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People with intellectual disabilities face health disparities, including in high‐income countries such as the United Kingdom, despite publicly funded healthcare. This paper describes the healthcare system in England (a nation of the United Kingdom) for the general population, and more specifically for people with intellectual disabilities. Key legislation that impacts the lives of people with intellectual disabilities, such as the UK Equality Act 2010 (https://www.legislation.gov.uk/ukpga/2010/15/contents), the Mental Capacity Act 2005 (https://www.legislation.gov.uk/ukpga/2005/9/contents), and the UN Convention on the Rights of Persons with Disabilities, and its implementation in the United Kingdom, is discussed. The role of deinstitutionalization and the shift to living in the community for people with intellectual disabilities is also discussed. Programmes that have been implemented to address the health disparities experienced by people with intellectual disabilities are reviewed. Finally, the recent changes to healthcare organization in the UK, the COVID‐19 pandemic, and the implementation of the Valuing People white paper are discussed. [ABSTRACT FROM AUTHOR]

A growing number of researchers are trying to provide explanations for continuity and change in drug policy in different contexts. Such research predominantly falls in the pluralist realm of public policy where various actors compete to have their policy proposals accepted. Using a critical framework called Policy Constellations (PC), developed by Stevens and Zampini, this paper attempts to explain reactions of the British Government to Novel Psychoactive Substances (NPS) between 2008 – 2016. Qualitative data comes from in-depth interviews with stakeholders (N = 15), including NGO workers, a former Home Secretary, drugs ministers, governmental advisors, a former senior police officer, former Deputy Drug Coordinator, and a former Advisory Council for the Misuse of Drugs (ACMD) member. Two 'constellations' competed in British NPS policy setting. The PC framework illustrates power imbalances between these competing stakeholders. Abstinence orientated actors (the conservative constellation) enjoyed strategic advantages and media power which allowed them to create a favourable policy setting. These advantages were not enjoyed by the liberal constellation who struggled to access the policy setting and influence policy developments. The prohibitive nature of the policy used to counter NPS can be explained with the domination of actors whose values align with the conservative constellation. [ABSTRACT FROM AUTHOR]

Using examples from the National Health Service in England, this paper illustrates key features of contemporary healthcare governance: the way decisions are hidden in places that are 'in between' and 'out of reach'; the enrolment of doctors in governing; and the important role played by 'boring things', such as power point slides, flow charts, and forms. The essay shows how anthropological proximity and perspectives can extend and deepen understanding of contemporary political power. It does this firstly by showing the importance of agency in the operation of governmentality, and secondly by illuminating the limits of governmentality. The different elements of governing assemblages, such as global management experts, medical leaders, forms of knowledge and analytical technologies, are brought together through the strategic act of framing. Frames are contested and resisted, requiring more visible forms of control. [ABSTRACT FROM AUTHOR]

Introduction: This study characterized the extent to which (1) financial barriers and (2) abortion care-seeking within a person's country of residence were associated with delays in abortion access among those travelling to England and the Netherlands for abortion care from European countries where abortion is legal on broad grounds in the first trimester but where access past the first trimester is limited to specific circumstances. Methodology: We drew on cross-sectional survey data collected at five abortion clinics in England and the Netherlands from 2017 to 2019 (n = 164). We assessed the relationship between difficulty paying for the abortion/travel, acute financial insecurity, and in-country care seeking on delays to abortion using multivariable discrete-time hazards models. Results: Participants who reported facing both difficulty paying for the abortion procedure and/or travel and difficulty covering basic living costs in the last month reported longer delays in accessing care than those who had no financial difficulty (adjusted hazard odds ratio: 0.39 95% CI 0.21–0.74). This group delayed paying other expenses (39%) or sold something of value (13%) to fund their abortion, resulting in ~ 60% of those with financial difficulty reporting it took them over a week to raise the funds needed for their abortion. Having contacted or visited an abortion provider in the country of residence was associated with delays in presenting abroad for an abortion. Discussion: These findings point to inequities in access to timely abortion care based on socioeconomic status. Legal time limits on abortion may intersect with individuals' interactions with the health care system to delay care. Plain Language Summary: This paper explores delays in accessing abortion care associated with financial and medical system barriers. We focus on residents of countries in Europe where abortion is available on broad grounds in the first trimester seeking abortion care outside of their country of residence. This study demonstrates an association between difficulty covering abortion costs for people facing financial insecurity and in-country care seeking and delays in accessing abortion abroad. Policy barriers, medical system barriers, as well as financial barriers may interact to delay access to care for people in European countries with broad grounds for abortion access in the first trimester but restrictions thereafter, especially for people later in pregnancy. [ABSTRACT FROM AUTHOR]

Accessibility Summary: What is known on the subject?: A significant number of people with mental health diagnoses have also experienced some form of trauma.In 2008, it was recommended that MHTs in England provide training to MHPs to support them in how to ask their service users about trauma and abuse.It has been identified that staff are not consistently enquiring about trauma and abuse in mental health services. What the paper adds to existing knowledge?: A description of how many MHTs in England are providing training for staff to ensure that they enquire about trauma and abuse.The current gaps in the resources available for mental health practitioners and staff. What are the implications for practice?: Much more work and development of trauma‐informed care and accessibility of training is needed for MHPs working in MHTs.Most MHTs still need to take the first step of implementing training in trauma‐informed care. This should involve ways to ask about trauma and abuse and advice on how to respond to any disclosures made. Introduction: Trauma, abuse and adversities are extremely prevalent for those who access secondary mental health services. Health policy guidance recommends that mental health professionals (MHPs) should routinely enquire about trauma and abuse. Staff training is required to adopt trauma‐informed approaches, as research has identified a clear gap in practice. This study provides a baseline measure of the current provision of trauma‐informed training in English mental health trusts (MHTs). Question: What trauma‐informed training is currently available for MHPs in England? Method: A freedom of information request was submitted to 52 MHTs in England to explore the current training available for MHPs in trauma‐informed care, routine enquiry into abuse and responding to disclosures. Results: The results showed 70% of respondents reported no available training in trauma‐informed care. Discussion: Many MHTs in England do not provide any trauma‐informed training (despite existing recommendations from 2008). Does this contribute to the re‐traumatisation of patients? Implications for Practice: MHTs in England require a responsible and active approach to training MHPs in sensitive routine enquiry into trauma and abuse as a first step to becoming trauma responsive. [ABSTRACT FROM AUTHOR]

Purpose: Local Safeguarding Adults Board (SAB) policies, procedures, guidance and related documents on self-neglect were gathered and analysed, to map what approaches are being taken across England. This paper aims to identify areas of divergence to highlight innovations or challenges faced by SABs. Design/methodology/approach: Self-neglect documents were identified by searching SAB websites. Data were extracted into a framework enabling synthesis and comparison between documents. Findings: This paper reports on how English SAB documentation defines self-neglect, treats executive capacity, lays out pathways for self-neglect cases, advises on refusal of service input and multi-agency coordination and draws on theories or tools. Greater coherence in understanding self-neglect has developed since it was brought within safeguarding in 2014; however, variation remains regarding scope, referral pathways and threshold criteria. Research limitations/implications: This review was limited to published SAB documentation at one point in time and could not consider either the wider context of safeguarding guidance and training or implementation in practice. Practical implications: This review provides an overview of how SABs are interpreting national guidance and guiding practitioners. The trends and areas of uncertainty identified offer a resource for informed research and policy-making. Originality/value: To the best of the author's knowledge, this is the first systematic survey of SAB self-neglect policies, procedures and guidance since self-neglect was included under safeguarding. [ABSTRACT FROM AUTHOR]

