Exploring the potential for social prescribing in pre-hospital emergency and urgent care: A qualitative study

There is a sustained increase in demand for emergency and urgent care services in England. The NHS Long Term Plan aims to reduce the burden on emergency hospital services through changing how pre-hospital care operates, including increased delivery of urgent care. Given the recognised potential of social prescribing to address wider determinants of health and reduce costs in other settings, this study aimed to understand the role that social prescribing can play in pre-hospital emergency and urgent care from the perspectives of staff. Semi-structured interviews (n = 15) and a focus group (n = 3) were conducted with clinical staff (n = 14) and non-clinical health advisors (n = 4) from an English Ambulance Service covering emergency (999) and non-emergency (111) calls. Data were analysed using a pre-defined framework: awareness of social prescribing; potential cohorts suitable for social prescribing; and determinants of social prescribing. Awareness and knowledge of social prescribing was limited, though when social prescribing was explained to participants they almost universally recognised its benefits for their role. Social prescribing was considered to be most beneficial to those calling for reasons relating to mental health, loneliness or social isolation, in particular older people and frequent users of 999 and 111 services. Determinants of social prescribing were identified across the micro (patient and staff acceptability of social prescribing), meso (triage and referral pathways) and macro (commissioning and funding) levels of analysis. This is the first empirical study to explore social prescribing in pre-hospital emergency and urgent care services, which suggests that it has potential to improve quality of care at the point of people accessing these services. There is a pressing need to address the micro, macro and meso level determinants identified within this study, in order to support staff within pre-hospital emergency and urgent care services to socially prescribe.     

Exploration of joint working practices on anti‐social behaviour between criminal justice,mental health and social care agencies: A qualitative study

Although the police play an important role for people with mental health problems in the community, little is known about joint working practices between mental health, social care and police services. There is potential for tensions and negative outcomes for people with mental health problems, in particular when the focus is on behaviours that could be interpreted as anti‐social. This study explores perceptions about joint working between mental health, social care and police services with regard to anti‐social behaviour. We conducted a multi‐method sequential qualitative study in the UK collecting data between April 2014 and August 2016. Data were collected from two study sites: 60 narrative police logs of routinely gathered information, and semi‐structured interviews and focus groups with professionals from a range of statutory and third sector organisations (N = 55). Data sets were analysed individually, using thematic iterative coding before integrating the findings. We also looked at sequencing and turning points in the police logs. Findings mapped on a continuum of joint working practices, with examples more likely to be away from the policy ideal of partnership working as being central to mainstream activities. Joint working was driven by legal obligations and concerns about risk rather than a focus on the needs of a person with mental health problems. This was complicated by different perceptions of the police role in mental health. Adding anti‐social behaviour to this mix intensified challenges as conceptualisation of the nature of the problem and agreeing on best practice and care is open to interpretations and judgements. Of concern is an evident lack of awareness of these issues. There is a need to reflect on joint working practices, including processes and goals, keeping in mind the health and welfare needs of people with mental health problems.     

Unmet health and rehabilitation needs of people with long‐term neurological conditions in Queensland,Australia

The survival and life expectancy rates of people with traumatic and degenerative neurological conditions are increasing, sometimes up to several decades. Yet compared to the general population, people with a disability continue to experience poorer health and are at greater risk of developing secondary health problems and facing barriers to services they require. These trends have significant implications for provision of health and rehabilitation services. In this study, the adequacy of health and rehabilitation services provided to people with long‐term neurological conditions and their unmet needs were explored from the perspectives of individual users, their nominated family members and key service providers. A qualitative research design with maximum variation sampling was used. Data were collected from semi‐structured interviews with 65 participants comprising 25 long‐term care service users, nominated family members or friends (n = 22) and care service providers (n = 18) in Queensland, Australia. All service users needed assistance with usual daily activities, and 22 were wheelchair dependent. The hours of funded personal care ranged from 2 to 201 hours per week. Data were analysed using framework analysis. Participants generally perceived that specialist medical and hospital services were adequate and satisfactory. They valued supportive health and rehabilitation professionals and receiving client‐centred physical rehabilitation. However, the majority of participants (n = 17) had perceived unmet needs for physical rehabilitation (n = 14), other health or rehabilitation services (n = 10) or counselling (n = 6). Community‐based physical maintenance rehabilitation was often perceived as inadequate, costly or inconveniently located. Participants highlighted the importance of personal and family counselling and information provision at time points such as diagnosis. The findings contribute to the limited international evidence on the gaps in health and rehabilitation services for people with neurological conditions receiving lifetime care services in the community. A continuum of integrated rehabilitation services to minimise avoidable impairments, optimise independence and functioning, and sustain quality of life is warranted.     

