Primary health care for older people: progress towards an integrated strategy?

The importance of providing integrated, holistic and cohesive primary care for older people has been increasingly emphasized in recent policy initiatives and directives in the UK. These have sometimes proved to be elusive goals, however, as an ageing population and rapidly changing health care environment have increased the pressures on the primary care team to keep pace with the growing level of need. As primary care faces a new set of challenges presented by the development of Primary Care Groups (PCGs), opportunities may be found to address older people's health needs in a more coordinated way. In South Buckinghamshire, a multi-agency group, Health for All (HFA), has been keen to develop collaborative and inter-agency working in older peoples' services and commissioned an evaluation to inform their work. This paper focuses on some of the key findings from the evaluation with reference to primary care. The purpose of the evaluation was to provide a snapshot of service provision for older people, identifying the level of access, availability of services and areas of unmet need. Twelve user groups were consulted and interviews held with 58 service representatives from health and social services agencies in the statutory and voluntary sectors. Primary care was considered in the wider context of service provision and key issues from the perspectives of providers and users were identified. A number of problems specific to primary care were identified which echo experiences in other parts of the country. However, also identified were common issues across a wide range of service provision, suggesting the need for coordinated strategies and more effective user participation. The HFA group is using the recommendations of the evaluation to assist in a priority setting exercise, which will inform the development of a strategy for older people in South Buckinghamshire.     

Older lesbian and gay adults’ perceptions of barriers and facilitators to accessing health and aged care services in Australia

Older lesbian and gay people can face considerable marginalisation, which may affect their perceptions and experiences of accessing health and aged care services. To inform strategies promoting accessibility, this study aimed to investigate perceived barriers and facilitators to health and aged care service access among older lesbian and gay adults. A sample of 752 cisgender lesbian women and gay men aged 60 years and older living in Australia responded to questions on a broad range of potential barriers and facilitators to service access. Several barriers and facilitators were commonly reported, with some differences between the women and the men. LGBTI inclusiveness was among commonly reported concerns. A majority of participants reported a lack of LGBTI-inclusive service providers and professionals as a barrier. A majority also reported a perceived lack of professionals adequately trained and competent to work with LGBTI individuals, with significantly more women than men indicating this as a barrier. Almost all participants indicated LGBTI-inclusive mainstream services as a facilitator for access. In all, inclusiveness appears to be a key issue for service access among older lesbian and gay people, which may need to be further addressed by service providers and policy makers for improving service accessibility.     

Support networks for Chinese older immigrants accessing English health and social care services: the concept of Bridge People

As Chinese immigrants in the United Kingdom age, they experience an increasing need to access health and care services. It has, however, been reported that older Chinese immigrants have difficulties in accessing these services. This study explored the experiences of this population in using health and care services and the strategies that they adopted to address their difficulties. A grounded theory method with a two‐staged research design was used. Stage 1 explored the participants’ experiences of ageing and use of health and social care services through focus group interviews. Stage 2 investigated the strategies individuals used to support access to and use of services through individual interviews. Forty‐four older Chinese people and 15 supporters participated in interviews during August 2011 and May 2013. These older Chinese immigrants were challenged in knowing about and in accessing services. Their difficulties were attributed to language barriers, lack of information and instrumental support, and emotional and cultural issues regarding use of health and care services. Their supporters facilitated access to services and acted as a bridge between the service and the user; therefore, they were given the title ‘Bridge People’. Bridge People have different backgrounds: family and friends, public sector workers and staff from community‐based Chinese organisations. The defining attributes of these supporters were: bilinguality, bicultural, multifunctionality and accessibility. There is no charge for this support; and the relationship between the Bridge Person and recipient involves trust and influence over decisions regarding use of health and care services. Bridge People should be recognised and identified by health, social care and housing services to promote engagement and use of services by older immigrant Chinese people.     

Accessibility and equity of health and social care services: exploring the views and experiences of Bangladeshi carers in South Wales, UK

There is a paucity of information regarding the extent and nature of caring provided by minority ethnic communities. The proportion of older people from these communities will dramatically increase in the next 20 years, which will be accompanied by increasing health and social care needs and an increased demand for carers. A qualitative, exploratory study was conducted to identify the health and social care needs of informal carers, who were caring for a dependent adult from a Bangladeshi community in South Wales, UK. This paper focuses on Bangladeshi carers' access to formal support services provided by the statutory, private and voluntary sectors to assist them with their caring responsibilities. The findings are based on data collected using face-to-face, focused interviews with 20 Bangladeshi carers. Purposive and snowball sampling were used to recruit the sample. The data were analysed using thematic content analysis. The dimensions of accessibility and equity of quality of care were drawn upon to aid understanding of the findings. Bangladeshi carers faced a number of barriers in accessing health and social service provision, which impeded uptake of these services. Additionally, there was evidence of inequity in service provision. Recommendations for improving the accessibility of health and social care services are proposed, which may assist in promoting more equitable services for carers from the Bangladeshi community.     