Over the past decade, there has been a growing trend towards the use of 'big qualitative data' in applied health research, particularly when used as part of mixed methods evaluations of health policy in England. These 'big qualitative' studies tend to be longitudinal, complex (multi-site and multi-stakeholder) and involve the use of multiple methods (interviews, observations, documents) and large numbers of participants (n = 100+). Despite their growing popularity, there is no methodological guidance or methodological reflection on how to undertake such studies. Qualitative researchers are therefore faced with a series of unknowns when designing large qualitative studies, particularly in terms of knowing whether existing qualitative sampling and analysis methods are appropriate in this context. In this paper, we use our experience of undertaking a big qualitative study, as part of a national mixed methods evaluation of a health policy in England to reflect on some of the key challenges that we faced in our qualitative study, which broadly related to: sample size, data analysis and the role of patient and public engagement. Underpinning these difficulties was the challenge of being flexible and innovative within the largely positivist research climate of applied health research and being comfortable with uncertainty relating to the three issues outlined. The reflections we present are not to be viewed as a method 'how to' guide, but rather as a platform to raise key issues relating to the qualitative methods that we found challenging, in order to stimulate discussion and debate amongst the qualitative community. Through this paper, we therefore hope to demystify what it is like to undertake such a study and hope to spark much needed discussion and innovation to support the future design and conduct of qualitative research at scale. [ABSTRACT FROM AUTHOR]

Accessible Summary: What is known on the subject?: 'Leave' is a common occurrence for patients detained in mental health settings. The term covers multiple scenarios, for example short periods to get off the ward through to extended periods at home prior to discharge.Despite the frequency and importance of leave, there is very little research about how it is implemented and whether, and in what circumstances, it is effective.While there is legislation about leave in the Mental Health Act (1983) mental health services are free to implement their own policies or not to implement one at all. What the paper adds to existing knowledge?: The leave policies of NHS mental health services in England and Wales are highly inconsistent.The extent to which policies are consistent with guidance differs depending on which service is providing care. What are the implications for practice?: It is very likely that, because of inconsistencies between services and policies, practice also differs.Clinicians need to understand their responsibilities in the leave process to ensure that patients are supported in their recovery journey.Policymakers need to revisit leave policies in light of evidence from this study. Introduction: Considerable guidance is available about the implementation of leave for detained patients, but individual mental health services are free to determine their own policies. Aim: To determine how consistent leave policies of NHS mental health services in England and Wales are with relevant guidance and legislation. Method: A national audit of NHS mental health services leave policies. Data were obtained through web searching and Freedom of Information requests. Policies were assessed against 65 criteria across four domains (administrative, Responsible Clinician, types of leave and nursing). Definitions of leave‐related terms were extracted and analysed. Results: Fifty‐seven (91.9%) policies were obtained. There were considerable inconsistencies in how policies were informed by relevant guidance: Domain‐level consistency was 72.3% (administrative), 64.0% (Responsible Clinician), 44.7% (types of leave) and 41.9% (nursing). Definitions varied widely and commonly differed from those in relevant guidance. Discussion: Mental health professionals are inconsistently supported by the policy in their leave‐related practice. This could potentially contribute to inconsistent practice and leave‐related patient outcomes. Implications for Practice: To ensure patients are treated fairly clinicians need to be aware of their responsibilities around leave. In some services, they will need to go beyond their organization's stated policy to ensure this occurs. [ABSTRACT FROM AUTHOR]

• Childcare policy responses towards Covid-19 differed in European welfare states. • Policy responses cause informalization of childcare to different degrees. • Informalization of childcare is mainly connected with social risks for women. • Cultural and institutional differences help to understand varying policy responses. The closure of extra-familial childcare facilities by European governments in 2020 was an important part of interventions against the spread of the COVID-19 pandemic. One consequence was that childcare was provided by parents at home, mainly by women. As a result, women mainly experienced financial and employment risks related to this "informalization" of childcare. The childcare policies of European welfare states differ in the extent to which they include measures to reduce the social risks related to informalization. Against this backdrop, this paper asks: How should one understand cross-national differences in childcare policies during the pandemic? We are also particularly interested in the effects of childcare policies on the social risks connected with the informalization of childcare and what these mean for the gendered division of paid work and care. Differences in childcare policies during the pandemic are commonly explained in terms of the path dependence of such policies. Using the theoretical approach of "care arrangement," this article introduces a broader theoretical framework that considers the role of cultural and institutional factors for understanding the cross-national differences in childcare policies during the pandemic. We introduce the findings of a comparative empirical study of childcare policies in three European welfare states—Denmark, Germany and England—that represent different types of care arrangements. This paper uses policy and media documents, quantitative data on childcare and women's employment, cultural ideas and secondary analysis of empirical studies. We find that governments did not per se respond to the pandemic based on institutional path dependence regarding childcare policies, while the integration of culture into the theoretical framework allows for a more comprehensive understanding. [ABSTRACT FROM AUTHOR]

Purpose: Health policies in England highlight the need for child and adolescent mental health services (CAMHS) to embed new knowledge in practice, yet evidence remains scarce about the services' ability to learn from the external environment. This paper aims to present a critical analysis of the CAMHS' ability to implement new knowledge through the lens of absorptive capacity, an organisation's ability to identify, assimilate and use new valuable knowledge. Design/methodology/approach: Sixteen semi-structured interviews were conducted with staff from the CAMHS department of a mental health organisation in England to explore the services' absorptive capacity. Findings: Professionals were identified having an impact on the main absorptive capacity components in the following ways: professional background and perceived reliability of knowledge sources appeared to affect knowledge identification; informal communication was found to facilitate knowledge assimilation and exploitation; trust was found to enable knowledge exploitation, particularly between senior management and frontline professionals. At an organisational level, team meetings and internal reporting were identified as enablers to knowledge assimilation and exploitation, while organisational hierarchy and patient data management systems were identified as barriers to knowledge assimilation. No organisational processes were found regarding knowledge identification, indicating an imbalanced investment in the main components of absorptive capacity. Practical implications: Investing in these underpinning factors of absorptive capacity can assist CAMHS with capitalising on new knowledge that is valuable to service provision. Originality/value: This study offers novel insights into the learning ability of CAMHS through the lens of absorptive capacity. [ABSTRACT FROM AUTHOR]

Making Every Contact Count (MECC) is a national, long‐term public health strategy in England. It supports public‐facing workers to use opportunities during routine contacts to enable healthy lifestyle changes. This paper reports the findings from an external evaluation of voluntary and community sector (VCS) delivery of MECC in the North East of England, which focused on engaging under‐represented client groups. The study aimed to (a) Establish if (and how) MECC had impacted the workforce, including changes to staff knowledge, confidence and behaviour; (b) Identify benefits, challenges and unintended consequences; and (c) Explore outcomes for service users. A multi‐stage qualitative design focused on understanding both process and outcomes. The study utilised three data collection methods, including a journey mapping workshop (n = 20), semi‐structured interviews with delivery leads, VCS workers and volunteers who had accessed MECC training (n = 11), and focus group discussions with clients (n = 22). The findings illustrated positive early outcomes, including improvements in self‐reported staff knowledge and confidence as well as emerging examples of organisational culture shift and individual behaviour change. Alongside this, the data provided a rich picture of barriers and challenges which are examined at different levels—national programme, local programme, VCS sector, partner organisation, worker and client. The research highlights clear successes of the VCS delivery model. However, it is presented as a 'double‐edged sword,' in light of associated challenges such as sector‐level funding uncertainty and accessibility of MECC resources to diverse client groups. The discussion considers issues related to the measurement and attribution of behaviour change outcomes for brief interventions, as well as fidelity, legacy and long‐term sustainability challenges. The recommendations call for system‐level analysis and comparison of different MECC implementation models, to improve our understanding of challenges, opportunities and programme reach for behaviour change intervention programmes—particularly in relation to seldom‐heard client groups. [ABSTRACT FROM AUTHOR]

