The social dimensions of therapeutic horticulture

Harnessing nature to promote mental health is increasingly seen as a sustainable solution to healthcare across the industrialised world. The benefits of these approaches to well‐being include reduced symptoms of anxiety, depression and improved social functioning. Many studies assume that contact with nature is the main therapeutic component of these interventions yet ‘green care’ programmes typically include activities not based on ‘nature’ that may contribute to positive outcomes. This study explored the views of service users participating in a Therapeutic Horticultural programme on what factors promoted their engagement in the project, to identify variables other than ‘nature’ that may be responsible for successful engagement in these programmes. A secondary aim was to assess the significance ‘nature’ plays including, for example whether a prior interest in horticultural‐related activities, such as gardening, is significant. Two focus groups were held with mental health service users (n = 15) attending a gardening project in south‐east England. Findings revealed that the social element of the project was the key facilitator to engagement; the flexible structure of the gardening project was also significant and allowed service users to feel empowered. ‘Nature’ evoked a sense of calm and provided participants with a non‐threatening space that was engaging.     

Measuring the health of Scottish drug users

Information on how individuals perceive their own health is important for providing appropriate health‐related support and monitoring health over time. The Short Form 36 (SF‐36) Health Status Questionnaire is one of the most widely used generic measures of self‐perceived health status. Despite this, there has been no large‐scale research documenting the SF‐36 scores of problem drug users in the UK. The present paper has two aims: (1) to compare the self‐perceived health of a sample of problem drug users with that of a sample from the general population; and (2) to investigate differences between the self‐perceived health of various subgroups of problem drug users. In total, 1179 individuals starting a new episode of drug misuse treatment in Scotland were invited to complete a structured questionnaire that included the SF‐36. Out of these, 1033 (87.6%) agreed and 990 successfully completed all SF‐36 questions. The 990 completers were more likely than the 43 partial completers to be male [odds ratio (OR) = 0.45; 95% confidence interval (95% CI) = 0.24–0.85] and not in prison (OR = 0.36; 95% CI = 0.19–0.68). The reliability of the SF‐36 – measured by internal consistency – was very good (Cronbach's α > 0.7 for all eight dimensions). Comparing the respondents’ mean dimension scores with those of a sample from the UK general population revealed that the drug users’ health was consistently worse than that of the general population (> 20 points on seven out of the eight scales). Differences between the mean SF‐36 scores of various subcategories of respondents were analysed using t‐tests or an analysis of variance, as appropriate. The factors considered were: sex; age; imprisonment; relationship status; homelessness; and recent drug injection. Significant differences between particular groups of respondents were identified. Despite limitations with the data presented, the paper highlights the utility of the SF36 for drug misuse treatment providers.     

Challenges for psychosocial rehabilitation services in the Lisbon Metropolitan Area: A qualitative approach

In Portugal, a mental health reform process is in place aiming to redefine the model of service provision. In 2008, a National Mental Health Plan (NMHP) was approved to provide policy guidance over the transition period. The NMHP intended, among others, to develop community‐based services, with a specific focus on rehabilitation and deinstitutionalization. This study aims to explore the perspectives of service managers of psychosocial rehabilitation services regarding the main challenges to support the community living of persons with severe mental illnesses (PWSMI) in the Lisbon Metropolitan Area (LMA). The paper also contextualises the provision of psychosocial services within the country's mental health reform process and characterises the profile of service users in socio‐occupational units (SOUs) of the LMA. Semi‐structured interviews were performed with all SOUs’ managers of the LMA (n = 13). Information regarding service user characteristics was collected based on service records (n = 344). Interviews were analysed according to the framework methodology. The results of the interviews were triangulated using document analysis. Fieldwork took place between June and July 2016. The findings suggest that the development of the mental health reform ensured significant changes to service delivery. Community‐based mental health organisations are an important actor for service provision. However, important asymmetries were identified in the provision of psychosocial care within the LMA. At the same time, family carers are perceived as responsible for ensuring a large part of the social needs of the PWSMI but there is an increasing concern with their own ageing processes. As a conclusion, it is highlighted the current inequality between services and the need to contemplate a life‐course perspective that comprehends the ageing process of caregivers poses an emerging challenge for psychosocial rehabilitation. These findings are also important for other low‐ and middle‐income countries passing through similar reforms.     

