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Background: The concept of recovery is contested throughout the existing literature and in mental health services. Little research exists that gives voice to service user perspectives of recovery. Aim: This paper explores how service users in two recovery oriented services run by the National Health Service in North West England talked about recovery and what it meant to them. Method: 14 service users accessing these services took part in semi-structured qualitative interviews focusing on the concept of recovery. Data were analysed using an interpretive phenomenological analysis approach. Results: Service users talked about recovery as a dynamic, day to day process as well as an outcome; specifically related to being discharged from inpatient settings. A number of factors including relationships and medication were cited to have the potential to make or break recovery. Conclusions: The study highlights the continued dominance of the biomedical model in mental health services. Service users appear to have internalised staff and services’ understanding of recovery perhaps unsurprisingly given the power differential in these relationships. Implications for clinical practice are explored. [ABSTRACT FROM AUTHOR]

Scientific-bureaucratic medicine (SBM) has been the dominant discourse on evidence-based medicine in the English National Health System (NHS). It has being claimed that SBM has led to new forms of medical professionalism with an emphasis on organisational values and the control of autonomy. This paper explores the medical professions' response to SBM, where SBM is manifested in the form of National Institute of Health and Clinical Excellence (NICE) guidelines. Seventy-four face-to-face informal interviews were carried out with clinicians and managers between 2007 and 2009. Three major themes emerged from the analysis each of which was linked to doctors' receptiveness to NICE guidelines implementation. The first emphasised organisational values, which accounted for conditional acceptance of NICE guidelines. The second was proactive professionalism or entrepreneurial professionalism, which was linked to the rejection of NICE guidelines and the emergence of alternative forms of introducing new ideas for the expansion of their clinical practice. The third was related to the prominence of clinical autonomy linked with doctors' resistance to the use of NICE guidelines. It is argued that this evidence does not reflect a significant emergence of new forms of professionalism but the development of multiple occupational identities. [ABSTRACT FROM AUTHOR]

This paper draws parallels between the market trend in the English NHS and Polanyi's (1957) The Great Transformation: The political and economic origins of our time, Beacon Press: Boston (originally published in 1944 in the United States as The Great Transformation, Rinehart: and Co: New York, and in 1945 in England as Origins of our time, Gollancz: London) account of how the rise of markets provokes a self-protective counter-reaction that tries to re-embed economic relations in social relations. We report findings from a qualitative study of NHS contracting, which examines the recent move to harder-edged contracts with greater use of financial penalties and incentives. In practice, use of these techniques tended to be confined to nationally-mandated sections of the contract rather than emerging from local bilateral agreements, and when things went wrong the parties relied more on cooperative behaviour than on the provisions of the contract to find solutions. Making the current contracting system work depended more on existing relational networks than on the incentive structures created by recent 'marketisation' initiatives, but the inability of the market to evolve as expected has encouraged policy makers to publish plans for further radical reforms. [ABSTRACT FROM AUTHOR]

Evidence suggests that despite the popularity and influence of key health equity concepts, they often fail to shift the thinking and actions of health workforces towards the social and structural determinants of health inequalities. These findings tend to be attributed to institutional constraints, along with the role of influential discourses which promote a focus on individuals and behaviours. However, questions have also been raised about the clarity and utility of the concepts themselves, and the extent to which the language they use works (or indeed fails to work) in reorienting thinking and action. The purpose of this study was to explore how partners in an applied health research collaboration in England interpreted the popular 'upstream-downstream' story, and what it means to work 'upstream' to reduce health inequalities. Where participants were not familiar with its academic or technical usage, the story was taken to be a metaphor for prevention generally, or it prompted a root cause analysis of the more discrete ways in which inequalities were encountered in participants' research or work. Even in instances where participants did hold more socio-political perspectives, these were often not evoked by the metaphor itself. Two of the 18 participants were unable to equate the metaphor with particular actions or ways of working, while others found it to be a poor fit with how they understood inequalities. The study findings illustrate and explain the challenges that arise when technical metaphors from the health equity literature are opened-up to interpretation by wider audiences. [ABSTRACT FROM AUTHOR]

