The impact of the economic recession on well‐being and quality of life of older people

The importance of economic well‐being is recognised in the recent UK Government policy. Older people may be particularly vulnerable to economic fluctuations as they are reliant on fixed incomes and assets, which are reducing in value. Within the literature, little is understood about the impact of the current economic downturn on people’s general quality of life and well‐being and, in particular, there is little research on the financial experiences and capability of the older age group, a concern in light of the ageing UK population. This article reports a qualitative research study into the nature of older peoples’ vulnerability by exploring their perceptions of the impact of the economic recession on their well‐being and quality of life. It explores specifically a group of older people who are not the poorest within the ageing population, but who may be described as the ‘asset rich‐income poor’ group. Key themes relate to the impact of the recession on the costs of essential and non‐essential items and dimensions of mental, physical and social well‐being. Implications for health and social care practice in meeting the needs of older people during times of economic recession are then explored. The paper adds to the debate by demonstrating that the recession is having adverse consequences for older people’s quality of life in terms of economic, mental and social well‐being, although there is also evidence that some of them are equipped with certain resilience factors due to their money management and budgeting skills.     

Lifestyle drift and the phenomenon of ‘citizen shift’ in contemporary UK health policy

Despite political change over the past 25 years in Britain there has been an unprecedented national policy focus on the social determinants of health and population‐based approaches to prevent chronic disease. Yet, policy impacts have been modest, inequalities endure and behavioural approaches continue to shape strategies promoting healthy lifestyles. Critical public health scholarship has conceptualised this lack of progress as a problem of ‘lifestyle drift’ within policy whereby ‘upstream’ social contributors to health inequalities are reconfigured ‘downstream’ as a matter of individual behaviour change. While the lifestyle drift concept is now well established there has been little empirical investigation into the social processes through which it is realised as policies are (re)formulated and implementation is localised. Addressing this gap we present empirical findings from an ethnography conducted in a deprived English neighbourhood in order to explore: (i) the local context in the process of lifestyle drift and; (ii) the social relations that reproduce (in)equities in the design and delivery of lifestyle interventions. Analysis demonstrates how and why ‘precarious partnerships’ between local service providers were significant in the process of ‘citizen shift’ whereby government responsibility for addressing inequity was decollectivised.     

Promoting mental health and emotional well‐being among children and youth: a role for community child health?

‘Teenage suicides double as the future crumbles’ with collapse of the economy in Argentina ( Arie 2002 ). Schizophrenia ‘linked to racism’, a study reveals among ethnic minorities in London ( Boydell et al. 2001 ). The promotion of emotional well‐being focuses on improving environments (social, physical, economic) that affect emotional well‐being and enhancing the ‘coping’ capacity of communities as well as individuals ( Wood & Wise 1997 ). What improvements in the ‘environment’ are required, and how does one ‘enhance coping’ in order to promote emotional well‐being? What is the role of those working in community child health in promoting mental health and emotional well‐being? Most of the research on the determinants of the health and well‐being of populations have focused on physical health problems, particularly mortality and life expectancy ( Marmot & Wilkinson 1999 ). There is less research on the ‘upstream’ (socioeconomic) determinants of mental health problems, and even less on emotional well‐being and enhancing ‘coping’ or promoting resilience. Examples of upstream determinants of mental health problems include good evidence linking the prevalence of mental health problems of children and young people to income, educational status and family structure ( Sawyer et al. 2001 ). Male youth suicide has been linked to such upstream determinants as relative unemployment rates. Suicide has increased with increasing ratio of youth to overall unemployment rates ( Morrell et al. 2001 ). A significantly higher risk of suicide in Australia over the past century was shown to be associated with conservative governments compared with social democratic government tenures ( Page et al. 2002 ).     

A community‐of‐care: the integration of a palliative approach within residential aged care facilities in Australia

In developed countries, residential aged care facilities (RACFs) are increasingly becoming the place of care and site of death for older people with complex chronic illnesses. Consequently, it is becoming ever more relevant for these facilities to provide appropriate complex, as well as end‐of‐life care for this growing group of people. Evidence‐based guidelines for providing a ‘palliative approach’ were developed and introduced in Australia in 2004, with the emphasis on improving symptom control earlier in the disease trajectory. The aim of the study reported here was to explore the extent to which a palliative approach was being used in the organisation and provision of care for older people with complex needs living in mixed‐level (a combination of low‐ and high‐level care) RACFs. This paper primarily reports on the qualitative findings. Two residential aged care organisations, one in rural New South Wales and the other in Sydney, Australia, participated. Data were collected over a 9‐month period from May until December 2008. Residents, family members and aged care staff were interviewed. Thematic analysis of participant interviews shows that while the various elements of a palliative approach are incorporated into the care of high‐level care residents, the discourse itself is not used. In this paper, we argue for a new conceptualisation of care for people in mixed‐level care facilities: a community‐of‐care, in which a palliative approach is one of several components of the care provided. The findings illuminate aged care staff experiences of providing care to high‐level care residents. They also provide valuable insights into high‐level care residents’ perceptions of their health, care provided and the way in which they foresee their care being provided in future. These findings will be important for informing clinical practice, research and policy in these settings.     