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.     

Community-backed drug initiatives in the UK: a review and commentary on evaluations

This article presents a review of evaluations of community‐backed initiatives for drug users in the UK. Community‐backed responses have taken a number of approaches. Despite accessing over 250 publications relating to initiatives in the course of this study, a paucity of published evaluative evidence on ‘what works?’ and ‘why does it work?’ was apparent. The readily accessible literature is examined under five broad types of initiative: self‐help groups, parents’ groups, residents’ groups, community development groups and diversionary activity groups. In a further commentary on evaluation issues for such drug initiatives, it is argued that they are under‐evaluated, partly because they are on the margins of drug services and partly because of a lacuna of support in evaluation skills.     

Co-morbid drug and alcohol and mental health issues in a rural New South Wales Area Health Service

Objective: In 2003 the New South Wales (NSW) Centre for Rural and Remote Mental Health (CRRMH) conducted an analysis of co‐morbid drug and alcohol (D&A) and mental health issues for service providers and consumers in a rural NSW Area Health Service. This paper will discuss concerns raised by rural service providers and consumers regarding the care of people with co‐morbid D&A and mental health disorders. Design: Current literature on co‐morbidity was reviewed, and local area clinical data were examined to estimate the prevalence of D&A disorders within the mental health service. Focus groups were held with service providers and consumer support groups regarding strengths and gaps in service provision. Setting: A rural Area Health Service in NSW. Participants: Rural health and welfare service providers, consumers with co‐morbid D&A and mental health disorders. Results: Data for the rural area showed that 43% of inpatient and 20% of ambulatory mental health admissions had problem drinking or drug‐taking. Information gathered from the focus groups indicated a reasonable level of awareness of co‐morbidity, and change underway to better meet client needs; however, the results indicated a lack of formalised care coordination, unclear treatment pathways, and a lack of specialist care and resources. Discussion: Significant gaps in the provision of appropriate care for people with co‐morbid D&A and mental health disorders were identified. Allocation of service responsibly for these clients was unclear. It is recommended that D&A, mental health and primary care services collaborate to address the needs of clients so that a coordinated and systematic approach to co‐morbid care can be provided.     

Tackling community integration in mental health home visit integration in Finland

Integration – and its synonym inclusion – is emphasised in the western welfare states and in the European Union in particular. Integration is also a central topic in the social sciences and in current mental health and homelessness research and practice. As mental healthcare has shifted from psychiatric hospitals to the community, it has inevitably become involved with housing and integration issues. This article explores how community integration is understood and tackled in mental health floating support services (FSSs) and, more precisely, in service user–practitioner home visit interaction. The aim, through shedding light on how the idea of integration is present and discussed in front‐line mental health practices, is to offer a ‘template’ on how we might, in a systematic and reflective way, develop community integration research and practice. The analysis is based on ethnomethodological and micro‐sociological interaction research. The research settings are two FSSs located in a large Finnish city. The data contain 24 audio‐recorded and transcribed home visits conducted in 2011 and 2012 with 16 different service users. The study shows how the participants in service user–practitioner interaction give meaning to community integration and make decisions about how it should (or should not) be enhanced in each individual case. This activity is called community integration work in action. Community integration work in action is based on various dimensions of integration: getting out of the house, participating in group activities and getting along with those involved in one's life and working life. Additionally, the analysis demonstrates how community integration work is accomplished by discursive devices (resistance, positioning, excuses and justifications, delicacy and advice‐giving). The article concludes that community integration is about interaction: it is not only service users' individual challenge but also a social challenge, our challenge.     