Purpose: Strategic socio-political views are notably scarce among contemporary discourses on the causes of abuse of vulnerable older people in care and nursing homes. This paper aims to catalyse higher order consideration and discussion of one socio-political characteristic that has relevance to the issue of abuse, that is, the market-like environment in which care and nursing homes in England operate. In doing so, the paper argues that the now firmly established but imbalanced "quasi-market" of care that has developed over many years fosters conditions under which both poor care and abuse are more likely to occur. The evidence presented in the paper focusses primarily on the rise to dominance of for-profit care home provision and the contraction of public sector provision. The paper does not examine in detail the characteristics and market presence of the not-for-profit sector because it has not held a numerically significant market share either historically or contemporarily. Design/methodology/approach: Outcomes of the marketisation of the care home sector that has its origins in the political landscape prevailing in 1979 and thereafter, along with the concurrent development of its regulation and oversight, are narrated and analysed. From this, a mythos of the motives behind the transition to a market-like economy that has taken place over four decades is developed and used to explain how prevailing market conditions contribute to the perpetuation of poor care and abuse. Findings: In the opinion of the author, there are identifiable consequences arising from the evolution of the current care economy that dispel the beliefs that providing care by means of current market-like arrangements is advantageous, that the independent regulation and monitoring of such a market is unproblematic and effective, and that the "consumers" in this market are exercising personal choice, in accord with classical economic theory. Practical implications: The paper offers the opportunity for the reader to consider how the development of a "quasi" market of care and nursing home services that has come to be dominated by for-profit private providers, and that is subject to ineffective oversight, may have contributed to conditions where abuse is more likely to occur and endure. Originality/value: This is a conceptual paper that explores the consequences of the creation of the market-like economy of care in which care and nursing homes now operate and suggests that it is time for prevailing market conditions to be re-visited and subjected to remedial strategic intervention. [ABSTRACT FROM AUTHOR]

Purpose: This paper aims to examine reform of mental health legislation in England and Wales. It covers the period from the introduction of the 1983 MHA to the proposed reforms outlined in the Wessley Review that was published in December 2018. Design/methodology/approach: This is a literature-based project. Findings: Reform of the mental health legislation reflects two potentially conflicting strands. One is the state's power to incarcerate the "mad", and the other is the move to protect the civil rights of those who are subject to such legislation. The failures to development adequately funded community-based mental health services and a series of inquiries in the 1990s led to the introduction of Community Treatment Orders in the 2007 reform of the MHA. Research limitations/implications: The development of mental health policy has seen a shift towards more coercive approaches in mental health. Practical implications: The successful reform of the MHA can only be accomplished alongside investment in community mental health services. Originality/value: The paper highlights the tensions between the factors that contribute to mental health legislation reform. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

This paper explores public health policy implementation through partnership working at the local level by examining how local actors from public health, and the wider workforce make sense of and work on social inequalities in health. An ethnographic case study was used to examine policy implementation in one local strategic partnership in north-west England during a period of significant resource constraint. Semi-structured interviews were the primary method of data generation. Sensitising concepts from figurational sociology were used to develop a theoretical account of how local policy implementation directed at narrowing social inequalities in health tended to give rise to relatively fragmented and short-term services, projects and practices, which focused on lifestyle factors and behaviour change. Theorising partnership work as figurations goes some way to explaining the apparent paradox among participants who expressed a relatively detached appreciation of wider social influences, alongside emotional involvement in their work. This process of individualisation explains how local professionals tended to conceptualise health inequality and the social determinants of health as personal troubles. Individualisation meant that the social reality of working in partnerships on difficult issues was simplified. Thus, any scope for working on the social determinants of health tended to be overlooked. The extent to which this was intentional or a matter of struggling to see opportunities, or a mixture of the two, was difficult to discern. Although the policy landscape has changed, the findings give some insight into understanding how local collaborative processes reproduce local public health work underpinned by lifestyle choices. [ABSTRACT FROM AUTHOR]

Background: Large system transformation in health systems is designed to improve quality, outcomes and efficiency. Using empirical data from a longitudinal study of national policy-driven transformation of maternity services in England, we explore the utility of theory-based rules regarding 'what works' in large system transformation.Methods: A longitudinal, qualitative case study was undertaken in a large diverse urban setting involving multiple hospital trusts, local authorities and other key stakeholders. Data was gathered using interviews, focus groups, non-participant observation, and a review of key documents in three phases between 2017 and 2019. The transcripts of the individual and focus group interviews were analysed thematically, using a combined inductive and deductive approach drawing on simple rules for large system transformation derived from evidence synthesis and the findings are reported in this paper.Results: Alignment of transformation work with Best et al's rules for 'what works' in large system transformation varied. Interactions between the rules were identified, indicating that the drivers of large system transformation are interdependent. Key challenges included the pace and scale of change that national policy required, complexity of the existing context, a lack of statutory status for the new 'system' limiting system leaders' power and authority, and concurrent implementation of a new overarching system alongside multifaceted service change.Conclusions: Objectives and timescales of transformation policy and plans should be realistic, flexible, responsive to feedback, and account for context. Drivers of large system transformation appear to be interdependent and synergistic. Transformation is likely to be more challenging in recently established systems where the basis of authority is not yet clearly established. [ABSTRACT FROM AUTHOR]

Objectives: The National Health Service Bowel Cancer Screening Programme (NHS BCSP) in England has replaced guaiac faecal occult blood testing by faecal immunochemical testing (FIT). There is interest in fully exploiting FIT measures to improve bowel cancer (CRC) screening strategies. In this paper, we estimate the relationship of the quantitative haemoglobin concentration provided by FIT in faecal samples with underlying pathology. From this we estimate thresholds required for given levels of sensitivity to CRC and high-risk adenomas (HRA). Methods: Data were collected from a pilot study of FIT in England in 2014, in which 27,238 participants completed a FIT. Those with a faecal haemoglobin concentration (f-Hb) of at least 20 µg/g were referred for further investigation, usually colonoscopy. Truncated regression models were used to explore the relationship between bowel pathology and FIT results. Regression results were applied to estimate sensitivity to different abnormalities for a number of thresholds. Results: Participants with CRC and HRA had significantly higher f-Hb, and this remained unchanged after adjusting for age and sex. While a threshold of 20 μg/g was estimated to capture 82.2% of CRC and 64.0% of HRA, this would refer 7.8% of participants for colonoscopy. The current programme threshold used in England of 120 μg/g was estimated to identify 47.8% of CRC and 25.0% of HRA. Conclusions: Under the current diagnostic policy of dichotomising FIT results, a very low threshold would be required to achieve high sensitivity to CRC and HRA, which would place further strain on colonoscopy resources. The NHS BCSP in England might benefit from a diagnostic policy that makes greater use of the quantitative nature of FIT. [ABSTRACT FROM AUTHOR]

This paper investigates the comprehensive compassionate care reform programme within the National Health Service (NHS) in England. Through a synoptic reading of policy documents, we show how 'compassion' is introduced as an overarching meta‐virtue designed to govern relationships and formal positions in health care. Invoking an 'ethics of office' perspective, mainly drawing on the thinking of Max Weber, we evaluate the promotion of compassion as a managerial technology and argue how seemingly humanistic and value‐based approaches to healthcare management might have unintended consequences for the quality of care and the conduct of health professionals that in some ways resemble and in some ways exceed those of the more traditional New Public Management measures, which the new compassion paradigm is expected to outdo. In the paper's final sections, we turn to the original work of the nursing icon Florence Nightingale to argue that compassion and other virtues should continuously be formulated and re‐formulated in relation to the role‐specific skills and duties of particular offices in the healthcare sector. [ABSTRACT FROM AUTHOR]

Major service change in healthcare – whereby the distribution of services is reconfigured at a local or regional level - is often a contested, political and poorly understood set of processes. This paper contributes to the theoretical understanding of major service change by demonstrating the utility of interpreting health service reconfiguration as a biopolitical intervention. Such an approach orients the analytical focus towards an exploration of the spatial and the population – crucial factors in major service change. Drawing on a qualitative study from 2011–12 of major service change in the English NHS combining documentary analyses of historically relevant policy papers and contemporary policy documentation (n = 125) with semi-structured interviews (n = 20) we highlight how a particular 'geography of stroke' in London was created building upon multiple types of knowledge: medical, epidemiological, economic, demographic, managerial and organisational. These informed particular spatial practices of government providing legitimation for the significant political upheaval that accompanies NHS service reconfiguration by problematizing existing variation in outcomes and making these visible. We suggest that major service change may be analysed as a 'practice of security' – a way of redefining a case, conceiving of risks and dangers, and averting potential crises in the interests of the population. • Foucault's work on biopolitics is applied to analyse major service change. • The reconfiguration of stroke services in London is explored. • Empirical and theoretical implications are discussed. [ABSTRACT FROM AUTHOR]

