RPP 17 2 Research Digest

Research Policy and Planning: The journal of the Social Services Research Group – Vol 17 (2) 1999

Research Digest

An open column intended to improve the dissemination of social services research. Contributions are welcome and should be sent to the Digest Editor

Resource allocation in primary care

Aims of research

North Derbyshire has one of the highest levels of fundholding in the country. At a relatively early stage it became apparent that funding levels varied widely across the authority largely as a result of historic budget setting methods. In 1995, the Health Authority established a General Practitioner group to bring forward proposals for a more equitable distribution of resources at practice level. The result was the ‘Equity Project’ which aims to redistribute hospital, community and prescribing resources on the basis of need rather than historical usage.

Method

Each practice received an equity position, calculated by comparing their actual and ‘fair share’ target spend, based on need. A practice whose spend was the same as their target would have a position of 100 per cent. Over target practices were encouraged to reduce expenditure and reach their target over a period of time assisted by:

  • an ‘equity disc’ containing comparative data on health needs, activity and finance;
  • a Clinical Information Facilitator who worked with the Medical Advisor and the Commissioning teams in helping practices to understand their position;
  • a series of practice visits, workshops and GP training sessions.

At the same time the principle was firmly established that under target practices should receive additional resources only if they could demonstrate unmet need and health gain. The equity position of practices was updated annually and a moving three year average position established to smooth out fluctuations. Two years ago practices agreed to share the information on the equity disc on a named basis, a major breakthrough in terms of openness and good practice.

Findings

A ‘fair’ share’ total resource allocation was set for all practices in 1998/9 which reflected a practice sensitive pace of change. Practices receive monthly statements on finance and activity, which also show a cumulative ‘equity position’ for the year. The Fundholder element was also set on equity principles and considerable progress was made in redistributing funds from over target practices. Key lessons were:

  • a practice sensitive approach is essential, ‘equity’ is not an exact science;
  • using detailed comparative information to understand the reasons for a practice’s position is crucial – over target does not always equate to bad practice;
  • practices require facilitation to understand the health needs of their patients;
  • making the link between providing a quality, evidence based service in primary care and subsequent use of
  • secondary care is important;
  • keeping GPS and their teams on board and involved in the decision making process is vital;
  • achieving a cross directorate approach in the Health Authority is vital;
  • ‘equity’ is a useful tool for all practices, regardless of position, to assess how they meet the needs of their
  • patients.

Availability/further information

For further information contact Cath Murray, North Derbyshire Health, Scarsdale, Newbold Road, Chesterfield S41 7PI` Tel: 01246 231255, ext. 4250

Life expectancy in residential care homes in the South West

Aims

The aim of the research, funded by the SSI, Department of Health, was to add to the existing knowledge about how long older people survive in residential settings and to complement the work being undertaken by the South West Regional Health Office looking at similar trends in nursing homes. This small study provides a ‘snapshot’ of how long older people survive after entering residential care.

Method

The study collected data from seven local authorities across the South West of England, Bath and North East Somerset (B&NES), Bristol, Dorset South Gloucestershire, Somerset, North Somerset and Wiltshire. All residential care homes in the South West were contacted and asked to provide details of any resident who died in their home during the period August 1st to October 31st, 1997. All local authority, voluntary, private and not-for-profit homes with more than four beds in the seven areas were included.

Findings

Of 675 residential homes contacted, 434 responded – an overall rate of 64%. There were 351 recorded deaths during the three month period (from 206 homes – an average of 1.7 deaths per home reporting a death). Most homes reporting a death had only one in the period, whilst some had as many as five. The majority of reported deaths were female residents (76%) and the average (mean) period of residence was 3.3 years. However, the length of time most people stay (median) was only 2.2 years. The average age at entry was 84.8 and at death 88.1. There were some noticeable differences in the figures for B&NES, where residents appeared to come into residential care between three and six years, and to die four to seven years, earlier than people in other counties. The B&NES sample, although very small, also shows the lowest average length of stay, at 2 years and 36 weeks.

Over 70% of people had survived for over one year in residential care and 39% for over three years. More than 65% had lived in their own homes before coming into homes and 54% were in local authority supported placements. 60% of the sample died at the home and 39% in hospital.

Availability/further information

For further information contact Louise Brown, Partnership Director, Dept of Social & Policy Sciences, University of Bath, Claverton Down, Bath, BA2 7AY. Tel: 01225 826949 E.mail: L.Brown@bath.ac.uk.

Out of School and into Trouble? Exclusion from school and persistent young offenders

Aims

The main aim of this exploratory study was to investigate and explore the nature of the association between school exclusion and persistent offending.

