Communicating Stuff: The Intercultural Rhizome

"A rhizome has no beginning or end; it is always in the middle, between things, interbeing, intermezzo. The tree is filiation, but the rhizome is alliance, uniquely alliance. The tree poses the verb 'to be', but the fabric of the rhizome is the conjunction, 'and ... and ... and'." (Gilles Deleuze and Felix Guattari, "A Thousand Plateaus," 1980

Identifying options for funding the NHS and social care in the UK: international evidence

We investigate how other high-income countries have thought about and implemented changes to their funding systems for health and social care to better meet the challenges ahead. This paper is part of a broader project funded by the Health Foundation, which aims to identify a range of feasible options for the future funding of health and social care in the four countries of the UK, and assess the relative (un-)attractiveness of different funding approaches to the general public. The research reported here examines trends and innovations in health and social care funding in a selection of high-income countries. We focus on where the money to pay for care comes from, not on how it is then spent. Drawing on a review of the literature and interviews with 30 key informants in a range of high-income countries, we explore current thinking on the options for funding health care and social care. Our aim is to add to the evidence base and improve the quality of the debate, rather than make recommendations. Specifically, we: • provide examples of funding configurations for health and social care, as well as changes that have been implemented, or are being considered, in a range of high income countries • explore the drivers of recent or planned health and social care funding changes and reforms and the contexts within which decisions around funding were taken • highlight key points that can inform the range of conceivable options for funding health care and social care in the four countries of the UK. Overall we find that: • most reviewed countries fund health care primarily from public sources, such as taxation and mandatory health insurance, while social care often relies to a comparatively greater extent on individuals paying privately • health and social care funding reforms tend to be incremental rather than radical, are path-dependent, and are catalysed by changes in economic conditions rather than by rising demand for care • high-income countries have taken diverse approaches to tackling the need to increase health and social care funding and there is no single optimal, or commonly preferred, solution to achieving sustainable revenues

Language choice of the Foochows in Sarawak, Malaysia

This paper investigates the factors affecting the language choices of the Chinese Foochows of Sarawak, focusing in particular on how the use of the Foochow dialect vis-a`-vis English and other languages might potentially result in a shift in language allegiance away from Foochow. In the context of Sarawak, the Foochows are a substantial, cohesive and homogeneous Chinese ethnic group with a distinctive language and ethnic identity. One would predict that they would engage in extensive language maintenance behaviour. Instead, Foochows living in non-Foochow dominant areas do not seem to have sufficient attachment to the language to transmit it to the next generation. Is this because the Foochows consider that accommodating to communicative norms is more important than preserving their native language as an inherent symbol of their ethnic identity? Or is it the result of the Foochows’ insecurity about the prestige of the dialect and the status of the Foochow people? These issues of accommodation and language allegiance are discussed, based on interview and questionnaire data from 11 Foochow participants. This data set is part of a larger study on the language use of different ethnic groups in multilingual organisational settings in Sarawak

Do reviews of healthcare interventions teach us how to improve healthcare systems?

Planners, managers and policy makers in modern health services are not without ingenuity e they will always try, try and try again. They face deep-seated or ‘wicked’ problems, which have complex roots in the labyrinthine structures though which healthcare is delivered. Accordingly, the interventions devised to deal with such stubborn problems usually come in the plural. Many different reforms are devised to deal with a particular stumbling block, which may be implemented sequentially, simultaneously or whenever policy fashion or funding dictates. This paper examines this predicament from the perspective of evidence based policy. How might researchers go about reviewing the evidence when they are faced with multiple or indeed competing interventions addressing the same problem? In the face of this plight a rather unheralded form of research synthesis has emerged, namely the ‘typological review’. We critically review the fortunes of this strategy. Separating the putative reforms into series of subtypes and producing a scorecard of their outcomes has the unintended effect of divorcing them all from an understanding of how organisations change. A more fruitful approach may lie in a ‘theory-driven review’ underpinned by an understanding of dynamics of social change in complex organisations. We test this thesis by examining the primary and secondary research on the many interventions designed to tackle a particularly wicked problem, namely the inexorable rise in demand for healthcare

Effect of aliskiren on post-discharge outcomes among diabetic and non-diabetic patients hospitalized for heart failure: insights from the ASTRONAUT trial

Aims The objective of the Aliskiren Trial on Acute Heart Failure Outcomes (ASTRONAUT) was to determine whether aliskiren, a direct renin inhibitor, would improve post-discharge outcomes in patients with hospitalization for heart failure (HHF) with reduced ejection fraction. Pre-specified subgroup analyses suggested potential heterogeneity in post-discharge outcomes with aliskiren in patients with and without baseline diabetes mellitus (DM). Methods and results ASTRONAUT included 953 patients without DM (aliskiren 489; placebo 464) and 662 patients with DM (aliskiren 319; placebo 343) (as reported by study investigators). Study endpoints included the first occurrence of cardiovascular death or HHF within 6 and 12 months, all-cause death within 6 and 12 months, and change from baseline in N-terminal pro-B-type natriuretic peptide (NT-proBNP) at 1, 6, and 12 months. Data regarding risk of hyperkalaemia, renal impairment, and hypotension, and changes in additional serum biomarkers were collected. The effect of aliskiren on cardiovascular death or HHF within 6 months (primary endpoint) did not significantly differ by baseline DM status (P = 0.08 for interaction), but reached statistical significance at 12 months (non-DM: HR: 0.80, 95% CI: 0.64-0.99; DM: HR: 1.16, 95% CI: 0.91-1.47; P = 0.03 for interaction). Risk of 12-month all-cause death with aliskiren significantly differed by the presence of baseline DM (non-DM: HR: 0.69, 95% CI: 0.50-0.94; DM: HR: 1.64, 95% CI: 1.15-2.33; P < 0.01 for interaction). Among non-diabetics, aliskiren significantly reduced NT-proBNP through 6 months and plasma troponin I and aldosterone through 12 months, as compared to placebo. Among diabetic patients, aliskiren reduced plasma troponin I and aldosterone relative to placebo through 1 month only. There was a trend towards differing risk of post-baseline potassium ≥6 mmol/L with aliskiren by underlying DM status (non-DM: HR: 1.17, 95% CI: 0.71-1.93; DM: HR: 2.39, 95% CI: 1.30-4.42; P = 0.07 for interaction). Conclusion This pre-specified subgroup analysis from the ASTRONAUT trial generates the hypothesis that the addition of aliskiren to standard HHF therapy in non-diabetic patients is generally well-tolerated and improves post-discharge outcomes and biomarker profiles. In contrast, diabetic patients receiving aliskiren appear to have worse post-discharge outcomes. Future prospective investigations are needed to confirm potential benefits of renin inhibition in a large cohort of HHF patients without D

