Jon Glasby

Commentary and Issues : Who knows best? Evidence-based practice and the service user contribution

This paper reviews the assumptions underlying traditional medical research and critiques the concept of ‘evidence-based practice’. In particular, it identifies and counters three basic tenets of this approach: the alleged need for objectivity in research, the notion of hierarchies of evidence and the primacy of systematic reviews. Instead, the paper argues for a new emphasis on ‘knowledge-based practice’, recognizing that the practice wisdom of health and social care practitioners and the lived experience of service users can be just as valid a way of knowing the world as formal research.

Why Partnership Working Doesn't Work

Abstract English public services in general (and health and social care in particular) have become increasingly dominated by the notion of partnership working. Despite this, more recent years have seen something of a reaction against partnerships. This article reviews lessons learned from a case study of a forensic mental health partnership, arguing that the service in question reveals a number of common pitfalls in terms of the way that partnerships are established and put into practice. In many ways, this was not the fault of the case study partnership, but the product of the wider institutional context in which health and social care partnerships have been developed and promoted. Ultimately, the article suggests some additions to the partnership theoretical literature, before concluding that the current concept of partnership working may lose credibility without additional work to clarify its meaning and contribution.

Social work and direct payments

Introduction History From indirect to direct payments I: Legislation From indirect to direct payments II: Guidance and extension Progress The experience of different user groups Possible difficulties Practical issues Conclusion: implications for community care

Cases for change in mental health: partnership working in mental health services

This article examines our current state of knowledge about partnership working between health and social care in UK adult mental health services. Drawing on a narrative review of the literature commissioned by the National Institute for Mental Health, this paper focuses on 43 documents from the review which discuss partnership issues. After exploring the rationale for partnership working, potential barriers and possible ways forward, the paper identifies gaps in the existing literature and discusses the implications of the review for current health and social care policy.

Redesigning mental health services: lessons on user involvement from the Mental Health Collaborative

Objectives  To explore the involvement of mental health service users in the redesign of in‐patient mental health services in six Trusts participating in a multi‐regional NHS modernization programme.

All dressed up but nowhere to go? Delayed hospital discharges and older people

Objective: Delayed hospital discharges are a key concern in a number of industrialized nations and are the subject of a range of government initiatives in the English National Health Service. The aim of this paper was to review the UK literature on delayed hospital discharges and older people in order to identify and explore the rate and causes of delayed hospital discharges, together with policies and practices that may reduce delayed discharges and improve the experiences of older people. Methods: Literature review based on searches of major health/social-care databases. Sources which explore the rate and cause of delayed discharges in the UK were included. Relevant documents were categorized using the research hierarchy set out in the National Service Framework for Older People and analysed according to criteria for appraising the quality of qualitative research proposed by Mays et al. Results: The review identified 21 studies, which suggest very different rates and causes of delayed discharge in different settings. The studies reveal the importance of rehabilitation services to reduce the rate of delayed discharge, the prevalence of delayed discharges caused by internal hospital factors, and the complex and multi-faceted nature of the factors contributing to delayed discharge. Despite this, the studies have a number of methodological flaws and often fail to include a patient perspective or to consider detailed policies and approaches to reduce the number of delayed discharges. There is also a failure to consider the needs of older people with mental health problems or people from minority ethnic communities. Conclusion: The evidence, as it currently stands, raises a number of issues about current hospital discharge policy, supporting some aspects of the current government agenda in England, but questioning other aspects.

Older people and the relationship between hospital services and intermediate care: Results from a national evaluation

In the UK, new intermediate care services have been established to prevent unnecessary hospital admissions, facilitate effective discharge and prevent premature care home admissions. This paper reports findings from a national evaluation of intermediate care, focusing on the relationship between hospital services and intermediate care. Participants included key managers and practitioners involved in the planning, management and delivery of intermediate care in five case study sites. During the study, they identified a range of tensions between hospital services and intermediate care, including concerns about the role and involvement of acute clinicians; the safety, quality and appropriateness of intermediate care; access to and eligibility for intermediate care; a lack of understanding and awareness of intermediate care; and the risk of intermediate care being dominated by acute pressures. Although participants were able to identify several practical ways forward, resolving such fundamental tensions seems to require significant and long-term cultural change in the relationship between acute and intermediate care. Overall, this study raises questions about the extent to which intermediate care will be able to rebalance the current health and social care system and make a substantial contribution to tackling ongoing concerns about emergency hospital admissions and delayed transfers of care.

