Search

Problem: Rapid referral and management of patients with transient ischaemic attacks is a key component in the national strategy for stroke prevention. However, patients with transient ischaemic attacks are poorly identified and undertreated. Design and setting: Before and after evaluation of quality improvement programme with controlled comparison in three primary care trusts reflecting diverse populations and organisational structures in an urban district in the North of England. Key measures for improvement: The proportion of patients receiving antiplatelet drugs and safe driving advice on referral to a speciality clinic, and the numbers of referrals, adjusted for age, to the specialist clinic before and after the improvement programme. Strategies for change: Interviews with patient and professionals to identify gaps and barriers to good practice; development of evidence based guidelines for the management of patients with transient ischaemic attacks; interactive multidisciplinary workshops for each primary care trust with feedback of individual audit results of referral practice; outreach visits to teams who were unable to attend the workshops; referral templates and desktop summaries to provide reminders of the guidelines to clinicians; incorporation of standards into professional contracts. Effects of change: A significant improvement occurred in identification and referral of patients with transient ischaemic attacks to specialist clinics, with a 41% increase in referrals from trained practices compared with control practices. There were also significant improvements in the early treatment and safety advice provided to patients before referral. Lessons learnt: A strategic approach to effective quality improvement across a diverse health community is feasible and achievable. Careful planning with patient and professional involvement to develop a tailored and multifaceted quality improvement programme to implement evidence based practice can work in very different primary care settings. Key components of the effectiveness of the model include contextual analysis, strong professional support, clear recommendations based on robust evidence, simplicity of adoption, good communication, and use of established networks and opinion leaders.

PurposeMainstream health economics labours under a misleading understanding of the nature of the topic area and suffers from a concomitant poverty of thinking about theory and method. The purpose here is to explore this critical position and argue that health economics should aspire to being more than a technical discipline. It can, and should, engage with transformative discourse.Design/methodology/approachIt is argued that the hermeneutic sciences, emphasising interpretation not instrumentality or domination, offer a route into the change to which one seeks to contribute. The article specifically focuses on the way Habermas provides insights in his approach to knowledge, reason and political economy. How he emphasises complexity and interaction within cultural milieu is explored and primacy is given to preserving the life‐world against the encroachments of a narrow rationalization.FindingsThe argument for a critical re‐imagining of health economics is presented in three stages. First, the antecedents, current assumptions and critical voices from contemporary economics and health economics are reviewed. Second, the way in which health is best understood via engaging with the complexity of both the subject itself and the society and culture within which it is embedded is explored. Third, the contribution that hermeneutics, and Habermas's critical theory, could make to a new health economics is examined.Originality/valueThe paper offers a radical alternative to health economics. It explores the shortcomings of current thinking and argues an optimistic position. Progress via reason is possible if one reframes both in the direction of communication and in the appreciation of reflexivity and communality. This is a position that resonates with many who challenge prevailing paradigms, in economics and elsewhere.

As nursing has been subject to successive waves of 'managerialism' there has been a drive on the part of government and elements within the profession to enhance the science base and promote cost-effective health care interventions. This has generated new interest in the 'economics of nursing' as efficiency and 'value for money' are viewed as necessary precondition for the provision of a high quality nursing service. As an academic subject health economics has brought an elegant set of theories to bear on the topic of health and health care. However, mainstream health economics is premised on a series of simplifying assumptions that, if applied uncritically, can induce a range of unintended and adverse consequences. This paper asks how ideas developed in one sphere (health economics) can be become influential in another (nursing management and practice) and it seeks explanations in the theories of Michel Foucault, specifically in his exploration of the reciprocal relationship between power and knowledge. How are our assumptions about what is possible and desirable shaped, how far do mechanisms of surveillance and self-subjugation extend? A range of alternative economic approaches have been developed which challenge many mainstream health economics assumptions. Some of these are better suited to the complex social environment present within health care. Nurses, nurse managers and researchers should question the assumptions of dominant economic models and explore a range of economic frameworks when planning services and evaluating their practice.

The arrival of AIDS has prompted much social research. In the early days of the epidemic the emphasis was, understandably, on gathering and publishing hasty findings to help inform policy-making and service delivery. By now more research that is both reflexive and theoretical has emerged. However, the development of the subject area has occurred over a time period in which the organisation of social research and the environment of the welfare marketplace into which it reports have also changed. Moreover, that change, to an increased emphasis on utilitarianism, has been in an opposite direction to the maturing trajectory of the AIDS social research agenda, which has recognised the strengths of alliance and reciprocity.