Access to diabetes services: the experiences of Bangladeshi people in Bradford, UK

Recent years have seen a renewed emphasis in UK healthcare policy on access to services, yet there has been little research into possible inequalities in access for people from different ethnic backgrounds. This paper examines access from the point of view of a group of Bangladeshi people with diabetes, whose views were obtained as part of a wider evaluation of diabetes services. Their message is a powerful one. The problems they experienced, however, cannot be attributed solely to cultural insensitivity, in which providers adopt a 'like it or lump it' approach. The wider evaluation provides a context within which to identify similarities with, as well as differences from, other groups in the community, and the findings show that the experiences of this vulnerable group highlight more general weaknesses in service provision. The paper also shows that conventional analysis of access in terms of barriers to be overcome misses a crucial dimension: the ability to make full use of services. Gaining access does not mean that needs will be met appropriately, and patients vary in the extent to which they are able and enabled to play an active role in obtaining the services they need.     

Engagement with health and social care services: perceptions of homeless young people with mental health problems

The present qualitative study describes and discusses the perspectives and experiences of young homeless people with mental health problems in relation to their interactions with health and social care services. Working in partnership with Streetlink, a supported accommodation assistance programme in Adelaide, Australia, the authors interviewed 10 homeless young people, aged from 16 to 24 years of age, who had experienced mental health problems. In-depth interviews elicited accounts of the best and worst of the participants' experiences of health and social care services. Access to services was not identified as being a significant problem in comparison with the participants' concerns regarding the quality of the services encountered. The central findings stress the importance of a respectful and supportive climate in relation to the qualities of service provision that the young people identified as valuable for their continuing treatment or consultation.     

A survey of service providers' views on care and support provision for older women from Black and minority ethnic backgrounds in Wales: Implications for policy and practice

Drawing on quantitative data from a large study, we explored service providers' perceptions of the care and support provided to older women from Black and minority ethnic backgrounds living in the UK. Analyzing 102 responses to a questionnaire, we found that the care needs of this group of older women were not adequately addressed, with ineffective communication being frequently reported. A number of information pathways and barriers to service provision were identified. More work is needed to explore not only how best to acknowledge diversity in care needs within older populations, but also to design and deliver responsive services accordingly.     

The health, social care and housing needs of lesbian, gay, bisexual and transgender older people: a review of the literature

This paper reports the findings of a literature review of the health, social care and housing needs of older lesbian, gay, bisexual and transgender (LGBT) adults undertaken in 2006 for the Welsh Assembly Government. Peer-reviewed literature was identified through database searches of BNI, PubMed, CINAHL, DARE, ASSIA and PsychInfo. Follow-up searches were conducted using references to key papers and journals as well as specific authors who had published key papers. A total of 187 papers or chapters were retrieved, of which 66 were included in the study; major themes were identified and the findings synthesised using a meta-narrative approach. The main themes that emerged from the review were isolation, health behaviours, mental health and sexual health behaviours. The literature indicates that the health, social care and housing needs of LGBT older people is influenced by a number of forms of discrimination which may impact upon the provision of, access to and take up of health, social care and housing services. Understanding of the health, social care and housing needs of older LGBT people is limited and research in this area is scarce. The research which exists has been criticised for using small samples and for tending to exclude participants from less affluent backgrounds. The focus of research tends to be on gay men and lesbians; consequently, the needs of bisexual and transgender people remain largely unknown. Additionally, research which does exist tends to focus on a narrow range of health issues, often related to the health needs of younger LGBT people. Discrimination in various forms has a major impact on needs and experiences, leading to marginalisation of LGBT people both in the provision of health and social care services and neglect of these groups in public health research.     