Wise owls and professors: the role of older researchers in the review of the National Service Framework for Older People

Aim This article explores the involvement of older people in research and inspection, reflecting on the learning from the recent ‘joint review’ of the National Service Framework for Older People in England. Methodological context Working in 10 different localities, the ‘joint review’ comprised a formal inspection of health and local council services (carried out by the Healthcare Commission, Commission for Social Care Inspection and the Audit Commission) and an externally commissioned university‐led research project designed to ascertain the views and experiences of older people living in the 10 inspection sites. In total, 1839 older people were interviewed individually and through focus groups and an additional 4200 older people completed questionnaires. A distinctive feature of the research was the inclusion of a team of older researchers who had undertaken training in research methods in later life. Reflections of the older researchers and other members of the research team on undertaking this large‐scale user involvement project were ascertained via a day‐long seminar which was tape recorded and transcribed. Learning While many espouse the principle of ‘service user involvement’ in research, there is a need to move beyond the rhetoric of participation and any blanket assumptions about what it means to be an ‘older researcher’, a ‘service user researcher’ or indeed, a ‘professional researcher’. This means ensuring that within any given team (user‐controlled or collaborative) there are clear lines of accountability and equal opportunities for individual appraisal, support, and personal or professional development. Such considerations are key to working with ‘older researchers’ and encouraging diversity in the research workforce more generally.     

Developing world class commissioning competencies in care services in England: the role of the service improvement agency

This article provides an insight into the support needs of health and social care commissioners seeking to develop world class commissioning competencies and the role of service improvement agencies in meeting these needs. Reporting findings from the evaluation of one service improvement agency based in England, we focus on the ‘improvement supports’ (the products and services) that were delivered by the ‘Care Services Improvement Partnership’ through its ‘Better Commissioning Programme’. In‐depth interviews were carried out with 25 care commissioners (n = 25) exploring how the Programme was used in their day to day work, its perceived value and limitations. Given the lack of employer‐led training and induction we conclude that service improvement agencies play an important role in developing commissioners’ skills and competencies. However, we suggest that achieving world class commissioning may depend on a more fundamental rethink of commissioning organisations’ approaches to learning and development.     

The impact of a community‐based music intervention on the health and well‐being of young people: A realist evaluation

In recent years, music‐based interventions have been utilised as a tool for improving public health, reducing inequalities and promoting well‐being of young people. Although some researchers have begun to draw links between music‐related interventions and positive health outcomes, there is little understanding as to how such effects are produced. Realist evaluations—understanding what works, for whom and under what circumstances—are a particularly apt means by which we can open this ‘black box’. In this paper, we use a realist evaluation to assess a community‐based music initiative designed and implemented to support the well‐being of disadvantaged young people in Scotland. In order to gain perspectives on the range of contextual characteristics, mechanisms and outcomes, we collected quantitative and qualitative data in the form of pre‐ and post‐questionnaires, as well as conducting interviews with beneficiaries and stakeholders. Our findings show that the intervention achieved a positive impact on the self‐confidence, well‐being and engagement of disadvantaged young people. This impact was achieved via an approach personally tailored to the individual needs of the young people; and an organisational environment characterised by trust, whereby young people felt safe to express themselves.     

Older persons’ experiences and perspectives of receiving social care: a systematic review of the qualitative literature

The topic of social care for older people has gained increasing attention from the part of academics, professionals, policy makers and media. However, we know little about this topic from the perspectives of older persons, which hinders future developments in terms of theory, empirical research, professional practice and social policy. This article presents and discusses a systematic review of relevant qualitative research‐based evidence on the older persons’ experiences and perspectives of receiving social care published between 1990 and September 2014. This review aimed to obtain answers to the following questions: How is the reception of social care experienced by the older persons? What are the negative and positive aspects of these experiences? What are the factors which influence the experiences? The synthesis of the findings of reviewed papers identified six analytical themes: asking for care as a major challenge; ambivalences; (dis)engagement in decisions concerning care; multiple losses as outcomes of receiving social care; multiple strategies to deal with losses originated by the ageing process; and properties of ‘good care’. These themes are discussed from the point of view of their implications for theory, care practice and social policy, and future research.     

