Comments on intergenerational report, 2002-2003

The Government's Intergenerational Report, tabled as one of a series of 2002 Federal Budget papers is the first in what may become a series of reports of this nature. Such a report is now required from time to time by the Government's Charter of Budget Honesty Act 1998 . The report (Table 13) highlights the concern that the future ageing of the Australian population may over-tax the workforce. So-called "demographic spending" on the part of the Commonwealth is predicted to rise from 13.9 percent of GDP in 2000 to 19.2 percent by 2041, a rise of just over five percentage points. This prediction is derived from baseline projections of demographic and economic trends. The impact of alternative demographic and economic scenarios is summarised in Table 15 of the report, with a downside of an additional two-and-a-quarter percentage points and an upside of a reduction in demographic spending of just under one -and-ahalf percentage points, relative to the baseline scenario. 1 The results of the report derive from the application of a complex model of future demography, future people-related federal outlays and future labour force trends, including labour productivity, labour force participation rates and unemployment. Clearly, over a 40-year period, there are substantial possibilities for variation in these trends. In general, we conclude that the report is conservative in its assumptions about possible variations as only relatively small variations from recent trends are tested. Future trends in all of the parameters of the model are based upon some form of extrapolation of past time trends. This means that what is presented is a projection of what will happen if demographic, health and economic trends and government policies remain much the same as they have been in the past. This approach is taken despite the fact that the report itself calls for policy initiatives such as encouraging mature-age employment that would lead to changes in the assumed parameters. It is our view that there is a range of possible policy initiatives that could significantly alter the assumptions of the model. These are discussed below. It is important also to realise that the outcome addressed by the report is the balance of Federal revenues and expenditure. The report does not deal with State and Territory budgets or with household budgets. However, given the cumulative impact of the productivity growth that is assumed in the report, output per worker doubles in the 40-year period and, accordingly, households would have considerably higher real incomes. Also, as the costs of children are primarily private costs rather than public costs, households on average would have lower child -related costs as the ratio of children to workers falls. If the sizeable real increase in household incomes leads to higher consumption expenditure, as is likely, then GST revenue would increase commensurately. The report, therefore, draws a picture of ageing leading to severe pressure on the Federal budget while the living standards of Australian households, including households of aged persons, and State revenues increase substantially. This distributional issue is a matter we think should have been addressed more explicitly in the report. While all of the major assumptions of the model are provided in the report, the workings of the model and numerous minor assumptions are not made explicit. This means that we are only in a position to make broad comments on the outcomes. We are not in a position to re-run the model with different assumptions. The assessment method we use, a proportional approach, is described in the following section

Boundary-Work and the Distribution of Care for Survivors of Domestic Violence and Abuse in Primary Care Settings:Perspectives From U.K. Clinicians

Health care encounters are opportunities for primary care practitioners to identify women experiencing domestic violence and abuse (DVA). Increasing DVA support in primary care is a global policy priority but discussion about DVA during consultations remains rare. This article explores how primary care teams in the United Kingdom negotiate the boundaries of their responsibilities for providing DVA support. In-depth interviews were undertaken with 13 general practitioners (GPs) in two urban areas of the United Kingdom. Interviews were analyzed thematically. Analysis focused on the boundary practices participants undertook to establish their professional remit regarding abuse. GPs maintained permeable boundaries with specialist DVA support services. This enabled ongoing negotiation of the role played by clinicians in identifying DVA. This permeability was achieved by limiting the boundaries of the GP role in the care of patients with DVA to identification, with the work of providing support distributed to local specialist DVA agencies

Generational perspective on asthma self-management in the Bangladeshi and Pakistani community in the United Kingdom: A qualitative study