Older UK sheltered housing tenants' perceptions of well‐being and their usage of hospital services

The aim of this study was to examine sheltered housing tenants' views of health and well‐being, the strategies they adopted to support their well‐being, and their use of health and social care services through a Health Needs Assessment. Sheltered housing in the UK is a form of service‐integrated housing for people, predominantly over 60. The study used a parallel, three‐strand mixed method approach to encompass the tenants' perceptions of health and well‐being (n = 96 participants), analysis of the service's health and well‐being database, and analysis of emergency and elective hospital admissions (n = 978 tenant data sets for the period January to December 2012). Tenants' perceptions of well‐being were seen to reinforce much of the previous work on the subject with strategies required to sustain social, community, physical, economic, environmental, leisure, emotional and spiritual dimensions. Of the tenants' self‐reported chronic conditions, arthritis, heart conditions and breathing problems were identified as their most common health concerns. Hospital admission data indicated that 43% of the tenant population was admitted to hospital (886 admissions) with 53% emergency and 47% elective admissions. The potential cost of emergency as opposed to elective admissions was substantial. The mean length of stay for emergency admissions was 8.2 days (median 3.0 days). While elective hospital admission had a mean length of stay of 1.0 day (median 0.0 days). These results suggest the need for multi‐professional health, social care and housing services interventions to facilitate sheltered housing tenants' aspirations and support their strategies to live well and independently in their own homes. Equally there is a need to increase tenants' awareness of health conditions and their management, the importance of services which offer facilitation, resources and support, and the key role played by prevention and reablement.     

Differential impacts of care‐giving across three caregiver groups in Canada: end‐of‐life care,long‐term care and short‐term care

Using data from Statistic Canada's General Social Survey Cycle 21 (GSS 2007), this study explores whether differences exist in the impacts of care‐giving among three groups of caregivers providing informal care either in the caregiver's or recipient's home, or in other locations within the community: (i) those providing end‐of‐life (EOL) care (n = 471); (ii) those providing long‐term care (more than 2 years) for someone with a chronic condition or long‐term illness (n = 2722); and (iii) those providing short‐term care (less than 2 years) for someone with a chronic condition or long‐term illness (n = 2381). This study lays out the variation in sociodemographic characteristics across the three caregiver groups while also building on our understanding of the differential impacts of care‐giving through an analysis of determinants. All three groups of caregivers shared a number of sociodemographic characteristics, including being female, married, employed and living in a Census Metropolitan Area (CMA). With respect to health, EOL caregivers were found to have significantly higher levels of ‘fair or poor’ self‐assessed health than the other two groups. Overall, the findings suggest that EOL caregivers are negatively impacted by the often additional role of care‐giving, more so than both short‐term and long‐term caregivers. EOL caregivers experienced a higher proportion of negative impacts on their social and activity patterns. Furthermore, EOL caregivers incurred greater financial costs than the other two types of informal caregivers. The impacts of EOL care‐giving also negatively influence employment for caregivers when compared with the other caregiver groups. Consequently, EOL caregivers, overall, experienced greater negative impacts, including negative health outcomes, than did long‐term or short‐term caregivers. This provides the evidence for the assertion that EOL care‐giving is the most intense type of care‐giving, potentially causing the greatest caregiver burden; this is shown through the greater negative impacts experienced by the EOL caregivers when compared with the short‐term and long‐term caregivers.     