Single-sided deafness presents communication challenges for adults. There are a range of care options, including CROS hearing aids, available but little is known about patient preferences for these interventions. The objective of this study was to understand the viewpoints of patients making decisions about audiological interventions they use. A constructivist worldview using thematic analysis to undertake a constant comparative analysis of 8 semi-structured interviews. Participants were recruited from Portsmouth Hospitals University NHS Trust audiology service in England. The results of the study describe ongoing iterative judgements being made by participants, informed by their access to information, effectiveness of audiological interventions, stigma, barriers to accessing care, and constant cost-benefit analyses being made. The key factors involved in decision-making by individuals with Single-sided deafness (SSD) are discussed. This study represents the first in-depth exploration of the individual's lifeworld related to which factors influence use of different audiological interventions by individuals with SSD. It highlights the complex and ongoing nature of how decisions are made by these individuals and identifies the need for greater information provision by clinicians, such as through use of a decision aid tool. [ABSTRACT FROM AUTHOR]

Hip precautions are movement restrictions that are often advised following primary total hip arthroplasty (PTHA) for osteoarthritis (OA), but there is limited evidence supporting their effectiveness in preventing dislocation. This study aimed to explore the clinical reasoning behind the continuation and discontinuation of hip precautions following PTHA for OA. Semi-structured interviews were conducted with therapists and surgeons at six centres using precautions and six centres not using precautions across secondary or tertiary NHS sites in England. Interviews were transcribed verbatim and thematically analysed. Interviews were conducted with fourteen surgeons and eighteen therapists. Of these clinicians, eight surgeons and ten therapists routinely advised precautions. Clinicians continued to use precautions to avoid dislocation by creating a boundary to movement, particularly important when dealing with patients who "push" these boundaries. Clinicians discontinued precautions because of a perceived negative impact on patients and the lack of supporting evidence. In the absence of a rise in dislocation rates for these centres, others have now changed practice. This study offers insight into the clinical reasoning behind the continuation and discontinuation of hip precautions following PTHA for OA. The use of precautions remains controversial and further work is required to determine whether or not they should be advised. Redesign of future rehabilitation pathways for primary total hip arthroplasty should take into account viewpoints from across the multidisciplinary team to aid decision making. Concern for patient behaviours, dislocation and litigation may be barriers to changing practice for rehabilitation after primary total hip arthroplasty. Clinicians may be discontinuing hip precautions because of known surgical advances, a perceived negative impact on patients and a lack of supporting evidence for historical practice. Individualised rehabilitation considerations are necessary for patients with risk factors that predispose them to dislocation after primary total hip arthroplasty, regardless of whether hip precautions are advised as standard at their given centre. [ABSTRACT FROM AUTHOR]

A new diagnosis of Complex Post-traumatic Stress Disorder, CPTSD, is included in ICD-11 which was adopted in May 2019 by the World Health Organisation, WHO. In addition to the symptoms of PTSD, CPTSD includes emotional dysregulation, negative self-concept, and disturbances in relationships. It may be a helpful diagnosis for trauma survivors with experiences of human mistreatment such as torture and abuse. This study explores the views of patients in the community on psychotherapy for the diagnosis of CPTSD, taking a qualitative, participatory approach. Twenty-four former patients from an NHS secondary mental health service in London interviewed each other about their treatment. Participants also collaborated in data analysis. All had a diagnosis of PTSD, with additional symptoms of CPTSD identified at assessment. The key factor in recovery was rebuilding relationships, beginning with the therapist. Groupwork was helpful in promoting relationships with others, as it may result in shame reduction. Involvement in the wider community through peer support groups was also valuable. The rebuilding of relationships based on trust was an active mechanism of change and recovery from CPTSD. Participants felt that sufficient time, at least one year of psychotherapy with weekly sessions, was needed. [ABSTRACT FROM AUTHOR]