Exploring the mealtime experience in residential care settings for older people: an observational study

Improving the mealtime experience in residential care can be a major facilitator in improving care, well‐being and QoL. Evidence suggests that, despite guidance on the subject of food, nutrition and hydration, there are still concerns. Although there is a range of methods to research and assess the quality of food provision, there is a challenge in capturing the experiences of those residents who are unable or unwilling to describe their feelings and experiences because of frailty, impaired communication or other vulnerability. The aim of this exploratory study was to capture and describe individual residents’ mealtime experience. In spring 2011, a small‐scale, observational study was carried out in seven dining settings in four residential care homes in Manchester. An adapted dementia care mapping tool was used alongside field notes. Observations showed two major differences in the way the mealtimes were organised: ‘pre‐plated’ and ‘family‐style’ (where either bowls of food are placed in the centre of the table or food is served directly from a hotplate by a chef). These two styles of service are discussed in relation to the emerging themes of ‘task versus resident‐centred mealtimes’, ‘fostering resident independence’ and ‘levels of interaction’. Although improving mealtimes alone is not enough to improve quality of life in care homes, findings showed that relatively small changes to mealtime delivery can potentially have an impact on resident well‐being in these homes. Observation is a useful method of engaging residents in care settings for older people who may not otherwise be able to take part in research.     

Older men’s participation in community‐based men’s sheds programmes

The purpose of this qualitative study was to investigate the lived experience of older men taking part in community‐based shed programmes. Five men, aged 65 and over, who attended two different community sheds participated in semi‐structured in‐depth interviews in 2007. Data were analysed thematically with six main themes emerging as follows: ‘company of fellas’; ‘everybody’s got a story to tell’; ‘still got some kick’; ‘passing on your experiences’; ‘get on your goat’ and; ‘nobody’s boss’. Participation in community‐based men’s sheds positively influences the health and well‐being of older Australian men through provision of a ‘men’s space’ in which meaningful activities occur. Provision of community‐based men’s shed programmes as among a range of activity options in the community may contribute positively to the physical, mental, social and occupational health of older men.     

Integrated health and social care in England – Progress and prospects

This paper reviews recent policy initiatives in England to achieve the closer integration of health and social care. This has been a policy goal of successive UK governments for over 40 years but overall progress has been patchy and limited. The coalition government has a new national framework for integrated care and variety of new policy initiatives including the ‘pioneer’ programme, the introduction of a new pooled budget – the ‘Better Care Fund’ – and a new programme of personal commissioning. Further change is likely as the NHS begins to develop new models of care delivery. There are significant tensions between these very different policy levers and styles of implementation. It is too early to assess their combined impact. Expectations that integration will achieve substantial financial savings are not supported by evidence. Local effort alone will be insufficient to overcome the fundamental differences in entitlement, funding and delivery between the NHS and the social care system.With a national election set to take place in May 2015, all political parties are committed to the integration of health and social care but clear evidence about the best means to achieve it is likely to remain as elusive as ever.     

Food provision for older people receiving home care from the perspectives of home‐care workers

Malnutrition is a significant cause of morbidity and mortality, particularly among older people. Attention has focused on the inadequacies of food provision in institutions, yet the majority suffering from malnutrition live in the community. The aim of this study was to explore barriers and facilitators to food provision for older people receiving home care. It was a qualitative exploratory study using semi‐structured interviews with nine home‐care workers in June 2013 employed by independent agencies in a large city in northern England. Data were analysed thematically, based on the principles of grounded theory. Findings showed that significant time pressures limited home‐care workers in their ability to socially engage with service users at mealtimes, or provide them with anything other than ready meals. Enabling choice was considered more important than providing a healthy diet, but choice was limited by food availability and reliance on families for shopping. Despite their knowledge of service users and their central role in providing food, home‐care workers received little nutritional training and were not involved by healthcare professionals in the management of malnutrition. Despite the rhetoric of individual choice and importance of social engagement and nutrition for health and well‐being, nutritional care has been significantly compromised by cuts to social care budgets. The potential role for home‐care workers in promoting good nutrition in older people is undervalued and undermined by the lack of recognition, training and time dedicated to food‐related care. This has led to a situation whereby good quality food and enjoyable mealtimes are denied to many older people on the basis that they are unaffordable luxuries rather than an integral component of fundamental care.     