Health needs of indigenous Mayan older adults in Mexico and health services available

Current data indicate that inequitable health service access is one of the major problems faced by indigenous people in Mexico and around the world. The aim of this study was to analyse the perceived health needs of indigenous older adults in a Mayan region of Mexico and the health services provided to address these needs. It used a qualitative design which explored health needs, perceptions of well‐being, experiences with public health services and obstacles in accessing services through semi‐structured interviews with 20 older adults, nine traditional healers and seven public healthcare providers from Mayan municipalities in southeastern Mexico during 2013–2014. We identified that cultural differences related to the language, values, beliefs and worldview of indigenous populations are ignored or incorporated only minimally by health services. The provision of services does not correspond to the health needs of indigenous Mayan older adults, and wide gaps still undermine their human rights and health status; despite the establishment of favourable regulations, healthcare services are organised for the non‐indigenous population. The conditions of social vulnerability affecting indigenous older adults require that healthcare institutions incorporate an intercultural approach in order to improve the quality of care according to the necessities of the population.     

The Gospel Oak Project: the use of health and social services by dependent elderly people in the community

The Gospel Oak Project surveyed a community sample of elderly people. Prevalence rates of depression and dementia were determined. Cases were assessed in detail and subject to long-term follow-up. Demographic information and morbidity data identified details of health service, social service and informal service contact. This paper reports the findings of the first survey of this population completed in 1987. It examines the effect of the increase in the very elderly on the need for health and social services, including contact with general practitioners. Duplication of service contacts are explored and the dependent elderly people not in receipt of services are identified. Finally, the survey investigates the effect of informal care on the level of service contact. Results confirm that contact increases with age, especially multiple service contact, implying a need for an expansion in future services. Although most depressed residents do not usually complain of depression, they have increased contact with health services but are not treated with anti-depressant medication. Few dependent elderly people receive no services; conversely there is no evidence of service duplication. Finally, receipt of informal care affected attendance at a day centre but no other service provision.     

Older people's views of a good death in heart failure: implications for palliative care provision

Palliative care in the UK has been developed to meet the needs of predominantly middle aged and younger old people with cancer. Few data are available regarding the extent to which services respond to the specific needs of an older group of people with other illnesses. This paper draws on in-depth interviews conducted with 40 people (median age 77) with advanced heart failure and poor prognosis to explore the extent to which older people's views and concerns about dying are consistent with the prevalent model of the 'good death' underpinning palliative care delivery. That prevalent model is identified as the "revivalist" good death. Our findings indicate that older people's views of a 'good death' often conflict with the values upon which palliative care is predicated. For example, in line with previous research, many participants did not want an open awareness of death preceded by acknowledgement of the potential imminence of dying. Similarly, concepts of autonomy and individuality appeared alien to most. Indeed, whilst there was evidence that palliative care could help improve the end of life experiences of older people, for example in initiating discussions around death and dying, the translation of other aspects of specialist palliative care philosophy appear more problematic. Ultimately, the study identified that improving the end of life experiences of older people must involve addressing the problematised nature of ageing and old age within contemporary society, whilst recognising the cohort and cultural effects that influence attitudes to death and dying.     

Family Support through Childcare Services: Meeting the Needs of Asylum-seeking and Refugee Families

This article is a summary of the research carried out in relation to the experiences of asylum-seeking and refugee families regarding access and participation in local childcare services. Focus groups and interviews were carried out with 16 refugee and asylum-seeking parents, five childcare practitioners, and two support and development staff in a small, mainly rural county, in the northwest of Ireland. Following a review of the literature in relation to social networks, social capital and social support, the research was designed to establish the perceptions of service users as well as service providers. The findings showed that levels of isolation experienced by both refugee and asylum-seeking families, largely because of current policy provisions, had a significant impact on their ability to develop informal supports networks in their host community. Families found that the formal and informal networks provided through childcare services were sources of valuable support. Both service users and staff identified a number of challenges in meeting various needs and in providing culturally responsive services. Challenges identified by service users came from their living experiences in the direct provision system, and social exclusion experienced by both asylum-seeking and refugee families, such as the cost of childcare and isolation. Communication and language barriers present as a significant challenge for both service users and service providers.     

Developing service user involvement in the South Korean disability services: lessons from the experience of community care policy and practice in UK

This paper considers the scope for the integration of service user involvement within services for people with disabilities in South Korea at a time of rapid development in social policy and practice. Using the UK experience of introducing community care and a mixed economy of service provision over the last 14 years, this paper considers the barriers to service user involvement inherent in the South Korean context and concludes that in a society where there is a shortage of services and a provider-orientated delivery system where most services are delivered by voluntary organisations, more public services are needed and a 'democratic' rather than a consumerist approach to user involvement is required. Some elements of the UK system could inform the development of a systematic approach to user involvement in South Korea, notably the right to assessment within a care management structure, the setting of quality care standards and inspection processes and a complaints procedure.     

