Rosemary Littlechild

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

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.

Co-research with older people: Perspectives on impact

Although research in partnership with older people has been slower to develop than that with some other service user ‘groups’, there are a growing number of health and social care studies that have involved older people as co-researchers. We build on this existing evidence by addressing two key areas. First, despite the growth of participatory research with older people generally, some groups tend to be excluded. We focus particularly on a project in which older people with dementia and older people from a black and minority ethnic community were involved as co-researchers. They worked with academic researchers in all stages of the research process, exploring other older people’s experiences of transitions between care services. Second, recent literature suggests a lack of critical evaluation of involvement, arguing that researchers tend to emphasise the positives on the basis of retrospective narrative accounts of the process, rather than critically appraising the impact of involvement. This article offers a critical account of the impact of a participatory approach at different stages of a research project, evaluating this from the perspective of different stakeholders. In so doing, we engage with incisive critiques which claim that, far from empowering service users, much service user involvement activity contributes to their oppression. We conclude that participatory research with marginalised older people has the potential to achieve meaningful change at both individual and social levels. However, in view of its dangers and limitations, we argue the need for the impact of participatory research to be carefully evaluated from the perspectives of all parties in the process.

Devising the Evaluation Strategy for a Mental Health Training Programme

What follows is an evaluation of the definitions and methods of evaluation that can be developed into an evaluation strategy. The strategy is derived from the use of a case-study research methodology applied to a UK postgraduate multi-disciplinary Programme in Community Mental Health. This chosen methodology is coupled with a model adapted from the training literature in an attempt to critically review how the strategy might be applied in practice.

Fighting fires?--emergency hospital admission and the concept of prevention.

Although the UKs health and social care system has always been geared towards dealing with crises, evidence suggests that this is becoming increasingly the case. Changes in health care and the prioritisation of scarce resources have resulted in a situation where those with low level needs are often left unsupported until they experience a major life crisis. To rectify this situation, the government has introduced a range of policies designed to emphasise the need for preventive work. Against this background, this paper focuses on the issue of emergency hospital admissions, critiquing the research methodologies that have been used to investigate the scope for preventive work in this area. Despite the use of more sophisticated and objective research tools, there is a need to develop new ways of researching emergency admissions which build on the strengths of existing approaches while at the same time incorporating more of a user perspective.

The Disability Profile of Adults Who Receive Adaptive Equipment from Local Authority Occupational Therapy Services

Little is known about the disability profile of people who receive adaptive equipment or about the efficacy or cost-effectiveness of provision. A cross-sectional survey of the records of eight purposefully chosen local authority occupational therapy departments in the Midlands, England, was conducted. The Barthel Activities of Daily Living Index was then used to describe the self-care dependency characteristics of 342 community-dwelling adults in receipt of the equipment provided, following an assessment by one of 24 occupational therapists or 8 assistants. The results indicated that the majority of service users were older than 65 years (78%) and experiencing difficulty in more than one domain. The median Barthel Activities of Daily Living Index score was 14.5, IQR 11–17, with greatest dependency in bathing, climbing stairs, dressing and transfers. Information about the population can help not only to plan service provision but also to underpin further evaluations of the effects of policy changes on the service.

The Use of Fair Access to Care Services' Eligibility Criteria for Equipment Provision within Local Authorities in England

In April 2003, the national eligibility framework for the provision of community care services, Fair Access to Care Services (FACS), was implemented. The aim of the framework was to ensure geographical equity in the provision of services, including equipment and minor works, so ending the postcode variability of care described in the Audit Commission report Fully Equipped. This study reports a postal questionnaire survey of a representative sample of 100 local authority occupational therapy teams across England to examine the implementation and use of the criteria for equipment provision. A 60% response rate revealed that only 9 out of 60 teams (15%) used solely FACS criteria; the remainder still used local criteria. Between-colleague differences in equipment provision persisted (68%). This suggests that the implementation of the FACS eligibility criteria has not achieved its goal.

Equipment Provision by Local Authority Occupational Therapy Teams Using the Fair Access to Care Services Eligibility Framework: A Vignette and Interview Study

Purpose: In April 2003, the first national eligibility framework for adult services, Fair Access to Care Services (FACS), was implemented by local authorities in England. The intention was to ensure equity in the provision of adaptive equipment. This study examined how the criteria were being used by local authority occupational therapy teams and if equity was being achieved. Procedure: Five vignettes or hypothetical case histories were used to capture the experiences of a purposefully selected group of 12 employees from three local authority occupational therapy teams in the Midlands. Semi-structured interviews were then conducted to explore the themes raised by responses to the vignettes. Interviews were recorded and transcribed. Thematic analysis was independently conducted by two of the authors. Findings: There are inconsistencies in the access to services and the use of eligibility criteria, particularly at the point of entry to the service and for those people who are classified as having ‘low’ level needs. However, there is consistency within professional practice and evidence that staff prioritise client need. Conclusion: The implementation of FACS has been inconsistent and has not resulted in equity of provision. Some occupational therapy staff appear to prioritise the needs of clients above organisational policies.

Interviewing older people about their experiences of emergency hospital admission: methodology in health services research

This essay makes the case for increased use of patient-centred methodologies, which involve patients and the public, in the area of emergency admissions research in the United Kingdom. Emergency admission research has rarely made use of the patient voice when attempting to find a rate of ‘inappropriate’ admission for older people, instead focusing on professional viewpoints and more abstract tools. We argue for the important insights that patients and their families bring to emergency admissions research and for the need to listen to and use these voices to find more holistic responses to the issue of unplanned admissions to hospital for those aged over 65. This area of health services research is highly complex, but without involving the patient viewpoint we risk not understanding the full story of events leading up to admission and what preventative measures might have helped, and therefore we also risk developing less effective, simplistic solutions. In the face of increasing challenges to the National Health Service’s ability to provide safe, effective and affordable care for older people, researchers need to listen to those with direct and longitudinal experience of their ill health and admission.

Enhancing Older People’s Mental Wellbeing Through Research: A Case Study

This chapter is based on a research project looking at the experiences of older people moving into or between dementia services offered by social care agencies or the NHS. The research was underpinned by a participatory research approach which included employing older people as coresearchers to work alongside academic researchers in different stages of the research process. This chapter shows how involvement in the research project can enhance the mental wellbeing of both older coresearchers and research participants.