BACKGROUND: Self‐management strategies improve asthma outcomes, although interventions for South Asian populations have been less effective than in White populations. Both self‐management and culture are dynamic, and factors such as acculturation and generation have not always been adequately reflected in existing cultural interventions. We aimed to explore the perspectives of Bangladeshi and Pakistani people in the United Kingdom, across multiple generations (first, second and third/fourth), on how they self‐manage their asthma, with a view to suggesting recommendations for cultural interventions. METHODS: We purposively recruited Bangladeshi and Pakistani participants, with an active diagnosis of asthma from healthcare settings. Semi‐structured interviews in the participants' choice of language (English, Sylheti, Standard Bengali or Urdu) were conducted, and data were analysed thematically. RESULTS: Twenty‐seven participants (13 Bangladeshi and 14 Pakistani) were interviewed. There were generational differences in self‐management, influenced by complex cultural processes experienced by South Asians as part of being an ethnic minority group. Individuals from the first generation used self‐management strategies congruent to traditional beliefs such as ‘sweating’ and often chose to travel to South Asian countries. Generations born and raised in the United Kingdom learnt and experimented with self‐management based on their fused identities and modified their approach depending on whether they were in familial or peer settings. Acculturative stress, which was typically higher in first generations who had migration‐related stressors, influenced the priority given to asthma self‐management throughout generations. The amount and type of available asthma information as well as social discussions within the community and with healthcare professionals also shaped asthma self‐management. CONCLUSIONS: Recognizing cultural diversity and its influence of asthma self‐management can help develop effective interventions tailored to the lives of South Asian people. PATIENT OR PUBLIC CONTRIBUTION: Patient and Public Involvement colleagues were consulted throughout to ensure that the study and its materials were fit for purpose

Modes of Interaction in Naturally Occurring Medical Encounters with General Practitioners: The ´One in a Million´ Study

In this article, we qualitatively explore the manner and style in which medical encounters between patients and general practitioners (GPs) are mutually conducted, as exhibited in situ in 10 consultations sourced from the One in a Million: Primary Care Consultations Archive in England. Our main objectives are to identify interactional modes, to develop a classification of these modes, and to uncover how modes emerge and shift both within and between consultations. Deploying an interactional perspective and a thematic and narrative analysis of consultation transcripts, we identified five distinctive interactional modes: question and answer (Q&A) mode, lecture mode, probabilistic mode, competition mode, and narrative mode. Most modes are GP-led. Mode shifts within consultations generally map on to the chronology of the medical encounter. Patient-led narrative modes are initiated by patients themselves, which demonstrates agency. Our classification of modes derives from complete naturally occurring consultations, covering a wide range of symptoms, and may have general applicability

‘I’d best take out life insurance, then.’ Conceptualisations of risk and uncertainty in primary care consultations, and implications for shared decision-making

The main objective of this study is to gain knowledge about interactional factors that support and obstruct mutual risk-assessments and shared decision-making (SDM) in clinical consultations. Through a narrative analysis of verbatim tran- scripts of 28 naturally occurring consultations performed in English National Health Service practices, we explore the ways in which patients and general practitioners conceptualise, construct and negotiate risks related to diagnostic tests and medical treatments. Consultations were sampled from a corpus of 212 consultation transcripts from the One in a Million: Primary care consultations archive on the basis that they contained the word ‘risk(s)’. Most sampled cases relate to cardiovascular conditions and cancer. Drawing on a social constructionist perspective and the relational theory of risk, we found that while GPs talked about mathematical-probabilistic population risk, patients expressed their own experiences of possible future dangers, conceptualised through words like ‘worried’, ‘scared’ and ‘concerned’. Risk objects, defined here as entities to which harmful consequences are conceptually attached, were constructed differently by patients and GPs, especially in relation to cardiovascular risks. Their different rationalities sometimes obstructed any form of mutual risk-assessments. The relational theory of risk proved to be a useful theoretical frame for exploring layers and configurations of risk constructions among patients and clinicians, and for capturing interactional factors that support and obstruct mutual risk-assessments and SDM. For patients to be able to engage in genuine dialogues and make informed decisions about their care, it is paramount for patients and doctors to co-construct patients’ health-risks during clinical encounters