'Nobody ever chooses this ...': a qualitative study of service providers working in the sexual violence sector – key issues and challenges

This paper describes the findings from the first stage of a study designed to assess the impact of sexual violence (SV) on the lives of Irish women. Stakeholder interviews ( n  = 18) were undertaken to explore experiences of delivering services to people who have experienced SV, in rural and urban settings in Ireland. A range of themes and sub-themes were identified through a thematic analysis, and interrelationships between two of the main themes (barriers to services and current gaps in service provision) are discussed. Sub-themes include: survivor guilt and shame, difficulties in naming the incident as SV, problems with the Criminal Justice System and the availability of Sexual Assault Treatment Units. Participants identified an urgent need for a co-ordinated national strategy in the form of a public awareness and education campaign in order to undermine commonly held rape myths and stereotypes. The findings will be of interest to all health and social care professionals who are in contact with women who have experienced SV. They will also help to raise an awareness of the 'hidden' costs of SV, and inform appropriate policies and community-based responses to this important social problem.     

A qualitative geographical information systems approach to explore how older people over 70 years interact with and define their neighbourhood environment

A growing body of literature explores the relationship between the built environment and health, and the methodological challenges of understanding these complex interactions across the lifecourse. The impact of the neighbourhood environment on health and behaviour amongst older adults has received less attention, despite this age group being potentially more vulnerable to barriers in their surrounding social and physical environment. A qualitative geographical information systems (QGIS) approach was taken to facilitate the understanding of how older people over 70 in 5 UK towns interact with their local neighbourhood. The concept of neighbourhood changed seasonally and over the lifecourse, and was associated with social factors such as friends, family, or community activities, rather than places. Spaces stretched further than the local, which is problematic for older people who rely on variable public transport provision. QGIS techniques prompted rich discussions on interactions with and the meanings of ‘place’ in older people.     

‘It felt like there was always someone there for us’: Supporting children affected by domestic violence and abuse who are identified by general practice

One in five children in the UK are affected by domestic violence and abuse. However, primary care clinicians (GPs and nurses) struggle to effectively identify and support children and young people living in homes where it is present. The IRIS+ (Enhanced Identification and Referral to Improve Safety) training and advocacy support intervention aimed to improve how clinicians respond to children and young people affected by domestic violence and abuse. IRIS+ training was delivered as part of a feasibility study to four general practices in an urban area in England (UK). Our mixed method design included interviews and questionnaires about the IRIS+ intervention with general practice patients, including children and young people as well as with clinicians and advocacy service providers. We collected the number of identifications and referrals by clinicians of children experiencing domestic violence and abuse through a retrospective search of medical and agency records 10 months after the intervention. Forty-nine children exposed to domestic violence and abuse were recorded in medical records. Thirty-five children were referred to a specialist domestic violence and abuse support service over a period of 10 months. Of these, 22 received direct or indirect support. The qualitative findings indicated that children benefitted from being referred by clinicians to the service. However, several barriers at the patient and professional level prevented children and young people from being identified and supported. Some of these barriers can be addressed through modifications to professional training and guidance, but others require systematic and structural changes to the way health and social care services work with children affected by domestic violence and abuse.     

Access to and use of out-of-hours services by members of Vietnamese community groups in South London: a focus group study.

BACKGROUND: Communication difficulties, lack of knowledge of services and the appropriateness of services influence access to health care services by black and ethnic minority groups. These problems may be accentuated outside normal working hours. This may be so particularly for those who do not speak English as a first language, as interpreting services across the UK are extremely limited in the out-of-hours period. OBJECTIVE: We aimed to describe the experiences and perceptions of members of the Vietnamese community groups in seeking out-of-hours health services and to identify potential solutions from participants' perspectives. METHOD: This qualitative study used a focus group methodology. Participants were members of three established community groups in the South London boroughs of Southwark and Lewisham. Participants attended six focus groups which were conducted in Cantonese and Vietnamese. RESULTS: Participants did not know about GPs' out-of-hours arrangements. And their access to the range of services normally available was limited. They were unable to communicate with health care professionals or answering services and were unaware of out-of-hours interpreting arrangements. Generally, participants were dependent on other people in gaining access to services. Some participants had used 999 services despite communication problems. Participants' experienced delays in seeking health care services and confusion regarding the medicines and advice given. CONCLUSIONS: Communication difficulties limited knowledge of and access to out-of-hours services for the Vietnamese participants. Direct contact with interpreters in the out-of-hours period was suggested as a means of increasing participants' ability to gain access to services. Health service planners need to be aware of the difficulties experienced by such groups if issues of equity in gaining access to health care services are to be addressed.