There has been a succession of policy documents related to active travel published by the British government since the implementation of a National Cycle Network (NCN) in 1995. However, as the latest National Travel Survey (NTS) reveals, the number of journeys made by bike in the UK has remained steadfastly around only 2% (Department for Transport [DfT], 2018a). By using documentary analysis of the available official policy documents and statements, the aim of this paper is to make sense of the policies that have been published concerning active travel (AT) in England. This is done from a figurational sociological perspective. Three key themes emerge from the analysis: (1) the rhetorical, advisory level of the vast majority of the policies; (2) the reliance on a wide network of local authorities to implement AT policy; and (3) the focus placed on individuals to change their behaviour. Furthermore, the analysis reveals that despite a large number of policy publications from a range of government departments claiming to promote AT, little has actually changed in this time period in terms of a national agenda. Despite the successive policies, it seems there is little appetite on behalf of recent governments to make widespread infrastructural changes, where instead the focus has largely been on persuading the individual to seek more active modes of travel, increasingly for their own, individual 'health' gains. Highlights •The paper is based on documentary analysis of available official policy documents from UK government on active travel since 1996 • The findings reveal the largely rhetorical, advisory level of the vast majority of the policies, which contributes to a lack of overall success in promoting active travel • The lack of success is compounded further by a reliance on a wide network of local authorities to implement active travel policy, when most local authorities appear more concerned with transport issues related to motorised vehicles • The findings reveal that active travel policy has becoming increasingly focussed on health gains that might be made from increasing the number of trips made by bicycle • The overwhelming focus of the policy documents analysed, however, is on encouraging individuals to change their behaviour, a process regarded as 'healthism', and one most sociologists of health suggest is likely to fail as a result • We conclude by suggesting that if the government is serious about wanting to see a 'step change' in the way in which people travel, particularly over shorter distances, then there is a need to have a more forceful approach to implementing policy within local authorities at the same time as making more substantial infrastructure changes to encourage cycling [ABSTRACT FROM AUTHOR]

Drawing on a 2010 analysis of the reform and costs of adult social care commissioned by Downing Street and the UK Department of Health, this paper sets out projected future costs under different reform scenarios, reviews what happened in practice from 2010-19, explores the impact of the growing gap between need and funding, and explores the relationship between future spending and economic growth. In the process, it identifies a 'lost decade' in which policy makers failed to act on the warnings which they received in 2010, draws attention to the disproportionate impact of cuts on older people (compared to services for people of working age) and calls for urgent action before the current system becomes unsustainable. [ABSTRACT FROM AUTHOR]

Background: Palliative care is insufficiently integrated in the continuum of care for older people. It is unclear to what extent healthcare policy for older people includes elements of palliative care and thus supports its integration. Aim: (1) To develop a reference framework for identifying palliative care contents in policy documents; (2) to determine inclusion of palliative care in public policy documents on healthcare for older people in 13 rapidly ageing countries. Design: Directed documentary analysis of public policy documents (legislation, policies/strategies, guidelines, white papers) on healthcare for older people. Using existing literature, we developed a reference framework and data extraction form assessing 10 criteria of palliative care inclusion. Country experts identified documents and extracted data. Setting: Austria, Belgium, Canada, Czech Republic, England, Japan, Mexico, Netherlands, New Zealand, Singapore, Slovenia, South Korea, Spain. Results: Of 139 identified documents, 50 met inclusion criteria. The most frequently addressed palliative care elements were coordination and continuity of care (12 countries), communication and care planning, care for family, and ethical and legal aspects (11 countries). Documents in 10 countries explicitly mentioned palliative care, nine addressed symptom management, eight mentioned end-of-life care, and five referred to existing palliative care strategies (out of nine that had them). Conclusions: Health care policies for older people need revising to include reference to end-of-life care and dying and ensure linkage to existing national or regional palliative care strategies. The strong policy focus on care coordination and continuity in policies for older people is an opportunity window for palliative care advocacy. [ABSTRACT FROM AUTHOR]

Purpose Comment on the contribution that housing can make to delivering better health and wellbeing outcomes. More specifically, the purpose of this paper is threefold: summarise recent evidence that makes the case for housing in helping to address health and social care issues; comment on the challenges and opportunities of partnership working; and describe examples of interesting and innovative local joint provision.Design/methodology/approach Draws on the author's briefing papers on housing, health and social care for housing quality network, which is a national housing consultancy organisation as well as the author's role as Chairperson of East Midlands Housing Care and Support, which is a regional housing association.Findings Collaboration between housing, health and social care is making slow progress at the national level in England. This is despite an ever-increasing evidence base highlighting that good housing can help to address issues, such as delayed discharges. Nevertheless, there are an increasing number of interesting examples of successful local initiatives on housing, health and adult social care. The way forward is to facilitate joint working at a local level.Originality/value Focusses on the success of examples of local joint working between housing, health and social care to achieve better outcomes for vulnerable people. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this paper is to update the core data set of self-neglect safeguarding adult reviews (SARs) and accompanying thematic analysis, and to address the challenge of change, exploring the necessary components beyond an action plan to ensure that findings and recommendations are embedded in policy and practice.Design/methodology/approach Further published reviews are added to the core data set from the websites of Safeguarding Adults Boards (SABs). Thematic analysis is updated using the four domains employed previously. The repetitive nature of the findings prompts questions about how to embed policy and practice change, to ensure impactful use of learning from SARs. A framework for taking forward an action plan derived from an SAR findings and recommendations is presented.Findings Familiar, even repetitive findings emerge once again from the thematic analysis. This level of analysis enables an understanding of both local geography and the national legal, policy and financial climate within which it sits. Such learning is valuable in itself, contributing to the evidence base of what good practice with adults who self-neglect looks like. However, to avoid the accusation that lessons are not learned, something more than a straightforward action plan to implement the recommendations is necessary. A framework is conceptualised for a strategic and longer-term approach to embedding policy and practice change.Research limitations/implications There is still no national database of reviews commissioned by SABs so the data set reported here might be incomplete. The Care Act 2014 does not require publication of reports but only a summary of findings and recommendations in SAB annual reports. This makes learning for service improvement challenging. Reading the reviews reported here enables conclusions to be reached about issues to address locally and nationally to transform adult safeguarding policy and practice.Practical implications Answering the question “how to create sustainable change” is a significant challenge for SARs. A framework is presented here, drawn from research on change management and learning from the review process itself. The critique of serious case reviews challenges those now engaged in SARs to reflect on how transformational change can be achieved to improve the quality of adult safeguarding policy and practice.Originality/value The paper extends the thematic analysis of available reviews that focus on work with adults who self-neglect, further building on the evidence base for practice. The paper also contributes new perspectives to the process of following up SARs by using the findings and recommendations systematically within a framework designed to embed change in policy and practice. [ABSTRACT FROM AUTHOR]

Objectives: To explore the extent to which national policy in end of life care in England influences and guides local practice, to ensure that care for patients over the age 75 years is of a consistently good quality. Method: This paper reports on phase one of a larger study and focuses its discussion on the high-level (macro) determinants emerging from the analysis. Fifteen in-depth interviews were conducted with professionals involved in the development of English policy in end of life care. Results: Factors influencing the quality of end of life care were stratified into three system levels: meso, macro and micro. English national policy was reported to be an important macro-level determinant of effective outcomes, and examples were provided to demonstrate how policy was influencing practice. Yet, the complexity of the area and the range of interacting contributory factors mean the value of policy alone is hard to assess. At the macro-level, concern was voiced around: whether policy was effective in tackling rising inequity; lack of mandatory leverage to exert change relating to end of life outcomes; the impact of ongoing infrastructural change on statutory services; workforce pressures; over-reliance on acute services and continued abdication of responsibility for end of life care to medical professionals supported by the continued dominance of the medical model of care. Conclusions: The links between the existence of policy at the macro-level of the system and the effective enactment of good practice remain unclear, although strategies are suggested to help achieve greater national consistency in end of life care outcomes. Policymakers must pay attention to the following: controlling the rise in localism and its contribution to regional inequalities; the impact of continuous infrastructural change together with increasing workforce pressures; encouraging broader professional and public responsibility for recognition and care of those at the end of life. [ABSTRACT FROM AUTHOR]