Objective: To understand the experience of people who seek help for subjective cognitive concern and memory loss, including people not referred for further assessment. To understand the patients' perspective of the medical process of receiving a cognitive assessment. This work is situated within the context of policy priorities for dementia diagnosis. Methods: Participants with and without dementia were recruited through NHS trusts and community organisations in four regional areas in England. Data were collected using longitudinal qualitative interviews. Transcript data were thematically analysed. Results: Sample of 41 people (mean 75 years, 25 dementia diagnoses). Interpretative thematic analyses focused on the presence or absence of trust in relational experiences. There were three transition points where trust could be specifically developed or undermined: (1) deciding to seek help; (2) healthcare practitioners' response to help-seeking; (3) process and outcome of assessment. Triggers for help-seeking for subjective cognitive concern were being prompted by family and knowing a relative with dementia. When participants perceived healthcare practitioners' behaviour as dismissive, they had less trust in the outcome of the healthcare encounter. Misunderstandings and absence of trust in assessment processes led to participants stating they did not fully agree with the outcomes of the assessment. Conclusions: Healthcare practitioners have an important role in supporting people with subjective cognitive concern ensuring patients have trust in assessment outcomes. Where the validity of the assessment process is seen as ambiguous, people can be left dealing with uncertainty, rather than being clear about ways they can manage their condition, situation or status. [ABSTRACT FROM AUTHOR]

The impact of working as art therapists in the NHS during protracted change processes, with people with learning disabilities (LD), was investigated in a qualitative heuristic doctoral study (Ashby, 2018), which considered concerns about emotional exhaustion and reduced efficacy, symptoms of burnout (Maslach, 1982), as a result of occupational stress. The researcher's own data was examined, and 15 art therapists employed by NHS Trusts across England were interviewed. This article explores how the research was conducted, its findings related to LD services in the NHS and wider employment issues, and addresses how the findings are relevant to all art therapists. Most burnout studies are quantitative and consider workplace sources of occupational stress, but this qualitative research importantly revealed how crucial personal sources of support and stress were in terms of aiding or reducing clinicians' capacities to cope. There was evidence of job satisfaction, resilience, and personal growth developed over years of practice, and high levels of stress resulted in symptoms of burnout in some participants, but recovery was shown to be possible. Plain-language summary Research into the impact of working as an art therapist in learning disability (LD) services in the NHS in England during long periods of change processes found sources of stress and of job satisfaction (Ashby, 2018). The doctoral research was qualitative, using heuristic methodology as the researcher had experience of the issues investigated, and 15 art therapists were interviewed. This article discusses the relevant literature, the way the research was done, and findings of the research; it applies the knowledge gained to the situations many art therapists experience in their practice with different organisations and work environments. The impact on art therapists was investigated as both positive and negative aspects of their working lives were evident, and sources of job satisfaction and of occupational stress were experienced, including burnout symptoms of emotional exhaustion and reduced capacity to work, though not depersonalisation (Maslach, 1982). Organisational sources of satisfaction and stress within NHS LD services were identified, and employment issues for art therapists became apparent in relation to job insecurity, within the depressed employment market. This qualitative research found that personal sources of support or stress could result in art therapists being able or unable to manage coping with occupational stress if multiple sources of stress were present. Burnout symptoms of emotional exhaustion and a reduced capacity to manage their workload resulted from these situations for some participants, however, those affected were able to recover when they addressed the occupational stress that had become too much for them; no participants avoided contact with service users. [ABSTRACT FROM AUTHOR]

Background and objectives: People with dementia occupy around one quarter of general hospital beds, with concerns consistently raised about care quality. Improving workforce knowledge, skills and attitudes is a mechanism for addressing this. However little is known about effective ways of training healthcare staff about dementia. This study aimed to understand models of dementia training most likely to lead to improved practice and better care experiences for people with dementia, and to understand barriers and facilitators to implementation. Method: A collective case study was conducted in three National Health Service Acute Hospital Trusts in England. Multiple data sources were used including interviews with training leads/facilitators, ward managers and staff who had attended training; satisfaction surveys with patients with dementia and/or carers; and observations of care using Dementia Care Mapping. Results: Interactive face-to-face training designed for general hospital staff was valued. Simulation and experiential learning methods were felt to be beneficial by some staff and stressful and distressing by others. Skilled delivery by an experienced and enthusiastic facilitator was identified as important. Staff identified learning and practice changes made following their training. However, observations revealed not all staff had the knowledge, attitudes and skills needed to deliver good care. Patient and carer satisfaction with care was mixed. A major barrier to training implementation was lack of resources. Supportive managers, organisational culture and strong leadership were key facilitators. Conclusion: Dementia training can lead to improved care practices. There are a range of key barriers and facilitators to implementation that must be considered. [ABSTRACT FROM AUTHOR]