Evaluation of a community based dental clinic for youth experiencing homelessness in Brisbane

The relationship between homelessness and ill health is complex, and many risk factors for homelessness such as unemployment, low income, and substance abuse are also risk factors for poor oral health. In order to overcome barriers to access dental care, previous studies have recommended integrating dental care, referral pathways, and information within the overall care provided by support services available to people at risk of homelessness. This study aimed to evaluate a dental service developed and implemented to improve access to oral health care of disadvantaged youth in Brisbane. A mobile dental clinic run by volunteer dental professionals was implemented into a community organisation for disadvantaged youth. Participants were clients of Brisbane Youth Services who were disadvantaged youth, ≤25 years and attended the dental clinic in a 1 year period. A questionnaire collected demographic information, a self‐assessment of oral health and an evaluation of their experiences with the dental clinic. Clinical data including DMFT, appointment attendance and items of service provided were collected. One hundred and twelve clients participated in the four dental clinic weeks and its evaluation. Cost was the greatest reported barrier to accessing dental care among participants. More than half (57%) of participants who pre‐booked an appointment failed to attend. A total of 640 services were delivered, with an estimated value of $48,000. The majority (69%, n = 444) of the services provided were preventative services. Almost all of the clients felt the service they received was suitable for them (97%, n = 98) and would use the service again (98%, n = 99). This dental clinic model is feasible and sustainable due to its integration into an existing homeless youth service, low running costs, acceptability to clients and an interest by dental practitioners to volunteer. It provides a useful model which could be scaled up and implemented in other regions.     

Link workers’ perspectives on factors enabling and preventing client engagement with social prescribing

For a social prescribing intervention to achieve its aims, clients must first be effectively engaged. A ‘link worker’ facilitating linkage between clients and community resources has been identified as a vital component of social prescribing. However, the mechanisms underpinning successful linkage remain underspecified. This qualitative study is the first to explore link workers’ own definitions of their role in social prescribing and the skills and qualities identified by link workers themselves as necessary for effective client linkage. This study also explores ‘threats’ to successful linked social prescribing and the challenges link workers face in carrying out their work. Link workers in a social prescribing scheme in a socioeconomically deprived area of North East England were interviewed in two phases between June 2015 and August 2016. The first phase comprised five focus groups (n = 15) and individual semi‐structured interviews (n = 15) conducted with each focus group participant. The follow‐up phase comprised four focus groups (n = 15). Thematic data analysis highlighted the importance of providing a holistic service focusing on the wider social determinants of health. Enabling client engagement required ‘well‐networked’ link workers with the time and the personal skills required to develop a trusting relationship with clients while maintaining professional boundaries by fostering empowerment rather than dependency. Challenges to client engagement included: variation in the volume and suitability of primary‐care referrals; difficulties balancing quality of intervention provision and meeting referral targets; and link workers’ training inadequately preparing them for their complex and demanding role. At a broader level, public sector cuts negatively impacted upon link workers’ ability to refer patients into suitable services due to unacceptably long waiting lists or service cutbacks. This study demonstrates that enabling client engagement in social prescribing requires skilled link workers supported by healthcare referrer ‘buy‐in’ and with access to training tailored to what is a complex and demanding role.     

Factors affecting general practice collaboration with voluntary and community sector organisations

Collaborative working between general practice (GP) and voluntary and community sector (VCS) organisations is increasingly championed as a means of primary care doing more with less and of addressing patients’ “wicked problems”. This paper aims to add to the knowledge base around collaborative practice between GPs and VCS organisations by examining the factors that aid or inhibit such collaboration. A case study design was used to examine the lived‐experience of GPs and VCS organisations working collaboratively. Four cases, each consisting of a GP and a VCS organisation with whom they work collaboratively, were identified. Interviews (n = 18) and a focus group (n = 1) were conducted with staff within each organisation. Transcribed data were analysed thematically. Whilet there are similarities across cases in their use of, for example, Health Trainers and social prescribing, the form and function of GP‐VCS collaborations were unique to their local context. The identified factors affecting GP‐VCS collaboration reflect those found in previous service evaluations and the broader literature on partnership working; shared understanding, time and resources, trust, strong leadership, operational systems and governance and the “negotiation” of professional boundaries. While the current political environment may represent an opportunity for collaborations to develop, there are issues yet to be resolved before collaboration—especially more holistic and integrated approaches—becomes systematically embedded into practice.     