Performing female genital mutilation (FGM) is prohibited within the UK by the FGM Act of 2003. A mandatory reporting duty for FGM requires regulated health and social care professionals and teachers in England and Wales to report known cases of FGM in under 18-year-olds to the police. An application to the court for an FGM protection order (FGMPO) can be made to keep individual women and girls safe from FGM. This paper reveals the significant disconnect between the number of FGMPO applications and known recorded cases of FGM. The introduction of FGMPOs requires critical exploration as there is insufficient evidence to show that FGMPOs are effective in protecting women and girls from FGM. It is therefore unclear what impact, if any, FGMPOs are having upon the protection of women and girls at risk of FGM. The barriers to the implementation of FGMPOs and possible solutions are discussed. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this paper is to report on the content of local policies on engagement and observation written by National Health Service (NHS) organisations in England and Wales. Design/methodology/approach: Engagement and observation policies were obtained from all (n = 61) NHS mental health trusts in England and health boards in Wales via a Freedom of Information Act 2000 request. Data were analysed using content analysis. Findings: All organisations had a specific policy referring to either "observation and engagement" or "observation". The policies varied considerably in quality, length, breadth and depth of the information provided. Significant variations existed in the terminology used to describe the different types of enhanced observation. Inconsistencies were also noted between organisations regarding: which members of the clinical team could initiate, increase, decrease and terminate observation; who could undertake the intervention (for example students); and the reasons for using it. Finally, despite rhetoric to the contrary, the emphasis of policies was on observation and not engagement. Research limitations/implications: This research has demonstrated the value of examining local policies for identifying inconsistencies in guidance given to practitioners on the implementation of engagement and observation. Further research should be undertaken to explore the impact of local policies on practice. Practical implications: Local policies remain variable in content and quality and do not reflect contemporary research. There is a need to produce evidence-based national standards that organisations are required to comply with. Originality/value: To the best of the author's knowledge, this is the first research in 20 years examining the local policy framework for the implementation of engagement and observation. [ABSTRACT FROM AUTHOR]

Objectives: To understand the potential impact of exposure misclassification on water fluoridation studies in England, this paper aims to describe the long‐term variation in water fluoride concentrations in both artificially and naturally fluoridated water supplies. Methods: Water fluoridation dose monitoring data were requested from all five English public water suppliers who artificially fluoridate their water, as well as from one water company that supplies naturally fluoridated water. Descriptive statistics were calculated, including annual means, standard deviations, minimum‐maximum and absolute and relative frequencies. Results: Data were made available by two of the five English water companies who supply artificially fluoridated water and one water company that supplies naturally fluoridated water (40 398 individual samples). The data for fluoridated water spanned 18‐35 years, whilst the data on naturally fluoridated water spanned 14 years. The artificially fluoridated samples showed wide variation in fluoride dose control, both between different water treatment works and over time. Mean fluoride concentrations in the artificially fluoridated supplies ranged from 0.53 (SD 0.47) to 0.93 (SD 0.22) mg F/L and were within the optimal range of 0.7‐1.0 mg F/L in 27.7%‐77.8% of samples. The naturally fluoridated supplies had a higher mean fluoride concentration of 1.06 (SD 0.18) and 1.15 (SD 0.16) mg F/L than the artificially fluoridated supplies, with lower variation over time. The naturally fluoridated supplies were above the optimal range in 75.5% and 53% of samples. Conclusions: Assumptions that populations living in areas with a water fluoridation scheme have received optimally fluoridated water (0.7‐1.0 mg F/L) are invalid. To support future research endeavours, as well as to provide 'external control' and facilitation of optimal dosing, it is recommended that a quarterly record of water fluoride concentrations (mean, standard deviation and minimum and maximum) are made available for every water supply in England, in a format that can be mapped against residential postcodes. [ABSTRACT FROM AUTHOR]

Public Health England recently launched an active travel strategy in which it advised local authorities, health professionals and community groups how to improve the physical and mental health of the population and to reduce health care costs by promoting walking and cycling. Despite highlighting the cost savings and health benefits across the population, disabled people are largely absent from the strategy. This is particularly notable given that people with disabilities have the poorest levels of mental and physical health. Moreover, cycling is easier than walking for most people with physical disabilities and is also crucial to mobility, exercise, and health. This paper draws on qualitative interviews with disabled cyclists to explore the physical and mental health impacts of cycling for disabled people. It also highlights the broader implications for wellbeing in terms of independence and autonomy and the deficit of knowledge about cycling for disabled people among health professionals and policy makers. [ABSTRACT FROM AUTHOR]

An endemic challenge facing healthcare systems around the world is how to spread innovation more widely and sustainably. A common response to this challenge involves conducting pilot implementation studies to generate evidence of the innovation's benefits. However, despite the key role that such studies play in the local adoption of innovation, their contribution to the wider spread and sustainability of innovation is relatively under-researched and under-theorized. In this paper we examine this contribution through an empirical examination of the experiences of an innovation intermediary organization in the English NHS (National Health Service). We find that their work in mobilizing pilot-based evidence involves three main strands; configuring to context; transitioning evidence; and managing the transition. Through this analysis we contribute to theory by showing how the agency afforded by intermediary roles can support the effective transitioning of pilot-based evidence across different phases in the innovation journey, and across different occupational groups, and can thus help to create a positive feedback loop from localized early implementers of an innovation to later more widespread adoption and sustainability. Based on these findings, we develop insights on the reasons for the unnecessary repetition of pilots – so-called 'pilotitis'- and offer policy recommendations on how to enhance the role of pilots in the wider spread and sustainability of innovation. • Innovation intermediaries mobilize evidence from pilot studies to spread innovation. • Pilot-based evidence can link early adoption to wider spread and sustainability. • Mobilizing involves co-creating multiple forms of evidence with different groups. • Intermediary roles allow transitioning of pilot-based evidence into wider adoption. • Pilotitis involves a failure to transition evidence along the innovation journey. [ABSTRACT FROM AUTHOR]

Purpose The increased involvement of adults at risk in the safeguarding process has become a prominent issue within English safeguarding policy. However, there is evidence to suggest that actual levels of involvement are still low. The purpose of this paper is to present findings from a PhD study in relation to the benefits of advocacy in supporting this involvement in adult safeguarding for older people.Design/methodology/approach Participants in the study included advocates and social workers who had experience of working with older people through the safeguarding process within two North East England local authorities. A critical realist approach through in-depth interviews was taken with all the participants.Findings The research findings in relation to the benefits of advocacy in supporting older people going through safeguarding processes are reported. The practical limitations and factors which help and hinder advocacy support within the process are also considered. The theoretical implications for power, empowerment, and advocacy are also explored.Research limitations/implications A key limitation of this research is that it did not include older people who had been through safeguarding amongst the participants.Practical implications Key implications for practice and policy are discussed.Originality/value The paper provides an overview and critique of empowerment in adult safeguarding and the role that advocates play in promoting this key principle. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this paper is to report on findings from an evaluative research study which looked at a timed intervention model of practice comprising of up to 24 weeks of intensive meetings with adult service users set up by one local authority in England, to prevent and delay the need for care and support. A particular focus of this paper is on adults who hoard.Design/methodology/approach The study employed a mixed-methods design, consisting of interviews with service users (n=13), social workers (n=3), social work managers (n=2) and stakeholders from external services and agencies (n=6). It included a costing analysis of staff time and an analysis of goals of service users and “satisfaction with life” self-report questionnaires (n=20), completed at pre- and post-intervention stages.Findings There was evidence that social workers used strengths, relationship-based and outcome-based focused approaches in their work. The techniques used by social workers to engage, achieve change and assess effectiveness with service users varied. These techniques included the use of photographs to enable the service user to map and assess their own progress over time, encouraging hoarders to declutter and reclaim their living space. The service users valued the time the social workers spent with them and the way that they were treated with sensitivity and respect.Research limitations/implications The study focused on one local authority in England; there was no comparison group. This, and the small sample size, means that statistical generalisations cannot be made and only limited conclusions can be drawn from the quantitative data.Originality/value The paper provides insights into the work undertaken by social workers with adults who hoard. It contributes to the body of knowledge on effective social work interventions with adults who hoard. [ABSTRACT FROM AUTHOR]