Method

A total of 495 juvenile offenders who made appearances at Havant Youth Court in 1997 were identified as the original population from which a sample of 44 individuals was chosen. These individuals were ‘persistent young offenders’. A number of sources were used to gather secondary data on the young people in the study, including court records, the police national computer, LEA admissions and exclusions files, educational welfare files and the social services client database. Of the 44 young offenders, ten individual case studies were selected for further investigation.

Findings

Schooling and educational difficulties were clearly a significant feature of the lives of the persistent young offenders in this study but the evidence collated did not support the claim that exclusion from school caused the onset of criminal behaviour. The evidence was inconclusive about whether exclusion from school led to increased criminal activity and the issue was identified as needing further in depth research.

Although school exclusion was associated with offending and an important predictor of offending behaviour, the evidence did not suggest that exclusion caused offending per se. Some young people appeared to have been excluded before they began to have records of offending and others began after. Many offences were committed outside the school term or day. Attendance issues and special educational needs were strongly associated with persistent young offenders. However, there were further indications that family based issues, as evidenced by time spent looked after by the local authority and child protection conferences were possibly more important in explaining the highest offending levels. This may have related to patterns of association when individuals lived in particular children’s homes and attended particular special schools. Thus the concentration of individuals with the same difficulties and vulnerabilities may have enhanced the possibilities of getting into further trouble.

Availability

For further details contact Carol Hayden at SSRIU, St George’s Building, 141 High Street, Portsmouth POI 2HY Tel: 023 9284 5550 Fax: 023 9284 5555 Email: ssriu@port.ac.uk

Risk assessment and management in multiagency, multi-professional care: education and practice

Aims

This study was designed to evaluate the educational preparation of nurses for the assessment and management of the risks associated with the support of vulnerable people in the community. It also sought to identify the significance of risk in the delivery of community based services. Decision making was identified as an important part of the management of risk and the research aimed to throw light on this process in the operation of multidisciplinary teams and in a variety of agency settings. To provide a balance, the views of practitioners and those involved in education were augmented by the views of users and carers. The project aimed to explore current educational preparation and also to provide a series of recommendations relevant to education and training providers and commissioners.

Methods

A variety of methods were used in this two year project. The first stage was a survey of 24 courses preparing nurses to work with vulnerable people with learning disabilities. A sample of courses was explored including those which were jointly provided for social workers. Course documentation was scrutinised and 72 individual and group interviews were conducted with 181 lecturers and students. To identify the significance of risk in practice the project needed to develop a strategy for capturing and analysing decisions and decision making about risk. This was done through an ethnographic approach, ‘capturing’ real decisions by shadowing or conducting participant observation in 9 multidisciplinary teams and by asking 26 individuals to keep diaries of decision making which were later analysed. Focus group material from six groups of users and carers was also gathered. All data was analysed and drawn together to form a final project report.

Findings

Risk was perceived as a central element of nursing in the community. Effective assessment and management of risk was seen as central to the effective support of vulnerable people. Half the nurses interviewed conceptualised risk as two interlinked elements: probability and consequence, while a significant proportion concentrated more on consequences and harm. The dominant definition of risk was ‘hazard’ although a minority viewed risk taking as providing opportunity or challenge. Some nurses identified risk as a matter of balance. There were differences according to the type of service users being worked with. Thus, within mental health services the emphasis was on risk as a threat. In work with older people the emphasis was on risk as balance, for example weighing the benefits of independence with the dangers of falling. In contrast, within learning disability services there was a greater emphasis on risk as opportunity, possibly related to the strong value base of normalisation within this area of work.

There was little evidence of systematic educational preparation. Only two courses had formal risk modules. In most courses risk was seen as something learned from personal and practice experience. The research team therefore recommended that risk assessment and management should be explicitly recognised in educational preparation. This should be linked to decision making and the development of competence. It pointed to nurses’ key role within multi-disciplinary teams and argued that further training in negotiation and advocacy would assist nurses in developing their participation in team work. Finally it pointed to nurses’ potential in developing communication skills and decision making skills among users and carers.

Availability

This research is published in summary and report form by the English National Board for Nursing, Midwifery and Health Visiting, 170 Tottenham Court Road, London Wl. Other work from the studies of risk from the University of Hull includes: Health, Risk and Welfare (eds. Alaszewski, Harrison and Manthorpe) and the journal Health, Risk and Society (pub. Carfax, Taylor and Francis). A book drawing on the project Managing Risk in Community Practice will be published by Balliere Tindall (early 2000) (eds. Alaszewski, Ayer and Manthorpe).