Austerity and the shaping of the ‘waste watching’ health professional: A governmentality perspective on integrated care policy

Discussion related to the boundary between health and social care has existed in the United Kingdom (UK) since the inception of the English National Health Service (NHS), with successive governments outlining a desire to ‘integrate’ care. Globally, high-income, and low- and middle-income countries, are increasingly advocating integrated care (IC) as a solution to financial and quality issues. Recent research has argued that IC policy works discursively to manage tensions between competing policy aims, facilitating the continuation of austerity measures and the fragmentation of health and social care services. This paper extends this debate by moving beyond the discursive realisation of IC policy in official governmental texts to instead investigate its reception among practitioners ‘on the ground’. By complementing the perspective of governmentality with Fairclough's (2008) Dialectical Relational Approach (DRA), our paper exposes shifting articulations and enactments of IC policy discourse as it moves through implementation in a community based integrated care service (CBIC) in England. Faced with the material reality of funding cuts to the service, integrated care is reformulated from ‘transformational change’ to the responsibilisation of ‘ideal integrated workers’ tasked with eliminating ‘waste’. Whilst frontline staff strongly resisted these subjectivities, they were ultimately subject to the harmful material effects of austerity politics with little in the way of positive change for patient care

Adult social care research and practice collaboration evidence synthesis

This document was produced based on the POSTnote approach (please see here for more information) to synthesising academic literature and stakeholder insights on a topical issue within policy and practice. This document was written by Hannah Kendrick (Care Policy and Evaluation Centre, LSE) with support from Juliette Malley (Care Policy and Evaluation Centre, LSE) and Annette Boaz (King’s College London) – members of the Creating Care Partnerships project. The intention was to develop a resource on behalf of the adult social care partnership community as a whole and so draws on a wide range of insights and expertise from all contributors (names & affiliations listed on p. 27 of the document). The document draws on studies funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research Programme (Grant Reference Numbers: NIHR31335, NIHR131373, NIHR131345, NIHR 131358, NIHR13110, NIHR133629). The views expressed in this document do not necessarily reflect the views of the NIHR or the Department of Health and Social Care

Integrated care policy implementation in England: A case study of a community based integrated care service

Discussion relating to the boundary between health and social care has existed since the inception of the NHS, with successive governments proclaiming the desire to ‘integrate’ care. This thesis draws on data collected from a case study community based integrated care service (CBIC), to explore the relationship between the macro level political environment governing health and social care integration in England, and the micro level managerial and organisational practice shaped and enacted within this context. Data collection took place between April 2017 and April 2019, using textual analysis, qualitative interviews and participant and non-participant observation. The methodological approach developed in this thesis integrates Fairclough’s Dialectical Relational Approach to Critical Discourse Analysis and Realist Evaluation, as a means to connect integrated care policy discourse with its enactment and operationalisation at the level of practice, within a critical realist ontological and epistemological position. Previous research has argued that integrated care policy works as a discourse to manage tensions between competing policy aims and to allow the continuation of austerity and fragmented health and social care services. Moving beyond its linguistic realisation within government policy texts, this thesis demonstrates how this discourse was put to work through implementation by actively shaping the materiality, managerial practices, and subjectivity of actors to mobilise neo-liberal economic austerity. Specifically, the resource pressure within the CBIC had a socially structuring effect on how the managerial, organisational, and technological resources sought to shape the subject positions of both health professionals and patients through the lens of ‘waste watching’, when attempting to implement integrated care. This had a dislodging effect on concerns for improvements in patient experience and resulted in work intensification, stress, and lost application of skill for staff

Agent-Based Models of the Green Dot Bystander Violence Prevention Program on College Campuses

Despite the hard work of a diverse collection of organizations committed to violence prevention, the prevalence of rape, abuse, and other forms of interpersonal violence remains startling, especially on college campuses. Here we present an agent-based model (ABM) of interpersonal violence rooted in the philosophy of the Green Dot Bystander Training Program, in the hopes of providing insight into ways in which training of students can be improved so that intervention attempts are more effective. Two models, with and without adaptive behaviors, are studied under two population sizes. Through sensitivity testing, various outcomes are analyzed to measure the effectiveness of each intervention strategy. The scenarios that result in the smallest relative number of violent acts are those with a denser population, while the adaptive models produce unexpected results that prompt questions about human behavior and our tendency toward bystander intervention

Identification and characterisation of Staphylococcus aureus on low cost screen printed carbon electrodes using impedance spectroscopy

Staphylococcus aureus infections are a cause of significant morbidity and mortality, in addition to representing a considerable economic burden. The aim of this study was to explore a low cost screen printed electrode as a sensor for the detection of S. aureus using impedance spectroscopy. S. aureus was incubated in chambers containing the electrodes and the results analysed using a novel normalisation approach. These results show that it is possible to detect the presence of S. aureus in LB media after 30 minutes incubation of a 1% growth culture, in addition to being able to see immediate cell concentration dependent changes in 0.9% NaCl. These observations imply that a number of electrochemical mechanisms cause a change in the impedance as a result of the presence of S. aureus, including adsorption to the electrode surface and the metabolism of the bacteria during growth. The study suggests that this detection approach would be useful in a number of clinical scenarios where S. aureus leads to difficult to treat infections

Exercise for reducing fear of falling in older people living in the community: Cochrane systematic review and meta-analysis

Objective: To determine the effect of exercise interventions on fear of falling in community-living people aged ≥65 years. Design: Systematic review and meta-analysis. Bibliographic databases, trial registers and other sources were searched for randomised or quasi-randomised trials. Data were independently extracted by pairs of reviewers using a standard form. Results: Thirty trials (2878 participants) reported 36 interventions (Tai Chi and yoga (n=9); balance training (n=19); strength and resistance training (n=8)). The risk of bias was low in few trials. Most studies were from high income countries (Australia=8, USA=7). Intervention periods (26 weeks=7) and exercise frequency (1-3 times/week=32; ≥4 times/week=4) varied between studies. Fear of falling was measured by single-item questions (7) and scales measuring falls efficacy (14), balance confidence (9) and concern or worry about falling (2). Meta-analyses showed a small to moderate effect of exercise interventions on reducing fear of falling immediately post intervention (standardised mean difference (SMD) 0.37, 95% CI 0.18, 0.56; 24 studies; low quality evidence). There was a small, but not statistically significant effect in the longer term (<6 months (SMD 0.17, 95% CI -0.05, 0.38 (four studies) and ≥ 6 months post intervention SMD 0.20, 95% CI -0.01, 0.41 (three studies)). Conclusions: Exercise interventions probably reduce fear of falling to a small to moderate degree immediately post-intervention in community-living older people. The high risk of bias in most included trials suggests findings should be interpreted with caution. High quality trials are needed to strengthen the evidence base in this area