Skill mix: The potential for personal assistants to undertake health‐related tasks for people with personal health budgets

Personal health budgets (PHBs) are being promoted in England as expanding the benefits of choice and control to individuals with healthcare needs. National Health Service (NHS) money is provided to eligible people to use as set out in approved care plans, including direct employment of personal assistants (PAs). The government plans to increase NHS‐funded PHBs and to further introduce integrated personal budgets (IPBs). This potentially creates more demand for directly employed or self‐employed PAs with health‐related skills. The objective of this paper is to report findings from interviews with PAs (n = 105) and key informants (n = 26) from across England, undertaken between October 2016 and August 2017, about the potential for the PA workforce to undertake ‘health‐related’ tasks as facilitated by the introduction of PHBs. PAs were purposefully recruited to ensure the sample included participants from different geographical locations. Key informants were purposefully selected based on their knowledge of policy and community services. Data were analysed quantitatively and qualitatively. This paper focuses on reporting qualitative findings, which are set within the theoretical framework of normalisation process theory to explore implementation challenges of PHBs. The majority (64%) of PAs confirmed that they saw their current roles as congruent with PHBs, were willing to engage with PHBs and undertake health‐related tasks. However, 74% of PAs said they would need additional training if enacting such roles. Key informant interviews appraised the development of PHBs as complex, noting incongruences arising from NHS and social care‐funded PAs carrying out similar roles within different organisational systems. We conclude the current PA workforce is willing to take on PHB work and is likely to interweave this with work funded by PBs and self‐funding care users. Implications include the need for careful consideration of training requirements and delivery for PHB‐funded PAs.     

Breaking down barriers: exploring the potential for social care practice with trans survivors of domestic abuse

There is increasing recognition that domestic abuse takes place outside the heteronormative paradigm of social life. This paper presents a discussion of the findings of doctoral research which explores trans people's experiences of domestic abuse, their social care needs and whether these are met by domestic abuse agencies. This paper foregrounds debate on the intersections of domestic abuse, trans communities and social care provision as this research, and previous studies, suggests that trans survivors do not seek out or benefit from social care intervention. Qualitative data, collected via narrative interviews, were collected during 2012 from participants mainly located in the United Kingdom (two participants were based in the United States). A total of 24 interviews were undertaken with trans people (n = 15) and social care practitioners (n = 9). Data were examined using a voice‐centred relational technique. The findings reveal that barriers are multiple and complex but work could be undertaken to encourage help‐seeking behaviours. Barriers include expectations of a transphobic response and ‘Othering’ practices; lack of entitlement felt by trans people; lack of knowledge/misunderstandings about trans social care needs; heteronormative bias of existing services; and practitioner attitudes fixed to notions about gender as binary. The paper ends by proposing a framework for practice with trans survivors which incorporates a person‐centred, narrative approach.     

Identification and Education of Adolescents with Asthma in an Urban School District: Results from a Large-scale Asthma Intervention

Asthma is a leading cause of hospitalizations, acute care utilization, health care costs, and school absences in children. Asthma morbidity is disproportionately high in inner city populations. In general, community-based public health interventions to reduce asthma morbidity have had modest success due in part to their limited reach and low participation by the targeted population. Adolescents have been especially difficult to reach. A coalition of community organizations developed a school-based, population-level system to identify, prioritize, and provide interventions for middle school children with asthma in a large urban school district in Oakland, CA. Nearly 92% (n = 8,326) of students in the targeted schools took an asthma case identification survey. Of those students who took the survey, 17.5% (n = 1,458) had active asthma and were eligible for services. Among those identified with active asthma, 83% (n = 1,217) voluntarily attended asthma self-management classes at school. The 4-week curriculum previously has been shown to significantly improve several indicators of asthma control in this population. Retention was high—72% of students who enrolled attended at least three of the four curriculum sessions. Many higher-risk students were subsequently referred to and enrolled in off-site asthma services. Large school districts with incomplete or inadequate health records, high asthma prevalence, and internal or external services available for students with asthma may benefit from a similar model. A system such as the one described may be an effective public health strategy for school districts, health departments, and community coalitions addressing asthma or other conditions with high childhood prevalence. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Definitions of health and social care standards used internationally: A narrative review

