupational Therapy

The work of health care professionals in the United Kingdom is continually influenced by the directions, goals and principles of government and dominant groups in the policy-making process (Ackers and Abbott 1996). For too long many occupational therapists have failed to acknowledge that their work exists within a wider social context. This context controls and rations the resources that support the health and social care system and ultimately affects what occupational therapy is and the way in which occupational therapy is delivered (Øvretveit 1992). For instance, Pringle (1996) suggested that in the 1970s and 1980s occupational therapy had experienced increased autonomy and freedom to define the role and scope of its practice. As a consequence of the recent health service reforms, it is argued that this autonomy and freedom seems to have been progressively undermined. This article aims to stimulate an awareness amongst occupational therapists of the fundamental importance and relevance of an understanding of social policy to their everyday practice.

Creating the asset base - a review of literature and policy on housing with care

Purpose – Appropriate housing for the growing population of older adults is becoming an international concern. The purpose of this paper is to report on a review of UK and international literature carried out as part of a project exploring the commissioning and delivery of social care in housing with care settings. The paper also considers housing with care in the context of UK policy and practice. Design/methodology/approach – The peer literature review process used a range of academic databases as well as government and third sector web sites, drawing on relevant material in English published from 1990 to 2012. Findings – Findings are presented within three main themes: how care and support is provided; the role of the built environment; and the benefits for resident well-being. The review found a paucity of literature focusing specifically on care and support in housing with care settings, particularly in terms of how social care is delivered, but the evidence base suggests that housing with care is in a strong position to deliver on most if not all UK government aspirations. Practical implications – Despite a growing literature both in the UK and internationally exploring the characteristics and benefits of housing with care for older people, substantial gaps remain in the research evidence. Originality/value – This paper presents an up to date review of the housing with care literature in the context of current UK policy.

Making the most of evaluation: a mixed methods study in the English NHS

Objectives: To increase understanding about how evaluations of health policy initiatives are commissioned, conducted and used. Methods: A mapping exercise was conducted to identify evaluation of initiatives promoted by the White Paper ‘Our health, our care, our say’ in the English NHS. All evaluations were subjected to critical appraisal and 21 were purposively selected as case studies, involving documentary analysis and 60 interviews with those commissioning, conducting and affected by the evaluation. Results: Variation in the types of evaluation being undertaken did not reflect the importance of the initiatives being evaluated. Most evaluations collected evidence about uptake, processes of care and users’ perceptions. While some provided useful information about how initiatives could be improved, few provided robust evidence about the benefits or costs of the initiatives. Those who commissioned evaluations had similar concerns to those who conducted them. There was a commitment to the concept of evaluation but little clarity about how findings would be used. Evaluation was often commissioned too late to influence decisions about implementation. Compromises over research design and difficulties collecting data limited the potential to provide robust evidence about benefits. There were tensions between the desire of evaluators for methodological rigour and the needs of service providers for swift, contextually relevant findings. There were concerns about the transparency of methods and results. Conclusions: Considerable public resources are committed to evaluation, but this investment is less productive than it could be. This article specifies several ways in which the use of evaluation of initiatives in health and social care could be improved.