Towards improved decision support in the assessment and management of pain for people with dementia in hospital: a systematic meta-review and observational study

BackgroundPain and dementia are common in older people, and impaired cognitive abilities make it difficult for them to communicate their pain. Pain, if poorly managed, impairs health and well-being. Accurate pain assessment in this vulnerable group is challenging for hospital staff, but essential for appropriate management. Robust methods for identifying, assessing and managing pain are needed.Aims and objectivesTwo studies were undertaken to inform the development of a decision support tool to aid hospital staff in the recognition, assessment and management of pain. The first was a meta-review of systematic reviews of observational pain assessment instruments with three objectives: (1) to identify the tools available to assess pain in adults with dementia; (2) to identify in which settings they were used and with what patient populations; and (3) to assess their reliability, validity and clinical utility. The second was a multisite observational study in hospitals with four objectives: (1) to identify information currently used by clinicians when detecting and managing pain in patients with dementia; (2) to explore existing processes for detecting and managing pain in these patients; (3) to identify the role (actual/potential) of carers in this process; and (4) to explore the organisational context in which health professionals operate. Findings also informed development of health economics data collection forms to evaluate the implementation of a new decision support intervention in hospitals.MethodsFor the meta-review of systematic reviews, 12 databases were searched. Reviews of observational pain assessment instruments that provided psychometric data were included. Papers were quality assessed and data combined using narrative synthesis. The observational study used an ethnographic approach in 11 wards in four UK hospitals. This included non-participant observation of 31 patients, audits of patient records, semistructured interviews with 52 staff and four carers, informal conversations with staff and carers and analysis of ward documents and policies. Thematic analysis of the data was undertaken by the project team.ResultsData from eight systematic reviews including 28 tools were included in the meta-review. Most tools showed moderate to good reliability, but information about validity, feasibility and clinical utility was scarce. The observational study showed complex ward cultures and routines, with variations in time spent with patients, communication patterns and management practices. Carer involvement was rare. No pain decision support tools were observed in practice. Information about pain was elicited in different ways, at different times, by different health-care staff and recorded in separate documents. Individual staff made sense of patients’ pain by creating their own ‘overall picture’ from available information.LimitationsGrey literature and non-English-language papers were excluded from the meta-review. Sample sizes in the observational study were smaller than planned owing to poor documentation of patients’ dementia diagnoses, gatekeeping by staff and difficulties in gaining consent/assent. Many patients had no or geographically distant carers, or a spouse who was too unwell and/or reluctant to participate.ConclusionsNo single observational pain scale was clearly superior to any other. The traditional linear concept of pain being assessed, treated and reassessed by single individuals did not ‘fit’ with clinical reality. A new approach enabling effective communication among patients, carers and staff, centralised recording of pain-related information, and an extended range of pain management interventions is proposed [Pain And Dementia Decision Support (PADDS)]. This was not tested with users, but a follow-on study aims to codesign PADDS with carers and clinicians, then introduce education on staff/patient/carer communications and use of PADDS within a structured implementation plan. PADDS will need to be tested in differing ward contexts

Describing placebo phenomena in medicine: a linguistic approach

The present paper reviews how language and communication are used to describe placebo phenomena in medicine, with particular reference at key points to the question of pain. Selected aspects of placebo language are submitted to lexical, grammatical and semantic analysis. We distinguish three uses of placebo, with three semantic components: “pleasing,” inert medication or procedure, and what is often called “deception.” The three uses of placebo are: PLACEBO-TREATMENT, which combines all three semantic components: “pleasing” patients with inert treatments, and possibly with “deception.” PLACEBO-TRIAL, which refers to the closely defined inert control in Randomized Controlled Trials. PLACEBO-RAPPORT, which covers all aspects of the health care encounter, excluding therapeutic interventions, but including psychosocial factors which can have a beneficial effect on the patient. Three key conclusions emerge from this analysis. First, the “deception” connotation of placebo found in PLACEBO-TREATMENT can contaminate the use of PLACEBO-TRIAL and especially PLACEBO-RAPPORT. Second, the enlarged “pleasing” framework of PLACEBO-RAPPORT, which includes the benefits of quality appropriate and helpful medical care, forces us to ask whether PLACEBO-TRIAL in Randomized Controlled Trials has in fact been a neutral baseline control. Biopsychosocial and other factors in PLACEBO-RAPPORT may have influenced the outcomes of many trials in medicine and pharmacology. And third, extending PLACEBO-RAPPORT to embrace all aspects of clinical care (except specific medication or procedural interventions) and psychosocial factors of the health care encounter engages patient beliefs, mindsets and interpersonal dynamics, as well as values and contextual and cultural issues. These take PLACEBO-RAPPORT substantially beyond what is currently seen as its identity and modes of operation