Setting standards is a quality improvement mechanism and an important means for shaping the provision of health and social care services. Standards comprise statements describing a process or outcome of care. Setting standards is a global practice. It would be useful to have an understanding of the underpinning definitions of standards used internationally. Therefore, the aim of this review was to examine definitions of health and social care standards used internationally and identify similarities and differences. A targeted grey literature search of standard-setting bodies' websites and related health legislation was conducted to retrieve explicit definitions of standards. Of 15 standard-setting bodies that were searched, 12 definitions of standards were narratively synthesised. Terms that appeared in two or more of the definitions were extracted. Counts and percentages were calculated for these terms to determine magnitude of use. The commonalities among definitions included ‘quality’ (n = 6, 50%), ‘statements’ (n = 5, 42%), ‘performance’ (n = 5, 42%), and ‘measureable’ (n = 4, 33%). The less commonly used terms were ‘processes’ (n = 3, 25%), ‘set’ (n = 3, 25%), ‘evidence based’ (n = 2, 17%), ‘outcome’ (n = 2, 17%), ‘safe’ (n = 2, 17%), and ‘guidance’ (n = 2, 17%). Explicit definitions of standards were not retrieved from health legislation documents. Standard-setting bodies develop standards in the context of the health systems in which they are implemented; some are aspirational levels of quality, while others are minimum levels of quality. Researchers, standards developers and policy makers should be cognisant of this when comparing standards between countries.     

Gaps in the evidence on improving social care outcomes: findings from a meta‐review of systematic reviews

Adult social care continues to be a central policy concern in the UK. The Adult Social Care Outcomes Framework (ASCOF) is a range of measures nationally available to drive forward improvement on outcomes and quality in local councils. While there is an emphasis on improving transparency, quality and outcomes, drawing on research evidence to achieve these aims is often difficult because the evidence is not easily identifiable, is disparate or of variable quality. We conducted a meta‐review to analyse and summarise systematic review‐level evidence on the impact of interventions on the four outcomes set out in the ASCOF: quality of life, delaying and reducing the need for services, satisfaction with services and safeguarding of vulnerable adults. This paper focuses on the availability of review‐level evidence and the presence of significant gaps in this evidence base. A range of health and social care databases were searched, including MEDLINE, ASSIA and The Cochrane Library in January and February 2012. All systematic reviews evaluating the efficacy of social care interventions for improving ASCOF outcomes for older people, people with long‐term conditions, mental health problems or physical and/or learning disabilities were eligible. Two reviewers independently screened systematic reviews for quality and relevance and extracted data; 43 systematic reviews were included, the majority of which examined the impact of interventions on quality of life (n = 34) and delaying and reducing the need for support (n = 25). Limited systematic review‐level evidence was found regarding satisfaction with services and safeguarding. There were also significant gaps in relation to key social care interventions and population groups. Research priorities include addressing these gaps and the collation of data on interventions, outcomes and populations more closely related to social care. Overall, a more relevant, comprehensive and robust evidence base is required to support improvement of outcomes for recipients of adult social care.     

