Kerry Allen

‘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.

Managing Prader-Willi syndrome in families: An embodied exploration

This paper aims to explore the management of a rare chromosome disorder, Prader-Willi syndrome (PWS), within families. It is particularly concerned with developing an understanding of the management of diet and other everyday practices affecting the body. People with PWS tend to experience poor muscle tone combined with food obsession. The level of control over diet needed to prevent obesity and related health complications is often lacking as individuals also experience various forms of learning disability, autistic spectrum disorders and behavioural problems. The findings are based on data from twenty qualitative case studies of English families with a young person with PWS. Analysis of management strategies highlights the centrality of embodied agency in shaping everyday practices and interactions. The significance and influence of biology within this process is particularly evident, as people with the genetic condition PWS experience embodiment and emotion in distinct ways and differently from non-PWS family members in the research sample. Focusing on the multidimensional nature of processes surrounding body management, the paper highlights three key management practices and explores how these practices are influenced by people with PWS and interpreted by family members. Three key practices are identified as: restricting access to food, keeping occupied, and use of routine. The study represents the first UK empirical sociological study of PWS and primarily adds an insight of family management of PWS to a medically dominated literature around the disorder. The findings can sensitise health and social care professionals to some potential issues for families managing PWS, and guide and develop appropriate interventions to support young people with PWS and their carers.

Designing whole-systems commissioning: Lessons from the English experience

The primary aims of this study were to identify determinants of successful strategic commissioning and to assess the overall state of current knowledge. It involved a review of the published literature and interviews with those involved in strategic commissioning in England. The combined evidence from these two sources suggests that structural solutions alone cannot deliver effective relationships and will not be effective when relationships are neglected. There is a prior requirement for staff, partner, and political buy-in. Work is required to ensure the right balance and distribution of commissioning skills and competencies. It is important to note here that many of the skills needed for strategic commissioning may be found in partner agencies (including providers), so organizational boundaries must be seen as porous as the new commissioning/provider roles emerge and are refined. Finance and incentive alignment are also crucial to ongoing strategic commissioning since organizations that contribute to the achievement of multiple outcomes will expect funding streams to recognize and reward these achievements. Overall, while evidence and evaluation are important, in a rapidly changing environment there are no clear-cut guidelines for success and there is an equal need for experimentation and flexibility.

Evidence, insight, or intuition? Investment decisions in the commissioning of prevention services for older people

AbstractEnglish adult social care commissioners are expected to make ‘evidence based’ decisions on how best to invest public sector funding. This study explores the types of evidence that commissioners use in relation to prevention services for older people and the other factors that influence their investment decisions. A study of local authority Directors of Adult Social Services (DASSs) was used to identify three local prevention interventions. Semi-structured interviews with leads for these interventions explored the evidence and other factors that influenced the investment process. Commissioners drew on a variety of published evidence, in particular that deriving from central government and its regional representative bodies, and third sector organizations with specialist knowledge. Local evidence was also generated through the undertaking of pilots and gathering of performance data. Alongside these ‘rational’ decision-making processes were strong political, personal, and relational dimensions relate...

Singing from the same hymn sheet? Commissioning of preventative services from the third sector

Purpose – The purpose of this paper is to explore the delivery of preventative services for older people from third sector organisations (TSOs) and the extent to which current commissioning arrangements enables the aspirations of policy to be achieved. Design/methodology/approach – Semi-structured interviews with key-contacts within a sample of TSOs which had been identified by directors of Adult Social Services as delivering one of the top three preventative interventions in their local authority area. Findings – There was evidence of considerable trust between local authorities and TSOs and as a consequence TSOs were given autonomy to develop holistic and integrated models of delivery that supported rather than diverted the TSOs’ core missions. Both sectors found it difficult to set target outcomes and connected performance frameworks for preventative services. As a consequence a major element of the commissioning cycle is not being completed and TSOs cannot be confident that they are using their resour...

Joint Working between Health and Social Care

Faced with a series of demographic, social and technological changes, countries across Europe have found themselves trying to respond to a series of long-term care (LTC) challenges, including: responding to increased numbers of frail older people and older people with dementia; changes in social/family structures (often reducing the availability of informal care); rising public expectations and the need to improve and assure quality; financial sustainability (in a difficult economic context but also long term); staff recruitment and retention; and the need to develop more preventative and rehabilitative approaches.

How does pre-dialysis education need to change? Findings from a qualitative study with staff and patients

BackgroundPre-dialysis education (PDE) is provided to thousands of patients every year, helping them decide which renal replacement therapy (RRT) to choose. However, its effectiveness is largely unknown, with relatively little previous research into patients’ views about PDE, and no research into staff views. This study reports findings relevant to PDE from a larger mixed methods study, providing insights into what staff and patients think needs to improve.MethodsSemi-structured interviews in four hospitals with 96 clinical and managerial staff and 93 dialysis patients, exploring experiences of and views about PDE, and analysed using thematic framework analysis.ResultsMost patients found PDE helpful and staff valued its role in supporting patient decision-making. However, patients wanted to see teaching methods and materials improve and biases eliminated. Staff were less aware than patients of how informal staff-patient conversations can influence patients’ treatment decision-making. Many staff felt ill equipped to talk about all treatment options in a balanced and unbiased way. Patient decision-making was found to be complex and patients’ abilities to make treatment decisions were adversely affected in the pre-dialysis period by emotional distress.ConclusionsSuggested improvements to teaching methods and educational materials are in line with previous studies and current clinical guidelines. All staff, irrespective of their role, need to be trained about all treatment options so that informal conversations with patients are not biased. The study argues for a more individualised approach to PDE which is more like counselling than education and would demand a higher level of skill and training for specialist PDE staff. The study concludes that even if these improvements are made to PDE, not all patients will benefit, because some find decision-making in the pre-dialysis period too complex or are unable to engage with education due to illness or emotional distress. It is therefore recommended that pre-dialysis treatment decisions are temporary, and that PDE is replaced with on-going RRT education which provides opportunities for personalised education and on-going review of patients’ treatment choices. Emotional support to help overcome the distress of the transition to end-stage renal disease will also be essential to ensure all patients can benefit from RRT education.