Good practice in social care: the views of people with severe and complex needs and those who support them

This paper reports findings drawn from a study of good practice in English social care for adults with disability and older people with severe and complex needs. People with severe and complex needs are a relatively small proportion of adult social care service users, but they are growing in numbers and have resource‐intensive needs. The study involved qualitative research with adults with disability and older people with severe and complex needs, family carers and members of specialist organisations (n = 67), focusing on the features of social care services they considered to be good practice. Data were collected between August 2010 and June 2011. The approach to data collection was flexible, to accommodate participants' communication needs and preferences, including face‐to‐face and telephone interviews, Talking Mats^© sessions and a focus group. Data were managed using Framework and analysed thematically. Features of good practice were considered at three levels: (i) everyday support; (ii) service organisation; and (iii) commissioning. Findings relating to the first two of these are presented here. Participants emphasised the importance of person‐centred ways of working at all levels. Personalisation, as currently implemented in English social care, aims to shift power from professionals to service users through the allocation of personal budgets. This approach focuses very much on the role of the individual in directing his/her own support arrangements. However, participants in this study also stressed the importance of ongoing professional support, for example, from a specialist key worker or case manager to co‐ordinate diverse services and ensure good practice at an organisational level. The paper argues that, despite the recent move to shift power from professionals to service users, people with the most complex needs still value support from professionals and appropriate organisational support. Without these, they risk being excluded from the benefits that personalisation, properly supported, could yield.     

Neither ‘foolish’ nor ‘finished’: identity control among older adults with HIV in rural Malawi

Prevalence of HIV after age 50 is considerable, especially in southern Africa. Negative social constructions of HIV in older age, and the health consequences of ageing with the virus, mean that having HIV presents a challenge for many people's roles and social memberships, threatening to disrupt their sense of self. Using constructivist grounded theory and qualitative data from rural Malawi, this paper describes how older men and women deal with these identity challenges. Drawing on a symbolic interactionist framework, it uses identity control theory to explore how the study's participants presented their post‐diagnosis behaviours in ways that maintained their most significant pre‐diagnosis identities as ‘adults’, a label they gave to the core identity of being a person who belongs in the social world. Considering the processes through which older people with HIV navigated challenges to their identities in light of the intersectional influences of HIV and age‐related stigma and illness, provides insight into how older people might experience HIV, as well as informing theoretical understandings of identity formation and maintenance in light of chronic and/or stigmatising illness more broadly.     

‘If I die,I die,I don’t care about my health’: Perspectives on self‐care of people experiencing homelessness

Self‐care, which refers to what people do to prevent disease and maintain good health, can alleviate negative health consequences of people experiencing homelessness. The aim of the study was to apply a theoretically informed approach in exploring engagement of people experiencing homelessness in self‐care and to identify factors that can be targeted in future health and social care interventions. Qualitative semi‐structured interviews were conducted with 28 participants opportunistically recruited from a specialist homelessness healthcare centre of North East Scotland, the United Kingdom (UK). An interview schedule was developed based on the theoretical domains framework (TDF). Interviews were audio‐recorded and transcribed verbatim. Six aspects of self‐care were explored, including (a) self‐awareness of physical and mental health, (b) health literacy, including health seeking behaviour, (c) healthy eating, (d) risk avoidance or mitigation, (v) physical activity and sleep and (e) maintaining personal hygiene. Thematic analysis was conducted by two independent researchers following the Framework Approach. Participants described low engagement in self‐care. Most of the barriers to engagement in self‐care by participants were related to 'environmental context and resources' domain of TDF. Participants often resorted to stealing or begging for food. Many perceived having low health literacy to interpret health‐related information. Visits to churches and charities to get a shower or to obtain free meals were commonplace. Participants expressed pessimism that there was ‘nothing’ they could do to improve their health and described perceived barriers often too big for them to overcome. Alienation, lack of social support and the perception that they had done irreversible damage to their health prevented their involvement in self‐care. The theme of ‘social circle’ held examples of both enabler and barriers in participants’ uptake of risky behaviours. Health and social services should work with persons experiencing homelessness in designing and delivering targeted interventions that address contextual barriers, multi‐morbidity, health literacy and self‐efficacy.     

Room for one more? A review of the literature on ‘inappropriate’ admissions to hospital for older people in the English NHS

This paper reports the findings of a review of the literature on emergency admissions to hospital for older people in the UK, undertaken between May and June 2014 at the Health Services Management Centre, University of Birmingham. This review sought to explore: the rate of in/appropriate emergency admissions of older people in the UK; the way this is defined in the literature; solutions proposed to reduce the rate of inappropriate admissions; and the methodological issues which particular definitions of ‘inappropriateness’ raise. The extent to which a patient perspective is included in these definitions of inappropriateness was also noted, given patient involvement is such a key policy priority in other areas of health policy. Despite long‐standing policy debates, relatively little research has been published on formal rates of ‘inappropriate’ emergency hospital admissions for older people in the UK NHS in recent years. What has been produced indicates varying rates of in/appropriateness, inconsistent ways of defining appropriateness and a lack of focus on the possible solutions to address the problem. Significantly, patient perspectives are lacking, and we would suggest that this is a key factor in fully understanding how to prevent avoidable admissions. With an ageing population, significant financial challenges and a potentially fragmented health and social care system, the issue of the appropriateness of emergency admission is a pressing one which requires further research, greater focus on the experiences of older people and their families, and more nuanced contextual and evidence‐based responses.