Attending to physical health in mental health services in Australia: a qualitative study of service users’ experiences and expectations

Evidence is unequivocal: the premature death of people with severe mental health problems is attributable primarily to cardiovascular disease, and healthcare provided is often suboptimal. With the overarching aim of improving outcomes, policies and guidelines oblige mental health services and psychiatrists to monitor cardio‐metabolic health of patients and intervene as appropriate. Practice is highly variable; however, with ongoing debate about resourcing and responsibilities dominated by clinicians who have identified disinterest among patients as influencing practice. Seeking to balance discussion, we posed the question ‘what do patients experience and expect of mental health services in relation to their physical health?’ To answer it, we interviewed a convenience sample of 40 service users recruited from a mental health service in Australia, early in 2015. Data were analysed using the framework approach. With few regarding themselves as healthy, participants were commonly concerned about side effects of medication, weight and fitness but rarely mentioned tobacco smoking. Participants’ accounts reinforce extensive research demonstrating variability in attention to physical health in mental health services. Reports by some participants of comprehensive care are encouraging, but widespread uncertainty about reasons for various assessments and denial of requests for management of medication side effects, including weight gain, gives cause for concern. Although participants in this study wanted to improve their health and health‐related quality of life, they acknowledged that their motivation and ability to do so fluctuated with mental health. They expected clinicians to work proactively, especially when symptoms compromised capacity for self‐care, and mental health services to provide or enable access to health‐promoting interventions. Attention should be given, as a matter of priority, to creating conditions (culture and infrastructure) needed to support sustained attention to physical health within services and, importantly, to full engagement of service users in management of their physical health.     

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.     

Codesigned recommendations for increasing engagement in structured physical activity for people with serious mental health problems in Australia

People with mental health problems are at higher risk of physical health comorbidities and early mortality. A key risk factor for poor health outcomes is a lack of regular physical activity. Mental health services have typically responded by focusing on screening and promoting lifestyle programmes within secondary care mental health settings. The aim of this study was to better understand the barriers and enablers for Australian mental health consumers to participate in physical activity or exercise programmes from the perspectives of consumers and exercise practitioners. Interviews with 15 consumers experiencing serious mental health problems and five exercise practitioners were undertaken, followed by two focus groups (involving eight consumers and two exercise practitioners) to gain consensus on themes from the interviews, and codesign a set of recommendations for services to support and increase the engagement of mental health consumers in regular community‐based exercise. Barriers that impacted on engagement in physical activity included: lack of social support, insufficient knowledge and information, difficulties with work/life balance, impact of physical and mental health issues, fear and lack of confidence, and financial cost. Enablers or motivators assisting engagement in community‐based physical activity programmes included: social support, access to person‐centred individualised exercise options, connection and a sense of belonging, and access to information and education. Recommendations and a checklist were developed to assist services to increase the involvement of mental health consumers in community‐based exercise and to ensure that exercise practitioners and their employing organisations are adequately equipped to work with this population.     

Self‐reported health,healthcare service use and health‐related needs: A comparison of older and younger homeless people

The number of older homeless people with a limited life expectancy is increasing. European studies on their health‐related characteristics are lacking. This study compared self‐reported health, healthcare service use and health‐related needs of older and younger homeless people in the Netherlands. It is part of a cohort study that followed 513 homeless people in the four major Dutch cities for a period of 2.5 years, starting from the moment they registered at the social relief system in 2011. Using cross‐sectional data from 378 participants who completed 2.5‐year follow‐up, we analysed differences in self‐reported health, healthcare service use, and health‐related needs between homeless adults aged ≥50 years (N = 97) and <50 years (N = 281) by means of logistic regression. Results show that statistically significantly more older than younger homeless people reported cardiovascular diseases (23.7% versus 10.3%), visual problems (26.8% versus 14.6%), limited social support from family (33.0% versus 19.6%) and friends or acquaintances (27.8% versus 14.6%), and medical hospital care use in the past year (50.5% versus 34.5%). Older homeless people statistically significantly less often reported cannabis (12.4% versus 45.2%) and excessive alcohol (16.5% versus 27.0%) use in the past month and dental (20.6% versus 46.6%) and mental (16.5% versus 25.6%) healthcare use in the past year. In both age groups, few people reported unmet health‐related needs. In conclusion, compared to younger homeless adults, older homeless adults report fewer substance use problems, but a similar number of dental and mental problems, and more physical and social problems. The multiple health problems experienced by both age groups are not always expressed as needs or addressed by healthcare services. Older homeless people seem to use more medical hospital care and less non‐acute, preventive healthcare than younger homeless people. This vulnerable group might benefit from shelter‐based or community outreach programmes that proactively provide multidisciplinary healthcare services.     