Background. The placement of welfare advice services in family practice to assist patients with health-related social and economic issues (e.g. disability benefits) has gathered momentum over the last decade in the UK. This expansion of primary care raises a number of issues for practices hosting these services. Objectives. To gain the views of advice workers and primary care staff about the issues raised in hosting a welfare advice service across 30 practices in inner city Bradford. Methods. Views were obtained through focus groups with six advice workers, and primary care staff in 14 practices. A questionnaire was also posted to all practice managers asking their opinions about the service. Results. The focus groups highlighted a number of advantages for patients, including improvements in health and quality of life through increased income and reduced stress from social and economic issues. For practice staff, the service provided a resource to refer patients for welfare advice, reducing the time spent dealing with welfare issues, thereby reducing workload. This was confirmed in the questionnaire to practice managers where 72% said the service had saved time for GPs and reception/office staff. The advice workers raised concerns about the perceived level of commitment to the service from some staff at some practices. Practice staff were particularly concerned about the need for feedback about referrals. Conclusion. Providing welfare advice in family practice can act as a valuable resource for primary care staff helping to address their patients health-related social and economic needs.

Summary Purpose: To examine the beliefs and experiences of South Asians with epilepsy and the extent of provision of appropriate information and accessible services for them by health professionals. Methods: Qualitative interviews with 30 South Asians with epilepsy, 16 carers and 10 health professionals. In addition, two focus groups were held with 16 South Asians without epilepsy recruited from community centers. The interview sample was divided by religious groupings (Hindus, Sikhs and Muslims). Fieldwork was conducted in Bradford and Leeds (England). Results: Beliefs that epilepsy is caused by spirit possession (Muslims) or attributable to sins committed in a past life (Sikhs and Hindus) were reported as being widely held among South Asians living both in the UK and the Indian subcontinent, although few informants themselves subscribed to such views. Compliance with conventional medication was high; however, those who experienced seizures most often were most likely to turn to traditional South Asian therapies. Most informants used both treatments simultaneously. The main issues regarding the provision of services were: lack of appropriate information and advice; language and communication barriers; problems in interaction with health professionals. Also discussed were the potential merits of attending support groups. Greatest dissatisfaction was expressed in relation to primary care, whereas the highest praise was reserved for specialist epilepsy nurses. Conclusions: Our findings show both similarities and differences between participants' experiences, where gender, age or other aspects of personal biography can be as important as religion, culture or country of origin. Furthermore, the impact of being diagnosed with epilepsy can be exacerbated by structural impediments to accessing information and appropriate services.

It has been acknowledged that religious and complementary therapies are commonly used among South Asian communities in the UK. However, little is known about their religious beliefs in relation to epilepsy and the type of South Asian therapies that they use to treat the condition.To explore the influences of spiritual and religious beliefs on explanation of the cause of epilepsy, and the choice of treatment in people of South Asian origin who have epilepsy.Qualitative study using interviews with patients, carers, health professionals, and focus groups of people from minority ethnic communities.Bradford and Leeds.Semi-structured individual interviews with 20 Muslims, six Sikhs, and four Hindus with epilepsy; 16 nominated carers (family members, friends); 10 health professionals (specialist GPs, neurologists, specialists nurses, social workers, community GPs); and two focus groups with a total of 16 South Asians without epilepsy.It was found that over half of responders attributed their illness to fate and the will of God, or as punishment for sins of a past life. Some patients had experienced prejudice from people who believed that their epilepsy was contagious. A strong network of traditional healers was found, providing a parallel system of health care in the UK and on the Indian subcontinent. People turned to religiospiritual treatments in desperation for a cure, often under the influence of their families after the perceived failure of Western medicine. Such treatments were viewed as complementary rather than as an alternative to Western medication. Younger people in particular expressed considerable scepticism about the effectiveness of these traditional South Asian treatments.In this study's South Asian sample, patients commonly turned to traditional healers in search of better health. Health professionals should be aware of the belief systems of these patients and understand the types of treatments in common use. Although these treatments might potentially compete with Western health care, they are used as an adjunct rather than a substitute. Patients have a 'healthy' scepticism about the effectiveness of such treatments, and adherence to medical therapy does not appear to be affected.