The providers’ profile of the disability support workforce in New Zealand

To understand one of the predominant groups supporting people with disabilities and illness, this study examined the profile of New Zealand paid caregivers, including their training needs. Paid caregivers, also known as healthcare assistants, caregivers and home health aides, work across several long‐term care settings, such as residential homes, continuing‐care hospitals and also private homes. Their roles include assisting with personal care and household management. New Zealand, similar to other countries, is facing a health workforce shortage. A three‐phased design was used: phase I, a survey of all home‐based and residential care providers (N = 942, response rate = 45%); phase II, a targeted survey of training needs (n = 107, response = 100%); phase III, four focus groups and 14 interviews with 36 providers, exploring themes arising from phases I and II. Findings on 17 910 paid caregivers revealed a workforce predominantly female (94%), aged between 40 and 50, with 6% over the age of 60. Mean hourly pay NZ$10.90 (minimum wage NZ$10.00 approx. UK3.00 at time of study) and 24 hours per week. The national paid caregiver turnover was 29% residential care and 39% community. Most providers recognised the importance of training, but felt their paid caregivers were not adequately trained. Training was poorly attended; reasons cited were funding, family, secondary employment, staff turnover, low pay and few incentives. The paid caregiver profile described reflects trends also observed in other countries. There is a clear policy direction in New Zealand and other countries to support people with a disability at home, and yet the workforce which is facilitating this vision is itself highly vulnerable. Paid caregivers have minimum pay, are female, work part‐time and although it is recognised that training is important for them, they do not attend, so consequently remain untrained.     

Targeting preventive home visits to older adults in disadvantaged communities: Perspectives of professionals

This study explored the implementation of multidimensional preventive home visits targeted to older adults living in a disadvantaged community in Denmark. The intervention was adapted to include the following key components: involvement of community members in recruitment processes; a combination of individual and group-based dissemination; adaptation of materials to overcome language barriers; and diversity-sensitivity training for professionals. The study took place over 12 months between August 2016 and August 2017 and used various data sources: registry-based data, participant observations, combined with individual and focus group interviews with the target population (n = 22) and relevant health care professionals (n = 8). Here, we report on findings pertaining to implementation barriers and facilitators as seen from the perspective of professionals. Socioeconomic vulnerability was prominent, and uptake of health care services was low, indicating under-utilisation. Implementation facilitators and barriers were identified including potentials in nurturing local partnerships and proximity during recruitment; overcoming language barriers; offering diversity-sensitivity training for professionals; and a need for a more multidisciplinary, comprehensive scope of preventive visits for diverse older adults in disadvantaged communities. Thus, more focus on participatory, comprehensive and community-based health promotion are needed to ensure healthy ageing in the context of social inequality and ethnic diversity.     

Mentoring at Men's Sheds: an international survey about a community approach to health and well‐being

Men's Sheds are named within the Australian and Irish National Male Health Policies as an exemplar of male health and well‐being and offer a range of formal and informal mentoring to counter the known consequences of social exclusion. The study aimed to report on whether Men's Sheds undertake mentoring programmes, and if so, who is being mentored; are mentors being trained, and if so by whom; and the perceived effectiveness of the mentoring programme. Furthermore, the study aimed to explore associations between sheds with a mentoring programme and factors that reflect an inclusive and a health‐focused environment. All known Men's Sheds were invited to participate in the survey; of those, 324 (42.8%) Men's Sheds in Australia and 59 (48.0%) International sheds participated in the study between April and August 2012. Overall, 39.2% (n = 127) of Australian sheds and 23.7% (n = 14) of International sheds undertook formal mentoring. Youth was the most common group being mentored in both Australia (60.6%; n = 77) and Internationally (71.4%; n = 10). Over half of Australian shed co‐ordinators rated their mentoring programme as moderately effective (52.8%; n = 67) and over a third as highly effective (36.2%; n = 46), while half of International shed co‐ordinators rated theirs as highly effective (50.0%; n = 7). The findings from this paper support the notion that a large number of Men's Sheds offer formal mentoring programmes targeting a range of disadvantaged sub‐populations, thus supporting social inclusion. Inter‐generational mentoring is the most frequently occurring type of mentoring programme. While training mentors occurs at some sheds, the efficacy of this training and programme outcomes are unknown. A typology of shed types appears to be emerging based on a divergence of sheds with a more utilitarian focus and sheds that appear to embrace a health and well‐being focus.