Profile of Community Mental Health Service Needs in the Moretele District (North-West Province) in South Africa

BACKGROUND: The emergence of democracy in South Africa led to a need to transform all public structures, including the health care system. The aim has been to transform these structures in order to bring them in line with the new culture of human rights. Transformation of the whole health care system is motivated by a number of key objectives, which include achieving equity in resource allocation and health service delivery, developing primary health care infrastructure and decentralising services to promote community participation. AIMS OF THE STUDY: In the context of de-institutionalising mental health services in South Africa, this study aimed to investigate community mental health service needs of mental health service users and that of their families in the Moretele district, North-West province, South Africa. METHODS: The study was conducted in three clinics situated in three different communities in the Moretele district. Data collection consisted of : 147 clinical record reviews, 105 interviews with patients followed by a joint interview with a family member, 83 interviews with caregivers and eight interviews with community key informants (traditional healers, a civic leader, a councillor, a retired teacher, and a physician). RESULTS: The majority of service users were males (54%). The mean age was 41 years and 63% had completed primary schooling.Patients were recorded as having only one of two primary diagnoses, namely schizophrenia (57%) or epilepsy (41%). However, a review of prescribed drugs and caregiver interviews showed that there was a presence of mood disorders among service users. The local hospital was service users primary entry point into the mental health care system, followed by traditional healers (30%). Interviews with service users, service providers and caregivers reveal limited knowledge of patient illness. Nevertheless, service users who had epilepsy were more likely to provide details of their illness than those with mental illness. Above half of service users had basic social skills such as bathing, eating, washing and using public transportation independently. Feelings of loneliness and isolation were common among service users in the community; seventy nine percent (79%), for example spent their days entirely in their homes. Only 7% reported contact with friends. Experiences of community discrimination and exploitation of people with mental illness were reported in key informant interviews and by service users themselves. DISCUSSION: The main community mental health service needs identified in this study were: (i) Improved quality of mental health services at clinics. (ii) Better co-ordination of services (clinic, hospital, social work and traditional healers) and removal of barriers to health service utilisation. (iii) Alleviation of the social isolation of mental health service users by building on existing community structures and individuals willing to engage in partnerships with service providers. The authors indentify a need to train primary health care providers in mental health in order to promote the adequate diagnosis and detection of common psychiatric illnesses.They also point out the need for social support interventions to enable people with mental illness to deal with loneliness and isolation and a need for psycho-educational programmes to make patients and caregivers better informed about mental illness.     

Service user experiences of specialist mental health supported accommodation: A systematic review of qualitative studies and narrative synthesis

Specialist supported accommodation services have become a key component of most community‐based mental healthcare systems. While mental health policies highlight the importance of service user involvement in service development and care planning, there are no comprehensive literature reviews synthesising services users’ perspectives on, or experiences of, supported accommodation services. This systematic review was undertaken to fill this gap. We searched electronic databases (January 2015, updated June 2017), conducted hand searches and used forward‐backward snowballing to identify 13,678 papers. We inspected the full‐text of 110 papers and included 50 of these in the final review. Data extraction and quality assessments were conducted. We used narrative synthesis to develop a conceptual model of service users’ experiences that included structural, process, relational and contextual factors, such as the characteristics of the service, relationships with staff and other service users, the intensity and nature of support, the physical environment, and social and community integration. The review highlights the complex interplay of individual, service‐level and community factors in shaping the lived experience of service users and their impact on personal identity and recovery. Our approach addressed some of the widely reported limitations of the quantitative research in this field, providing a conceptual model relevant to service user experiences across supported accommodation service types, population groups and countries.     