Summary The paper reports on the development and piloting of the Social Inclusion Interview Schedule (SIIS). This uses pictures to explore social networks and feelings of social inclusion. The background, conceptual framework and development of the interview schedule are discussed and interim findings are highlighted. The challenge of not just identifying the constituents of a social network but also attributing some measure of intensity to the relationships and activities identified will be considered. The study site is Bradford in the UK and the study population are young people with learning disabilities and their carers. There is a specific focus on people from the South Asian community resident in the city.

This chapter discusses what has changed and what has remained the same in the National Health Service (NHS). It enumerates the crucial developments that have occurred in the NHS since 1997 and highlights key features of the development of consumerist rhetoric. The chapter also considers how changing times and policy initiatives impact on palliative care and how user involvement developed here. It concludes with a consideration of whether the new NHS constitutes an opportunity or a threat for the capacity of palliative care to maximize its achievements and overcome its challenges.

The first three teaching primary care trusts, which came into operation in April 2001, have increased recruitment of GPs and practice staff. Sunderland PCT has reduced practice list sizes as a result of the initiative. Salford teaching PCT has tripled the number of training practices. Eighteen GPs have been recruited in Bradford.

Putting six advice workers into general practices for three hours a week over 10 months resulted in 500,000 Pounds being identified in benefits for patients. Many referrals came from GPs, but patients referred themselves in a fifth of cases. Patients welcomed the service and found it convenient. The co-operation of reception staff was vital.

PCTs allow a strategic approach to primary care research that supports collaboration between professionals and practices and reflects local and national priorities. The implementation of a research strategy in one PCT provides a useful working model.

Death has often been represented as the ‘great leveller’ who returns both monarch and beggar to a common dust. As such this image has been used both to diminish the political zeal of those who would reform earthly inequalities (Illich 1977) as well as to undermine the power and status of those who assume positions of authority. This volume demonstrates that while the image of death as the great leveller may have powerful political and religious overtones, it is a far from accurate representation. Worldly inequalities are in no way levelled at the time of death but persist, permeating every aspect of death and dying. The timing, place, manner and social implications of an individual’s death are shaped by their social position in the society. Age, ethnicity, gender, social class and sexuality all profoundly affect the ways people experience death, dying and bereavement. Such forms of social differentiation should not be seen as fixed elements of a reified ‘society’ which bear down upon us in life and in death (West and Zimmerman 1991) for they are produced precisely through the ways in which we live our lives and encounter our deaths. Rather than being unaffected by them, differences and diversity in the manner and social implications of dying are both constituted by and constitutive of such social identities. This volume takes gender and ethnicity as its areas of interest but many of the chapters reveal the ways in which these are themselves cross-cut by other forms of social identity and social differentiation such as age and social class.

Introduction 1. Making Sense of Difference: Death, Gender and Ethnicity in Modern Britain David Field, Jenny Hockey and Neil Small 2. Death at the Beginning of Life Alice Lovell 3. 'Shoring up the Walls of Heartache': Parental Responses to the Death of a Child Gordon Riches and Pamela Dawson 4. Masculinity and Loss Neil Thompson 5. Women in Grief: Cultural Representation and Social Practice Jenny Hockey 6. Death and the Transformation of Gender in Image and Text Elizabeth Hallam 7. Beauty and the Beast: Sex and Death in the Tabloid Press Mike Pickering, Jane Littlewood and Tony Walter 8. Absent Minorities? Ethnicity and the Use of Palliative Care Services Chris Smaje and David Field 9. Culture is not Enough: A Critique of Multi-culturalism in Palliative Care Yasmin Gunaratnam 10. Death, Gender and Memory: Remembering Loss and Burial as a Migrant Gerdian Jonker 11. Death and Difference Neil Small Index

3. Costs of palliative care in the community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 3.1. Measuring costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 3.2. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 3.2.1. Analysis of service usage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 3.2.1.1. Primary and secondary care . . . . . . . . . . . . . . . . . . . . . . . . 73 3.2.1.2. Additional costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 3.2.2. Analysis of the cost of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 3.2.2.1. Cost of care by follow-up assessment . . . . . . . . . . . . . . . . . . . 75 3.2.2.2. Cost per week by subsequent assessment . . . . . . . . . . . . . . . . . 76 3.2.2.3. Costs by patient characteristics . . . . . . . . . . . . . . . . . . . . . . 76