CMakeCatchTemplate: A C++ template project

CMakeCatchTemplate (https://github.com/MattClarkson/CMakeCatchTemplate) is a project to provide a starting structure for C++ projects configured with CMake, that can be customised to work in a variety of scenarios, allowing developers to deploy new algorithms to users in a shorter timeframe. Main features include a SuperBuild to build optional dependencies; unit tests using Catch; support for CUDA, OpenMP and MPI; examples of command line and GUI applications; Doxygen integration; Continuous Integration templates and support for building/deploying Python modules

Process evaluation for complex interventions in primary care: understanding trials using the normalization process model

Background: the Normalization Process Model is a conceptual tool intended to assist in understanding the factors that affect implementation processes in clinical trials and other evaluations of complex interventions. It focuses on the ways that the implementation of complex interventions is shaped by problems of workability and integration.Method: in this paper the model is applied to two different complex trials: (i) the delivery of problem solving therapies for psychosocial distress, and (ii) the delivery of nurse-led clinics for heart failure treatment in primary care.Results: application of the model shows how process evaluations need to focus on more than the immediate contexts in which trial outcomes are generated. Problems relating to intervention workability and integration also need to be understood. The model may be used effectively to explain the implementation process in trials of complex interventions.Conclusion: the model invites evaluators to attend equally to considering how a complex intervention interacts with existing patterns of service organization, professional practice, and professional-patient interaction. The justification for this may be found in the abundance of reports of clinical effectiveness for interventions that have little hope of being implemented in real healthcare setting

Help Seeking and Access to Primary Care for People from “Hard-to-Reach” Groups with Common Mental Health Problems

Background. In the UK, most people with mental health problems are managed in primary care. However, many individuals in need of help are not able to access care, either because it is not available, or because the individual's interaction with care-givers deters or diverts help-seeking. Aims. To understand the experience of seeking care for distress from the perspective of potential patients from “hard-to-reach” groups. Methods. A qualitative study using semi-structured interviews, analysed using a thematic framework. Results. Access to primary care is problematic in four main areas: how distress is conceptualised by individuals, the decision to seek help, barriers to help-seeking, and navigating and negotiating services. Conclusion. There are complex reasons why people from “hard-to-reach” groups may not conceptualise their distress as a biomedical problem. In addition, there are particular barriers to accessing primary care when distress is recognised by the person and help-seeking is attempted. We suggest how primary care could be more accessible to people from “hard-to-reach” groups including the need to offer a flexible, non-biomedical response to distress

Re-ordering connections: UK healthcare workers' experiences of emotion management during the COVID-19 pandemic

This paper examines the impact of disruptions to the organisation and delivery of healthcare services and efforts to re-order care through emotion management during the COVID-19 pandemic in the UK. Framing care as an affective practice, studying healthcare workers' (HCWs) experiences enables better understanding of how interactions between staff, patients and families changed as a result of the pandemic. Using a rapid qualitative research methodology, we conducted interviews with frontline HCWs in two London hospitals during the peak of the first wave of the pandemic and sourced public accounts of HCWs' experiences of the pandemic from social media (YouTube and Twitter). We conducted framework analysis to identify key factors disrupting caring interactions. Fear of infection and the barriers of physical distancing acted to separate staff from patients and families, requiring new affective practices to repair connections. Witnessing suffering was distressing for staff, and providing a 'good death' for patients and communicating care to families was harder. In addition to caring for patients and families, HCWs cared for each other. Infection control measures were important for limiting the spread of COVID-19 but disrupted connections that were integral to care, generating new work to re-order interactions

SnappySonic: An Ultrasound Acquisition Replay Simulator

SnappySonic provides an ultrasound acquisition replay simulator designed for public engagement and training. It provides a simple interface to allow users to experience ultrasound acquisition without the need for specialist hardware or acoustically compatible phantoms. The software is implemented in Python, built on top of a set of open source Python modules targeted at surgical innovation. The library has high potential for reuse, most obviously for those who want to simulate ultrasound acquisition, but it could also be used as a user interface for displaying high dimensional images or video data