The British National Health Service (NHS) relies for the great bulk of its funding on direct taxation, but the contribution of charitable sources of income to the NHS is not well-understood. The few studies of charitable giving to the NHS to date have concentrated on aggregate levels of income and expenditure. However, to date there has been limited collective understanding about the extent to which different kinds of NHS Trusts benefit from charitable funding and about the persistence of inequalities between trusts in their access to these resources. This paper presents novel analyses of the distribution of NHS Trusts in terms of the proportion of their income that comes from charitable sources. We build a unique linked longitudinal dataset which follows through time the population of NHS Trusts, and the population of associated NHS charities, in England since 2000. The analysis illustrates intermediate levels of charitable support for acute hospital trusts compared with the much lower levels of charitable support for ambulance, community and mental health Trusts and, conversely, much higher levels of charitable support for Trusts providing specialist care. These results represent rare quantitative evidence relevant to theoretical discussions about the uneven nature of the voluntary sector's response to healthcare need. They provide important evidence for a key feature (and arguably weakness) of voluntary initiative, namely philanthropic particularism - the tendency for charitable support to focus on a restricted range of causes. We also show that this 'philanthropic particularism' – reflected in the very sizeable differences in charitable income between different sectors of NHS trusts - is becoming more marked over time, while spatial disparities, notably between elite institutions in London and other locations, are also substantial. The paper reflects on the implications of these inequalities for policy and planning within a public health care system. • Novel analyses of pattern of charitable resources supporting NHS Trusts in England. • Trust – level comparisons of the ratio of charitable income to total Trust income. • Lower levels of fundraising for ambulance, community and mental health Trusts. • Higher levels of charitable support for larger Trusts and Trusts in London. • Charitable income of specialist Trusts has grown; other Trusts have seen decline. [ABSTRACT FROM AUTHOR]

Purpose Opinion is divided on whether a new power of entry should be introduced for social workers in cases where individuals seem to be hindering safeguarding enquiries for community-dwelling adults at risk in England who have decision-making capacity. The purpose of this paper is to investigate the prevalence and circumstances of situations where access to an adult at risk is denied or difficult and what helps those in practice. The study consists of a literature review, a survey of adult safeguarding managers and interviews with social care staff in three case studies of local authorities. As part of the contextual literature review, during 2014 the authors located parliamentary debates on the subject and this paper reports on their analysis.Design/methodology/approach Following approaches were used in historical research, documentary analysis was carried out on transcripts of parliamentary debates available online from Hansard, supplemented by other materials that were referenced in speeches and set in the theoretical context of the representations of social problems.Findings The authors describe the content of debates on the risks and benefits of a new right to access for social workers and the role of parliamentary champions who determinedly pursued this policy, putting forward three unsuccessful amendments in efforts to insert such a new power into the Care Act 2014.Research limitations/implications There are limits to a focus on parliamentary reports and the limits of Hansard reporting are small but need to be acknowledged. However, adult safeguarding research has surprisingly not undertaken substantial analyses of political rhetoric despite the public theatre of the debate and the importance of legislative initiatives and monitoring.Originality/value This paper adds to the history of adult safeguarding in England. It also offers insight into politicians’ views on what is known/unknown about the prevalence and circumstances of the problems with gaining access to adults with capacity where there are safeguarding concerns and politicians’ views on the merits or hazards of a power of access. [ABSTRACT FROM AUTHOR]

Background and aims: During the past three decades an expansive literature has emerged that is dedicated to analysing the processes of policy transfer. One neglected pathway involves subnational agents emulating crime control innovations that have emerged in subnational jurisdictions of other nations. This paper presents the case of the London Mayor's Office for Policing and Crime's (MOPAC) Alcohol Abstinence Monitoring Requirement (AAMR) Pilot to examine the multi‐level factors that facilitate and/or constrain international–subnational crime and justice policy transfer. Methods: A qualitative case study design reconstructed the (in)formal events that led to components of the South Dakota 24/7 Sobriety Project (USA) being either abandoned or integrated into MOPAC's AAMR Pilot. Evidence is drawn from elite interviews and documentary materials. Results: A series of inter/transnational‐, macro‐domestic‐, meso‐ and micro‐level factors enabled and/or obstructed processes of complete international–subnational policy transfer. Exclusion of domestic violence perpetrators from the London Pilot was fuelled by interest‐group hostility and mobilization. Use of alcohol tags rather than breathalysers to monitor compliance was a result of political–economic constraints, concern surrounding intrusion, technological innovation and policy‐orientated learning. The decision to omit an 'offender pays' funding mechanism was a consequence of legal incompatibility and civil service reluctance, while 'flash incarceration' for breach was not implemented due to European policy harmonization. Conclusions: The London Alcohol Abstinence Monitoring Requirement Pilot was a policy 'synthesis' that combined ideas, goals, vocabulary, principles, technology and practices from the South Dakota model with the existing English and Welsh criminal justice framework. Structural factors and the actions of particular agents limited the extent to which policy transfer occurred. [ABSTRACT FROM AUTHOR]

The National Institute for Health Research (NIHR) aims to improve national 'health and wealth' by providing infrastructural support to enable clinical research in National Health Service settings in England and Wales. Cognisant of the consequences of studies' failure to achieve required numbers of participants, it also actively campaigns to promote patient awareness of research, and willingness to participate in trials. In this paper, we analyse recent NIHR campaigns and policies designed to encourage patients to participate in clinical research to interrogate how they are implicated in the national bioeconomy. In doing so we expand the notion of 'clinical labour' to include the work of patient recruitment and highlight an emergent obligation on patients to contribute to research processes. Whereas once patient knowledge and experience may have been devalued, here we draw on the concept of 'assetisation' (Birch 2012) to explore the emergent relationship between healthcare system and patient as research participant. We consider how patients' contribution goes beyond the provision of standardised objects of valuation so that patients themselves may be perceived as assets to, not only recipients of, the national healthcare system. [ABSTRACT FROM AUTHOR]

Attention has turned to welfare advice as a potential health and social care intervention. However, establishing direct evidence of health impact has proven difficult. This is compounded by the need to understand both the facilitative contexts and mechanisms through which this impact occurs. This study investigated if, how and in which circumstances an intensive advice service had an impact on stress and well‐being (as precursors to health impacts), for clients attending a branch of Citizens Advice, located in the North East of England. A mixed methods realist evaluation of three intensive advice services offered by Citizens Advice (CA) was operationalised in five phases: (a) Building programme theories, (b) refining programme theories, (c) Development of a data recording tool, (d) Testing programme theories with empirical data, (e) Impact interviews. This paper focuses on phase 4. The Warwick Edinburgh Mental Wellbeing Scale (WEMWBS) and Perceived Stress Scale (PSS) were completed by 191 clients, with a 91% follow‐up rate (data collected: February 2016 to March 2017). Twenty‐two CA clients participated in interviews (data collected: October 2015 to November 2016). The PSS indicated a significant decrease in stress from initial consultation to approximately 4–6 weeks post advice from 31.4 to 10.3 (p < 0.001) and the WEMWBS indicated a significant increase in client well‐being from a mean of 26.9 to 46.5 (p < 0.001). Nine refined programme theories are presented which combine the qualitative and quantitative analysis; they are underpinned by three abstract theories: Capabilities model, The Decision to Trust Model, and Third Space. An explanatory framework is presented covering the micro, meso, and macro levels of CA. Use of a stress and well‐being lens has allowed insight into the precursors of health in those receiving intensive advice. Using these measures whilst explaining contextual and mechanistic properties, begins to build a complex and real picture of how advice services impact on health. [ABSTRACT FROM AUTHOR]