On 1 December 1995, like 1 December for several previous years, I was with a group of people remembering those who have lived with and died from HIV-related illness. In my home city of Leeds we met in the Town Hall. There were more than a hundred people, many familiar faces, but some new. We heard people talking about their own life with the virus or about caring for people now dead. It was moving and tender: at times the spontaneity faltered but the sense of comradeship and of reverence did not. People spoke out loud the name of the one they loved. On display were sections of the Quilt, in which individuals are remembered but which also serves to illustrate how, when the sections are put together, the whole tells a further story than that told in the particular. We then moved outside on to the Town Hall steps. We carried candles, sang songs, ‘We are the World, We are the People …’ and released white balloons, one for each person from our region who had died — more balloons than you expected. The wind carried them towards and over the adjacent hospital and the ward where many of those deaths had occurred.

This chapter is concerned with the provision of palliative care. Palliative derives from the Latin word pallium, meaning a cloak or cover. In this context it refers to the provision of active care for a person whose condition is not responsive to curative treatment. A more developed definition is that palliative care is

In the spring of 1993 the UK succumbed to a new variation in the recurring scenario of ‘AIDS panics’. This panic related to the risk to their patients from HIV positive health workers. The panic was manifest in five settings — the media, the public, the professional, the political and finally in the lives of some individuals. In this paper I will introduce some details associated with this panic and specifically with the way it appeared to be understood by the various parties concerned.

Objective To describe and compare the distributions, including extent of missing data, in measures of socio-economic position (SEP) between women of white British and Pakistani ethnicity. We also compare distributions of measures of SEP between Pakistani women born in UK and those born in Pakistan and also compare distributions by the woman9s age at migration to the UK. Design The Born in Bradford birth cohort study recruits pregnant women at 26–28 weeks gestation when they complete a baseline questionnaire; approximately half these women are of Pakistani origin. Setting Bradford, UK. Participants Data are currently available for 2005 White British and 2444 Pakistani women. Main outcome measure Indicators of SEP included in these analyses are: the woman9s education and employment, her partner9s education and employment and household income. Results 57% of the Pakistani ethnicity women were born in Pakistan and there was a bimodal distribution of age at migration to the UK with peaks at ages 1 and 18 years. 92% of the White British women were, or had been, in paid employment compared to 51% of the Pakistani women. This figure was 82% for UK-born Pakistani women, 73% for those born in Pakistan who moved aged 5 or under and 22% for those who moved after the age of 5. Overall 23% of women reported that they didn9t know their family income; this varied by ethnicity and country of birth (8% for White British women, 21% for UK-born Pakistani women and 49% for those born in Pakistan). The percentage of women reporting an income of less than £20 000 was highest in Pakistani women, while the percentage of women reporting an income of £20 000 and over was highest for the White British women. 11% of White British women had no educational qualifications compared to 22% of Pakistani women; this figure was lowest for UK-born Pakistani women. The percentage of women with degree level education was higher in Pakistani than White British women (26% and 19%, respectively) and was similar for all Pakistani women irrespective of migration history. The percentage of women9s partners with no qualifications was similar between ethnic groups, however the percentage of partners with degree level education was higher for the Pakistani women. Conclusion These differences in the distributions of SEP measures by ethnicity and migration are important to understand health inequalities and for ensuring appropriate adjustment of SEP confounding.

Objective To assess the cost effectiveness of post-acute care for older people in a locality based community hospital compared with a department for care of elderly people in a district general hospital, which admits patients aged over 76 years with acute medical conditions. Design Cost effectiveness analysis within a randomised controlled trial. Setting Community hospital and district general hospital in Yorkshire, England. Participants 220 patients needing rehabilitation after an acute illness for which they required admission to hospital. Interventions Multidisciplinary care in the district general hospital or prompt transfer to the community hospital. Main outcome measures EuroQol EQ-5D scores transformed into quality adjusted life years (QALYs), and health and social service costs over six months from randomisation. Results The mean QALY score for the community hospital group was marginally non-significantly higher than that for the district general hospital group (0.38 v 0.35) at six months after recruitment. The mean (standard deviation) costs per patient of the health and social services resources used were similar for both groups: community hospital group £7233 (euros 10 567; $13 341) (£5031), district general hospital group £7351 (£6229), and these findings were robust to several sensitivity analyses. The incremental cost effectiveness ratio for community hospital care dominated. A cost effectiveness acceptability curve, based on bootstrapped simulations, suggests that at a willingness to pay threshold of £10 000 per QALY, 51% of community hospital cases will be cost effective, which rises to 53% of cases when the threshold is £30 000 per QALY. Conclusion Post-acute care for older people in a locality based community hospital is of similar cost effectiveness to that of an elderly care department in a district general hospital.