Making sense of joint commissioning: three discourses of prevention, empowerment and efficiency

BackgroundIn recent years joint commissioning has assumed an important place in the policy and practice of English health and social care. Yet, despite much being claimed for this way of working there is a lack of evidence to demonstrate the outcomes of joint commissioning. This paper examines the types of impacts that have been claimed for joint commissioning within the literature.MethodThe paper reviews the extant literature concerning joint commissioning employing an interpretive schema to examine the different meanings afforded to this concept. The paper reviews over 100 documents that discuss joint commissioning, adopting an interpretive approach which sought to identify a series of discourses, each of which view the processes and outcomes of joint commissioning differently.ResultsThis paper finds that although much has been written about joint commissioning there is little evidence to link it to changes in outcomes. Much of the evidence base focuses on the processes of joint commissioning and few studies have systematically studied the outcomes of this way of working. Further, there does not appear to be one single definition of joint commissioning and it is used in a variety of different ways across health and social care. The paper identifies three dominant discourses of joint commissioning – prevention, empowerment and efficiency. Each of these offers a different way of seeing joint commissioning and suggests that it should achieve different aims.ConclusionsThere is a lack of clarity not only in terms of what joint commissioning has been demonstrated to achieve but even in terms of what it should achieve. Joint commissioning is far from a clear concept with a number of different potential meanings. Although this ambiguity can be helpful in some ways in the sense that it can bring together disparate groups, for example, if joint commissioning is to be delivered at a local level then more specificity may be required in terms of what they are being asked to deliver.

‘It Ain’t What You Do It’s the Way That You Do It’: Lessons for Health Care From Decommissioning of Older People’s Services

Public sector organisations are facing one of the most difficult financial periods in history and local decision-makers are tasked with making tough rationing decisions. Withdrawing or limiting services is an emotive and complex task and something the National Health Service has always found difficult. Over time, local authorities have gained significant experience in the closure of care homes - an equally complex and controversial issue. Drawing on local knowledge and best practice examples, this article highlights lessons and themes identified by those decommissioning care home services. We believe that such lessons are relevant to those making disinvestment decisions across public sector services, including health-care. The study employed semi-structured interviews with 12 Directors of Adult Social Services who had been highlighted nationally as having extensive experience of home closures. Interviews were conducted over a 2-week period in March 2011. Results from the study found that having local policy guidance that is perceived as fair and reasonable was advocated by those involved in home closures. Many local policies had evolved over time and had often been developed following experiences of home closures (both good and bad). Decisions to close care home services require a combination of strong leadership, clear strategic goals, a fair decision-making process, strong evidence of the need for change and good communication, alongside wider stakeholder engagement and support. The current financial challenge means that public sector organisations need to make tough choices on investment and disinvestment decisions. Any such decisions need to be influenced by what we know constitutes best practice. Sharing lessons and experiences within and between sectors could well inform and develop decision-making practices.

New horizons: Reablement - supporting older people towards independence

As the overwhelming majority of older people prefer to remain in their own homes and communities, innovative service provision aims to promote independence of older people despite incremental age associated frailty. Reablement is one such service intervention that is rapidly being adopted across high-income countries and projected to result in significant cost-savings in public health expenditure by decreasing premature admission to acute care settings and long-term institutionalisation. It is an intensive, time-limited intervention provided in peoples homes or in community settings, often multi-disciplinary in nature, focussing on supporting people to regain skills around daily activities. It is goal-orientated, holistic and person-centred irrespective of diagnosis, age and individual capacities. Reablement is an inclusive approach that seeks to work with all kinds of frail people but requires skilled professionals who are willing to adapt their practise, as well as receptive older people, families and care staff. Although reablement may just seem the right thing to do, studies on the outcomes of this knowledge-based practice are inconsistent-yet there is an emerging evidence and practice base that suggests that reablement improves performance in daily activities. This innovative service however may lead to hidden side effects such as social isolation and a paradoxical increase in hospital admissions. Some of the necessary evaluative research is already underway, the results of which will help fill some of the evidence gaps outlined here.