“A Mile in Her Shoes”: A qualitative exploration of the perceived benefits of volunteer led running groups for homeless women

“A Mile in Her Shoes” is a volunteer‐led charity which provides running groups for homeless women. The objective of this study was to explore the experiences of homeless women attending these running groups and to establish how participation in a supported running group impacted their lives. This exploratory qualitative study was carried out across two sites in London UK during February and April 2017. All regular attenders of the running groups were invited to participate in the study; subsequently, a self‐selected sample of 11 women consented to being interviewed. Data were collected by female interviewers on a one‐to‐one basis, steered by a semi‐structured topic guide. All interviews were digitally recorded, transcribed verbatim, and analysed using thematic analysis. Themes were cross‐referenced by the research team and findings were supported by direct quotes. Five main themes emerged from the findings: the positive impact of the charity; homeless women's motivations and barriers to participating in running groups; the benefits of participating on physical and mental health; the importance and value of social support from the group; and the value of being provided with quality running kit. This study concludes that volunteer‐led running groups are valued by homeless women by helping them take control of their health. It provides insight into their engagement in physical activity, thus potentially helping prevent injury or illness, and aiding recovery and rehabilitation. One implication of this study is that gathering homeless women's views helps to steer how community‐based physical activity programmes can benefit their wellbeing. However, this small‐scale study may have limited generalisability, with the topic warranting further research.     

An evaluation of mental health service provision in Northern Ireland

Although Northern Ireland has high levels of mental health problems, there has been a relative lack of systematic research on mental health services that can provide an evidence base for legal, policy, and service developments. This article aims to provide a review of the central issues relating to mental health service provision in Northern Ireland, and to gather the perceptions of different stakeholders of these services. The study utilised in‐depth qualitative interviews, focus groups, and an online survey to collect data from respondents throughout the region. This method involved the completion of semistructured interviews with significant mental health commissioners and senior managers, and with service‐users and their key workers. Focus groups sessions were also completed with mental health professionals, service‐users, and carers. Data collection occurred between December 2014 and June 2015. Thematic analysis was used to identify key issues. The findings identified that considerable progress had been made not only in the development of mental health services in the last decade, but also highlighted the significant limitations in current services. Most notably, strengths in provision included the transition from long‐stay hospital care to community‐based services and person‐centred approaches. The researchers identified the need to improve funding, address problems with fragmentation, and gaps in service provision. Based on these findings, the authors consider the implications for practice and policy relating to the human and organisational aspects of service development. In particular, services should be developed focusing on a recovery ethos and on person‐centred and relationship‐based approaches. The needs of carers should additionally be considered and programmes developed to tackle stigma.     

Interorganisational cooperation and its effects on community rehabilitation for people with severe mental disorders in Beijing,China: A case study