Stroke is the UK's fourth highest cause of death and an estimated 300,000 people in England are living with related disability. This paper explores the six‐month review (6MR), a policy initiative that aimed to ameliorate unmet need. A multiple case study approach underpinned by critical realism was used to elicit the views of patients, carers, providers and commissioners across three sites using interviews, observations and documentation. Forty‐six patients (age range 28–91 years), 30 carers and 28 professionals were interviewed between December 2015 and October 2016. Twenty‐nine reviews were observed. Data was analysed thematically across sites. 6MRs carried out by stroke nurse specialists (SNSs) were found to be more medically orientated than those completed by a Stroke Association (SA) co‐ordinator who focused on social issues. Reviewers regarded reviews primarily as an opportunity to address unmet need and signpost to further services. Patients responded in three different ways: proactive and engaged, reflected an active orientation to recovery and self‐management; proactive and self‐managing on their own terms, encompassed patients who were striving for independence but took their own approach sometimes at odds with that of clinicians; and passive orientation, whereby patients did not engage in rehabilitation or self‐management. Patients identified different priorities to those of reviewers, particularly those with other long‐term conditions and this appeared to contribute to the dissatisfaction that some expressed. In conclusion, there was little evidence that the 6MR played a key role in recovery. Locally defined outcomes for the 6MR reflecting national policy were not substantiated by the findings. Our findings suggest that the 6MR should review therapy goals and facilitate patient‐led goals. Reviewers should be allowed the freedom to individualise the process rather than adhering to a rigid framework dictated by national policy and local protocols. [ABSTRACT FROM AUTHOR]

Highlights • On most indicators, social exclusion was associated with rural/urban residence. • Higher levels of social exclusion were associated with lower well-being. • Seven social exclusion indicators were significant in an urban model of well-being. • Five social exclusion indicators were significant in a rural model of well-being. • Neighbourhood exclusion significantly improved rural and urban models of well-being. Abstract Background Social exclusion (SE) is a process that limits participation in society across life domains, and is associated with poor quality of life. Neighbourhood exclusion has been identified as particularly important for older adults. This paper examines the association between SE and well-being in older adults from urban and rural areas, focusing on neighbourhood exclusion. Methods Using a cross-sectional survey design with a stratified sampling frame, participants (aged 65+) from rural (n = 628) and urban (n = 627) areas of Barnsley, United Kingdom, completed a questionnaire containing indicators of five SE domains: civic activity, material resources, social relationships, services and neighbourhood. Sequential multiple regression models were developed for 1) total sample; 2) rural areas; and 3) urban areas, with well-being regressed on SE indicators after controlling for self-reported health. Results SE indicators explained 13.4% of the variance in well-being in the total sample (of which neighbourhood exclusion explained 1.2%); corresponding figures for the rural model were 13.8% (3.8%) and for the urban model 18.0% (1.7%); the addition of neighbourhood exclusion significantly improved all three models. Five SE indicators were significant in the rural model, compared with seven in the urban model, with four common to both. Discussion Neighbourhood exclusion explained more variance in well-being in rural than urban areas, whereas exclusion from services explained more variance in urban than rural areas. Area characteristics and the role of neighbourhood should be considered in policy initiatives to reduce SE and promote well-being. [ABSTRACT FROM AUTHOR]

Purpose – The purpose of this paper is to describe and discuss the pilot Making Safeguarding Personal (MSP) project that ran in three London boroughs in England in 2014-2015. The project aimed to help local authority social work practitioners better engage with adults at risk at the beginning, middle and end of safeguarding work and to develop a more outcomes focused approach to safeguarding. Design/methodology/approach – Three adult social care teams volunteered to take part in the MSP pilot for four months, November 2014-February 2015. They were closely supported through telephone conferencing, bespoke training and individual mentoring. Evaluative data were collected from the participating teams about their work and the MSP change processes to assist in further implementation. Findings – The findings suggested that staff felt that the open discussions with adults at risk that were encouraged by the MSP initiative enabled safeguarding to be more effective and provided a better basis of support for adults at risk. The support from the project team was appreciated. Staff reported their own increased confidence as a result of involving adults at risk in decisions about their situations and risks of harm. They also reported their increased awareness of cross-cutting subjects related to adult safeguarding, such as domestic abuse and working with coercive and controlling behaviours. Permission to exercise greater professional discretion to make responses more considered, rather than the need to adhere to time-limited imperatives, was received positively. Staff felt that this enhanced discussions about resolution and recovery with adults at risk although it required greater expertise, more extensive managerial support, and more time. These were available in the pilot. Research limitations/implications – The MSP pilot was confined to three teams and took place over four months. The numerical data reported in this paper are provided for illustrative purposes and are not statistically significant. As with other evaluations of implementation, the data provided need to be set in the local contexts of population profiles, care settings and the reporting source. The pilot also took place during the early implementation of the Care Act 2014 which affected the context of practice and training. The views of adults at risk were not collected. There is a risk of bias in that participants may have wished to convey positive views of MSP to their colleagues. Practical implications – The paper indicates a need for the roll out of MSP philosophy and MSP approaches to be communicated with other agencies supporting adults at risk and for project support of some form to continue. It will be important to see if the overall enthusiasm, support and motivation reported by the pilot teams when taking a MSP approach in practice extend beyond a pilot period during which the staff received substantial support from a dedicated Professional Standards Safeguarding Team. Many of those staff participating in the pilot perceived the MSP approach as a return to core social work principles and welcomed putting these into practice. Originality/value – The paper provides details of one pilot in which the feasibility of the MSP approach was tested by supporting three frontline teams working in different contexts. The pilot suggests that the level and type of support offered to the pilot teams were effective in a variety of practice settings. It draws attention to the need for the MSP concept and approach to be shared with other agencies and for implementation support to continue beyond initial pilot period. [ABSTRACT FROM AUTHOR]

Much concern has been expressed about the quality of care and poor outcomes for looked‐after children (‘children in care’) in England, especially regarding residential homes. This paper builds on a recent evaluation of the piloting of the continental European model of social pedagogy (SP) in English residential care. It does three things: it considers the theoretical social policy literature on policy transfer and its implications; discusses European residential care for children and the discipline of SP; and reflects on these debates and the situation of children's residential care in England. The paper concludes that there are some major hurdles to a widespread implementation of SP in England. This particularly concerns the differing social, professional and political context of children's residential services across neighbouring countries. [ABSTRACT FROM AUTHOR]

Purpose – Transition from education to adult life is a stated policy aim for young people with learning disabilities. The purpose of this paper is to examine the extent to which 16-18-year olds with learning disabilities or autistic spectrum disorder are remaining in state school education beyond the minimum school leaving age. Design/methodology/approach – A tabulation from the Department for Education Children and Early Years Data Unit for 2014, combined with School Census data and age-specific population estimates, allowed us to compare the rates of children identified as having moderate, severe or profound/multiple learning difficulties (MLD, SLD, PMLD), or autistic spectrum disorder (ASD) in state education at the ages of 16-18 years vs five to 15 years. Findings – For all types of need analysed in the paper, the rate of children in state school dropped considerably at the ages of 16-18 years: 10 per cent of the rates of children with MLD, 62 per cent of children with SLD, 49 per cent of children with PMLD and 23 per cent of children with ASD at ages five to 15 years were in state education at ages 16-18 years. Almost all young people aged 16-18 years in state education with SLD or PMLD were in special schools, compared to just over half of young people with MLD or ASD. For all these figures, there was considerable regional variation. Social implications – Substantial numbers of children with learning disabilities or ASD do not remain in post-16 state education, with wide regional variations that do not seem to correspond to regional variations in need or national policy concerning transition. Originality/value – This is the first data set to examine this issue. [ABSTRACT FROM AUTHOR]

Purpose – The purpose of this paper is to provide a commentary on “A summary of government initiatives relating to employment for people with learning disabilities in England”. Design/methodology/approach – In her paper, Blamires outlines the development of policy in employment for people with learning disabilities. This commentary explores whether this policy development is having any impact. Findings – The statistics indicate that development of policy does not appear to be making a difference. It is concluded that this is about how it is being implemented and the time it takes for policy to have an impact. What is needed to fully implement these changes is a huge cultural shift, changing people’s mindset about what people with learning disabilities can achieve. Originality/value – This paper provides an individual perspective on the impact of policy on the lives of people with learning disabilities. [ABSTRACT FROM AUTHOR]