In the United Kingdom, speech and language therapists (SLTs) and Stroke Association communication support coordinators (CSCs) are both employed to provide services for people with communication difficulties following stroke. There is very little literature of this type of collaborative working. This research is unique because it explores collaborative working between SLTs who are employed by the National Health Service and CSCs who are employed by the Stroke Association. Five CSCs and seven SLTs from the East of England participated in a series of in-depth interviews. Data were analysed using thematic analysis informed by an interpretative phenomenological approach. The analysis suggested complex negotiation processes occur at a number of different levels. These levels include negotiation of individual relationships between SLTs and CSCs, negotiating the particular challenges involved in working across organisations and professions, and the need for both roles to negotiate and promote the value of their services at a societal level. The findings of this research are discussed in relation to existing theories and research within the field of collaborative working. Clinical applications are suggested for collaborative working within communication services. We propose that our findings may have relevance to other individuals and organisations delivering services collaboratively. [ABSTRACT FROM AUTHOR]

Background: Since 1990, health policy in England has stressed the importance of user involvement in shaping and delivering services. Aims: To explore mental health service user-led organisations (ULOs) in England, as they interact with decision-makers to bring about change desired by them with a focus on institutional norms behaviour and specialised knowledge impacting service users' relationships with services. Method: An ethnography of five ULOs in two provider organisations (NHS Trusts) including observing their meetings and interactions with decision-makers, conducting in-depth interviews and collecting reflective diaries kept by two members of each group. Results: During the study, one group ceased to operate. This was a group which refused to adopt the institutional rules and norms of managerial discourse. The other four groups survived by navigating the changing environment which existed at the time of the study, although often at some cost. Themes of autonomy and leadership were also identified. Conclusion: The current environment is one of the organisational complexity and change and the place of ULOs is an ambiguous one as they strive to maintain autonomy whilst at the same time being an acceptable voice to managers. [ABSTRACT FROM AUTHOR]

The National Health Service Institute for Innovation and Improvement was established to help the NHS to improve healthcare by rapidly developing and disseminating knowledge and evidence about new ways of working. One example is the Emergency and Urgent Care Pathway for Children and Young People which focused on providing high quality and safe healthcare for children and young people requiring urgent or emergency treatment for the most common illnesses and injuries. Monkey’s Guide to Healthy Living and NHS Services was developed to increase awareness of acute health services in primary school-aged children. This free resource was posted to every primary school in England. A process and impact evaluation was undertaken to explore how the resource was being utilized during 2013–2014. A small number of in-depth case studies were developed involving classroom-based observations and teacher interviews along with a much larger online survey which was emailed to all primary schools in England. On the whole, the resource was viewed as useful, engaging, and informative; with children, teachers, and other professionals particularly valuing the monkey puppet, video clips, and teacher resources. The National Evaluation highlighted that most respondents integrated the materials into the curriculum, used them as a one-off lesson, or developed their own innovative and strategic approaches to make the best use of the resources; almost two-thirds of schools who responded to the survey felt the resources led to pupils knowing about the available NHS services and healthy lifestyles; over half felt pupils were now more informed about the most appropriate services to use. [ABSTRACT FROM PUBLISHER]