A national comprehensive management pilot project for mental health has been implemented in China to provide integrated care for people with severe mental disorders through strengthened cooperation among government organisations and between government and other relevant social organisations. The promotion of community rehabilitation has been included as a key part of this pilot program. The present study took the AD district of Beijing as a case study to examine interorganisational cooperation and its effects on community rehabilitation in a real-world setting. Interviews were conducted with 14 frontline workers, including 7 mental health workers from community health centres and 3 staff and 4 social workers working in rehabilitation centres. Five officials from relevant health and social welfare departments and a social work organisation were also interviewed. Experiences in Beijing revealed that interorganisational cooperation helped to build a multiagency workforce furnished with basic mental health knowledge at the community level, which rendered it possible for frontline workers to provide fundamental follow-up services, pilot the case management model of service provision and increase the provision of psychosocial rehabilitation services within the poorly resourced context of Chinese mental healthcare. Moreover, the engagement of social organisations provided bottom-up pressure to innovate through the active bringing forward of new ideas concerning cooperation and service delivery. However, differences in professional authority and commitment were observed. Health department officials and health professionals seemed to exercise a dominant role as compared to social welfare department officials and social workers. Future policy making should motivate social welfare department officials to improve social care for people with severe mental disorders. Social workers require training to improve their knowledge of mental health matters, and social organisations need greater latitude to strengthen their influence over the development of community rehabilitation services for people with severe mental disorders.     

A scoping review to understand the effectiveness of linking schemes from healthcare providers to community resources to improve the health and well‐being of people with long‐term conditions

The prevalence of people living with long‐term conditions is increasing, accompanied by an increased expectation that patients will become more involved in self‐management. Long‐term conditions are associated with increased social isolation and poor physical and mental health. But there remains a gap in health provision between providing medical treatment and effectively addressing psychosocial well‐being. One potential way of addressing this gap is by utilising social interventions which link patients from health services to community‐based sources of support. However, the mechanisms involved in the delivery of interventions providing that link and their effectiveness remain unclear. This review adopted the methodological framework for conducting scoping studies, searching for both academic and grey literature on social interventions which link people from healthcare settings to a range of community and voluntary sector organisations. A literature search between May and June 2013, involving five electronic databases, hand searching of two journals and the use of Google search engine, identified seven studies relevant to the review question. In terms of key characteristics and mechanisms of the interventions, mental health conditions and social isolation were the most common reasons for referral to the interventions, and referrals were usually made through general practices. Almost all the interventions were facilitator‐led, whereby the facilitator worked to identify and link participants to appropriate community‐based resources. In regard to health and social outcomes and their cost‐effectiveness, studies reported improvement to participants' psychological and social well‐being as well as their decreased use of health services, although there were limited measures of participants' physical health outcomes. Interventions for linking patients from healthcare setting to community‐based resources target and address psychosocial needs of participants. The review identified involvement of health professionals in aiding the referral of patients to the intervention and the role of the intervention facilitators as key components of the interventions.     

Assessment without action; a randomised evaluation of the interRAI home care compared to a national assessment tool on identification of needs and service provision for older people in New Zealand

Comprehensive geriatric assessment (CGA) is considered the cornerstone of good practice, as it identifies need across multiple domains such as social, physical and psychological. The interRAI home care (interRAI‐HC), probably the most well‐researched and supported community‐based CGA has been implemented globally, often at considerable expense. Policy‐makers, managers and clinicians anticipate significant gains in health outcomes following such investment; however, the implementation of CGA is often undertaken in the absence of community service development. This study sought to compare the interRAI‐HC with an existing CGA [the Support Needs Assessment (SNA)] in community‐dwelling older people. A randomised controlled trial was undertaken from January 2006 to January 2007 comparing the interRAI‐HC and the SNA in 316 people (65+) referred for assessment of needs with follow‐up at 1 and 4 months. Outcomes included health‐related quality of life, physical function, social support, cognitive status, mood and health service usage as well as identified need. The study found that significantly more support needs were identified using the interRAI‐HC compared to the SNA. More social and carer support were recommended by SNA and more rehabilitation and preventive health screens were recommended by interRAI‐HC. Despite these differences, the mean healthcare use was similar at 4 months, although interRAI‐HC participants had more Emergency Department presentations and hospital admissions. No statistically significant differences between groups were reported in terms of outcomes. In conclusion, the interRAI‐HC was found to identify more unmet support needs than the SNA though resulted in no favourable outcomes for the older person or their carer. The study highlights the need to invest attention around the service context to maximise outcomes based on identified needs.