Purpose – The purpose of this paper is to provide a synthesis of current and previous government policies and strategies, in relation to people with learning disabilities and employment, to facilitate a better understanding of the current situation and future challenges. Design/methodology/approach – A search was completed to identify government policies relating to the employment of people with learning disabilities. Key policies were identified and their impact was discussed in the paper. Findings – It appears there is a necessity to identify how successful pilot projects can be replicated on a national scale, with clear targets and measures and initial financial support to set up these services. Alongside this there is a need for interventions targeting not just employers, but the general population, educating people about the importance of including and valuing people with learning disabilities in the workforce. Originality/value – It is important that policy is analysed and the impact of it is assessed to determine whether more action is necessary. This paper adds updates to some of the issues discussed in Melling et al.’s (2011) paper about “Supported employment for people with learning disabilities”. [ABSTRACT FROM AUTHOR]

Background: Early Intervention in Psychosis (EIP) services have been implemented with the dual aims of preventing harmful outcomes associated with early‐onset psychosis and improving prognosis. However, concerns have been raised regarding the ethical implications of involving young people in EIP services. One way to ensure high ethical standards and promote good practice in EIP delivery is through governance of clinical practice. This study aimed to investigate the normative dimensions of good practice in EIP through examination of clinical guideline documents published in England over the past 15 years. Methods: A total of 14 clinical guidelines and relevant policy documents for EIP were retrieved and analysed using a mixed inductive and deductive thematic approach. Themes were derived from the data itself, whereas the development of broader categories was performed through a constant comparison with the scientific literature describing ethical issues in EIP. Results: Ethical touchpoints of good practice in EIP included both procedural and substantive factors, which were seen to be interdependent and mutually constitutive. These ethical touchpoints were largely implicit in the documents analysed. Procedural requirements of EIP service delivery consisted of norms and rules pertaining to EIP service structure, adherence to codes of ethics, inclusivity, patient and family centredness and appropriate treatment provision. Substantive factors consisted of moral attributes that should be cultivated by healthcare professionals working in EIP: competency, empathy, sensitivity and trustworthiness. Conclusions: We argue that, to ensure good practice in EIP, procedural and substantive ethical expectations embedded in EIP guideline documents should be made explicit in EIP service and care delivery. We suggest that the procedural and substantive factors highlighted in this paper contribute useful dimensions for the eventual evaluation of good practice in EIP services across England. [ABSTRACT FROM AUTHOR]

There is a prevalent view in England that family-based care is the preferred placement option for children placed in out-of-home care. Nonetheless, it is acknowledged that for some young people residential group care can offer the best chance of positive outcomes, transition, and in some cases a route to permanence. With an emphasis on innovation, there has been a recent governmental focus on the role and purpose of these placements. This conceptual paper explores how the political and legislative context has influenced the current opinion and use of residential care, as well as examining the importance of factors such as attachment and relationships, parenting/intervention, the notion of home, a sense of belonging, and adolescent development. Evidence exploring associated risk and resilience factors is also discussed. We question whether adopting a child development perspective and moving the discourse away from placement type to placement purpose would better support children and young people to fulfill their life chances. Residential care undoubtedly offers a different experience to that of family-based care, although, further research assessing a wider range of attributable outcomes is necessary to understand how policy and practice can intervene to best support development and opportunity for children placed in out-of-home care. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this paper is to provide a commentary on “Learning disability services: user views on transition planning”.Design/methodology/approach The commentary provides a discussion of the concept of continuity of care (Forbes et al., 2001; Freeman et al., 2000) in relation to transition from children’s to adults’ services for young people with intellectual/developmental disabilities.Findings Continuity of care is an important consideration for this population and is emphasised in recent policy initiatives in England, as well as being highlighted by young people and their families as a significant aspect of their transition experience. Despite this, evidence suggests it is not currently achieved for many young people and their families, and a number of challenges that may contribute to this are highlighted.Originality/value The commentary emphasises that continuity of care should be a key consideration for services supporting young people and their families at transition. [ABSTRACT FROM AUTHOR]

The two reclassifications of cannabis in England & Wales in 2004 and 2009 have been subjected to a series of academic analyses which have largely been centred on either the relationship to evidence, or in terms of the implications and realities of policing and health under the changes. However, despite the wealth of attention on this area, there have been relatively few attempts to understand these policy movements through broader criminological theoretical frameworks. One recent exception is Shiner's (2015) utilisation of Garland's (2001) concept of 'structured ambivalence'. This paper seeks to test this application through drawing upon an alternative source of evidence, namely, a series of 'elite' qualitative interviews, and using Kingdon's (1995) Multiple Streams model to make sense of the policy processes. In doing so, it largely corroborates Shiner's conclusions whilst also further illuminating particular agentic aspects and their intertwining with other structural and cultural forces which led to the reclassifications. These findings demonstrate the value of triangulating evidential sources and advances knowledge about the role of individuals in pursuing policy agendas within a broader shifting political climate. This provides greater scope to further test and understand how structured ambivalence manifests itself in other cultural contexts and policy domains. [ABSTRACT FROM AUTHOR]

Objectives: The Health and Social Care Act 2012 introduced Clinical Commissioning Groups to take responsibility for commissioning (i.e. planning and purchasing) the majority of services for local populations in the English NHS. Constituted as 'membership organizations', with membership compulsory for all GP practices, Clinical Commissioning Groups are overseen by, and are accountable to, a new arm's-length body, NHS England. This paper critically engages with the content and policy narrative of the 2012 Act and explores this in relation to the reality of local policy enactment. Methods: Set against a careful review of the 2012 Act, a case study of a nascent Clinical Commissioning Groups was conducted. The research included observations of Clinical Commissioning Group meetings and events (87 h), and indepth interviews (16) with clinical commissioners, GPs, and managers. Results: The 2012 Act was presented as part of a broader government agenda of decentralization and localism. Clinical Commissioning Group membership organizations were framed as a means of better meeting the needs and preferences of local patients and realizing a desirable increase in localism. The policy delineated the 'governing body' and 'the membership', with the former elected from/by the latter to oversee the organization. 'The membership' was duty bound to be 'good', engaged members and to represent their patients' interests. Fieldwork with Notchcroft Clinical Commissioning Group revealed that Clinical Commissioning Groups' statutory duty to NHS England to 'ensure the continuous improvement' of GP practice members involved performance scrutiny of GP practices. These governance processes were carried out by a varied cast of individuals, many of whom did not fit into the binary categorization of membership and governing body constructed in the policy. A concept, the governing assemblage, was developed to describe the dynamic cast of people involved in shaping the work and direction of the Clinical Commissioning Group, many of whom were unelected and of uncertain status. This was of particular significance in Notchcroft Clinical Commissioning Group because the organization explicitly pursued a governance system based on developing positions of consensus. The governing assemblage concept is valuable in articulating the actual practices of Clinical Commissioning Group governance, how these relate to the normative content of the 2012 Act, and the tensions that emerge. Conclusions: The governing assemblage concept provided clarity in discussion of the dynamics of organizational governance in Notchcroft Clinical Commissioning Group, which did not follow the simple template articulated in the 2012 Act. The concept merits application in the study of other Clinical Commissioning Groups and may prove valuable in illuminating governance processes within a range of other health care organizations in different contexts. The governing assemblage holds promise for the analysis of ongoing changes to NHS organization, as well as international health care organizations such as accountable care organizations in the US. [ABSTRACT FROM AUTHOR]

Increasing attention has focused on the role of joint commissioning in health and social care policy and practice in England. This paper provides an empirical examination of the three discourses of joint commissioning developed from an interpretative analysis of documents by Dickinson et al. (2013; BMC Health Services Research, 13) and applied to data from our study exploring the role of knowledge in commissioning in England. Based on interviews with 92 participants undertaken between 2011 and 2013, our analysis confirms that the three discourses of prevention or empowerment or efficiency are used by professionals from across health and social care organisations to frame their experiences of joint commissioning. However, contrary to Dickinson et al., we also demonstrate that commissioners and other stakeholders combine and trade off these different discourses in unexpected ways. Moreover, at sites where the service user experience was central to the commissioning process (joint commissioning as empowerment), a greater sense of agreement about commissioning decisions appeared to have been established even when the other discourses were also in play. [ABSTRACT FROM AUTHOR]