The phenomenon of violence towards social workers is examined using two complementary approaches. The first is a detailed description of the incidence of violence both in social work and more generally in society. The second is arz examination of changing practices in social work and a changing dynamic within society both of which will make social work more difficulet. My approach involves an interplay between specific observation and theoretical speculation and in so doing perhaps raises as many questions as it seeks to answer Specifically it questions why issues become matters of public concern at par ticular points in time and also asks why some forms of violence are responded to differently than others.

Social Policy responses to AIDS are much in accord with prevailing practice in other areas, the constructs used are typical of crime and disorder rather than illness and treatment. This article analyses the implications of this particularly as it relates to policy on prevention. It questions the value of using analytic frameworks evolved in identifying moral panics and suggest that homophibic and racist social policy responses to AIDS link with a prevailing construct of dangerousness. This argument is related to the impact of AIDS and responses to it on the distinction between the public and private world. Finally AIDS policy is located within an analysis of public expenditure and a consistent emphasis on a presentation of generosity hiding a pratice of parsimony is identified.

Neil Small, Lecturer in Social Work in the School of Applied Social Studies, Bradford University, is currently researching into the process of planning and decision making within a District Health Authority. Isobel Conlon is a group and individual psychotherapist with the Women's Counselling and Therapy Service in Leeds. She has previously worked in therapeutic communities and in two general practices in the north of England.

Aims: To explore the characteristics and views of the family carers of older people with heart failure. Method: 213 family carers of heart failure patients >60 years were recruited from UK general practitioner (GP) practices. Carer strain, quality of life (QOL) and service satisfaction questionnaires were completed every 3 months for 2 years, as well as 16 interviews with patients and carers, and 9 focus groups with health care professionals. Results: 76% of carers were female, 70% were >60 years and 73% were spousal carers. Predictors of carer strain were symptoms of depression, age and patient NYHA. Predictors of lower QOL were: spousal carer; 2+ health conditions and symptoms of depression. Qualitative findings related to the change in circumstances, impact of responsibilities and health conditions of the family carers. Conclusion: Carers were mainly older women, often experiencing multiple health conditions. Addressing the practical and emotional support required presents a challenge for specialist palliative care in responding to calls for increased involvement in heart failure. A shared care model with liaison between specialist heart failure nurses, cardiologists, primary care teams and hospice services is advocated.

We will describe four models used to understand dementia: as a neurological condition; as a neuro-psychiatric condition; as a normal part of ageing; and seeing dementia from a person-centred perspective. Adopting the last of these allows an engagement with palliative care that has the potential to enrich the end-of-life experience of people with dementia, of their families and of the professional care staff who work with them. In this article, it will be argued that our perceptions of what is possible for practising person-centred care at the end of life are constrained by the paradigms we work within. There is developing evidence about how approaches to end-of-life care for people with dementia can move beyond what was, at best, therapeutic pessimism and at worst ill-treatment towards something that optimizes the capacities of those with dementia and mobilizes imaginative care practice.

Objectives: To examine how people from Bradford's Pakistani Muslim community experience living with epilepsy. Specifically, the paper addresses social interactions and negotiations with care providers and considers how different understandings of epilepsy are integrated. Methods: Interviews were conducted with a sample of Bradford's Pakistani Muslim community ( n=20). Interviews were analysed to identify themes and significant areas of shared concern. Results: This paper identifies popular, professional and folk sectors contributing to an individual's `health system'. Where sectors overlap, zones of hybridity are created: that is, a person might simultaneously seek help from a doctor and from a religious healer, or might offer explanations for seizures that include neurological and spiritual components. Discussion: While there are many similarities between the experiences of these minority ethnic community members and published work on the lived experience of epilepsy in other communities, there are also important differences that service providers need to recognize and respond to. Differences include forms of cultural expression and specific language needs. Improving communication between professionals and persons with epilepsy needs to be prioritized.