Enhancing choice and control for people using services is a mental health and social-care service priority in England. Personalisation is a new policy and practice for delivery of social-care services where eligible adults are allocated a personal budget to spend to meet their agreed support needs. To describe approaches to introducing personal budgets to people with severe and enduring mental health needs, and to identify facilitators or barriers encountered. Within four English local authority (LA) areas, purposively selected to provide maximum variation, semi-structured interviews were undertaken with 58 participants from LAs, NHS trusts and third-sector organisations. An Interpretive Framework analysis considered within- and across-site insights. Issues arising from the implementation of personalisation for people with mental health needs are presented under two general themes: "responsibility and power" and "vision and leadership". Key challenges identified were complexities of working across NHS and LAs, the importance of effective leadership and engagement with service user representatives. Implementing personal budgets in mental health requires effective engagement of health and social-care systems. Change processes need strong leadership, clear vision and personal commitment, with ownership by all key stakeholders, including front-line practitioners. [ABSTRACT FROM AUTHOR]

Health promotion (HP) amongst older people is an increasingly prominent policy concern for governments. The development of an evidence-base and the advocacy of effective interventions in the light of this act as legitimation tools for the overall HP phenomenon – assisting the growth of state and non-state funding for public health initiatives for older people. In structuring decision-making as to which individual projects/initiatives receive funding, frameworks for acknowledging efficacy impact on formats of HP work both positively and negatively. Drawing on recent research across the EU and focusing on the specific national contexts of Austria and England, this comparative policy analysis triangulates best-practice modelling, evaluation data and interviews with project coordinators to explore how policy contexts impact on the nature and format of HP interventions. Amidst a developing awareness of what effective practice looks like, successful HP initiatives must advocate their legitimacy within narrow rules of quality, where measurable outcomes have become the keys which unlock financial resources. Findings across both countries suggest that this instrumentalisation of legitimation, driven by economic pressures and bureaucratic generalisability, threatens the rationality of HP. From a Habermasian perspective, tensions emerge between projects’ remaining reflexive towards processes and their need to articulate the ‘success’ of the interventions in a language of outcomes. Over time, in an era where resources are increasingly scarce and competition over these intensifies, a danger exists whereby the instrumentality of HP begins to separate from, and impinge upon, the capacity for projects to think and act holistically. [ABSTRACT FROM PUBLISHER]

This qualitative study explores the experiences of five primary care counsellors working in the NHS with clients identified as diagnosable with borderline personality disorder (BPD). Participants completed a semi-structured interview about their experiences of clinical work with BPD clients. Interview transcripts were analysed via Interpretative Phenomenological Analysis (IPA) and three master-themes were identified: recognition and implications; managing feelings of inadequacy; and managing dilemmas in the primary care context. Despite struggling to manage feelings of failure evoked by these clients, counsellors described feeling a sense of ethical responsibility, and adapted the traditional short-term model of counselling to ensure clients received ongoing, supportive work. Whilst NHS guidelines propose that BPD is best managed and treated in secondary care and specialist services, this study found that counsellors are working with this complex group of clients in primary care and require specialist supervision and support in managing unconscious process issues emerging from the work. [ABSTRACT FROM AUTHOR]

As a route to providing a framework for elucidating the content of public thinking concerning emerging and re-emerging infectious diseases (EID), this article examines public engagement with methicillin-resistant Staphylococcus aureus (MRSA). It explores how British lay publics represent MRSA utilising a social representations framework. For this group, MRSA is associated primarily with dirty National Health Service (NHS) hospitals that have been neglected due to management culture having superseded the matron culture that dominated the putative golden age of the NHS. Furthermore, MRSA represents a transgression of the purpose of a hospital as a clean and curative institution. While this widely shared picture is accompanied by a strong sense of general concern, the respondents associate contracting MRSA with other identities, such as hospitalised, young and old people. These associations are linked to feelings of personal invulnerability. There is also blame of foreigners - especially cleaners and nurses - for MRSA's spread. Thus, the data corroborate a key pattern of response found in relation to myriad EID - that of othering. However, the identities associated with contracting MRSA are mutable; therefore, the threat cannot be distanced unequivocally. Beyond developing an understanding of the relationship between epidemics and identities, this article proposes a fitting theory with which to explore EID-related public thinking. [ABSTRACT FROM AUTHOR]