Genetics After the Act: A Specialist Health Service Amid NHS Reform

This article considers the impact of the recent reform of the National Health Service (NHS) on specialist regional health services. A case study of medical genetic services is presented to highlight some problems arising from the implementation of the 1990 NHS and Community Care Act. New financial arrangements introduced by the Act have led many regional health authorities to devolve the finance and organization of specialist health services to districts. The introduction of competition and devolved budgets may pose especial problems for some specialist health services. In the case of genetic services these difficulties are exacerbated by new pricing rules. The paper explores these issues and suggests that the imposition of the market model on health care overlooks some vital, human elements which do not fit neatly into such a model.     

Inter‐agency joint protocols for safeguarding children in social care and adult mental‐health agencies: a cross‐sectional survey of practitioner experiences

Parental mental illness, substance misuse and domestic violence are common risk factors for the maltreatment and neglect of children. Safeguarding children is everyone's responsibility, including professionals working primarily with adults. In the UK, Local Safeguarding Children Boards (LSCBs) were established to ensure that all agencies work together to safeguard children. Many LSCBs developed multi‐agency joint protocols to enhance collaboration, but there is limited evidence of their effectiveness. This paper reports findings from a cross‐sectional survey of practitioner self‐reported experiences of joint protocols, which was conducted in one inner London borough, to evaluate their impact on professional practice. A self‐complete questionnaire administered to all professionals in adult mental‐health and children's social care services in the borough yielded a response from 119 practitioners. The survey found that the protocols had been widely disseminated and provided clear guidance to practitioners. Practitioners perceived that they had increased awareness of the risk factors for safeguarding children and some had used the protocols to help them gain access to services for their clients. Practitioners also perceived that they had improved inter‐agency working between children's social care and adult mental‐health services. However, respondents indicated that positive interpersonal contact with practitioners from other agencies was equally important in promoting joint working and inter‐agency collaboration.     

Child Poverty in Northern Ireland: The Limits of Welfare-to-Work Policies

Levels of child poverty in Northern Ireland are high; 32 per cent of children live in households whose only income derives from benefits, compared with 19 per cent of children in Britain living in families totally dependent on benefits. Unemployment, low pay, a higher cost of living, low levels of public services, including childcare and support services for people with disabilities, slightly larger families and a lack of access by poorer women to the means of limiting their family size, together with even greater levels of inequality than in Britain, all contribute to the high levels of child poverty in Northern Ireland. This paper argues that even the less ambitious child poverty targets announced by the Department of Work and Pensions at the end of 2003 will not be met unless there is a fundamental change in the government's approach. In particular, evidence from Northern Ireland suggests that its insistence on work as the primary—if not only—route out of poverty will not lead to a radical reduction in levels of child poverty.     

Practitioners preferences of care coordination for older people: A discrete choice experiment

These findings demonstrate the importance of organisations providing care coordination for older people receiving long-term funding. Further research is required to investigate the influence of service setting on practitioner preferences.

This study explored practitioner preferences about the relative value of attributes of care coordination services for older people. A Discrete Choice Experiment (DCE) survey was used to identify the views of 120 practitioners from 17 services in England in 2015. The survey design was informed by an analysis of standards of care coordination, a postal survey and a consultation with carers of older people. Results of the DCE survey were supplemented by a content analysis of qualitative comments and fieldwork notes. Most respondents were over 30 years of age, female and almost half worked part-time. Continuity of care (care provided by the same care coordinator) and the ability to access the range of services outlined in the care plan were the most important service attributes. Service setting influenced practitioner preferences. Those in specialist services for people with dementia identified the length of time a service was provided as another important attribute. The DCE methodology has provided the opportunity to systematically canvas practitioner preferences.     

Social Participation and Family Welfare: The Money and Time Costs of Leisure in Australia

The concept of social exclusion has become a central organizing concept in social policy research. Indeed "social exclusion" has displaced many of the terms formerly in use, such as "inequality", "deprivation" and "poverty". Social exclusion is a multidimensional concept embracing economic, social and political deprivations, that alerts us to the significance of social identity, culture, agency and, ultimately, power relations. In contrast to some earlier research traditions, the perspective of social exclusion draws our attention to how people can be "shut out of society" by their inability to participate in customary leisure activities. The ability to participate in leisure is the product of both access to leisure goods and services, and a sufficient quantity of leisure time. An analysis of Australian Household Expenditure Survey data shows that the consumption of leisure goods and services is powerfully determined by income. Consequently, low income can lead to exclusion from leisure participation. However, analysis of Time Use Survey data also shows that access to time for leisure participation is most powerfully determined by hours of employment, family responsibilities and gender. After controlling for working hours, household income has no significant effect on available leisure time. A leisure-time poverty line, based on half-median leisure time, is used to show which groups are most excluded from leisure by time constraints. The paper concludes by considering a range of policies to alleviate social exclusion from leisure participation.     

Making Sen’s capability approach operational: a random scale framework

Amartya Sen has developed the so-called capability approach to meet the criticism that income alone may be insufficient as a measure of economic inequality. This is because knowledge about people’s income does not tell us what they are able to acquire with that income. For example, people with the same income may not have the same access to health and transportation services, schools and opportunities in the labor market. Recently, there has been growing interest in empirical studies based on the capability approach. Most of these, however, are only loosely related to quantitative behavioral theory, at least in a concrete and empirically operational way. The purpose of this paper is to demonstrate that the theory of random scale (utility) models offers a powerful theoretical and empirical framework for representing and accounting for key aspects of Sen’s theory.     

The attitudes and beliefs of the child protection workforce and why they matter to children who live with violence

In Australia, like other developed countries, there has been an increase in reports to child protection services about children experiencing domestic violence. While there is research on the importance of the skills and knowledge of the child protection workforce for this growing problem, little is available about practitioner attitudes and beliefs. This paper presents findings on research undertaken in New South Wales, which is the most populated state in Australia. The research considered the attitudes and beliefs of the statutory child protection workforce about domestic violence. It relied on a large-scale survey of 1041 child protection practitioners. In order to compare the attitudes and beliefs of child protection workforce with those of the general community, the survey replicated questions from the Australian National Community Attitudes towards Violence against Women Surveys. Overall, the attitudes and beliefs of the workforce more closely reflected contemporary theory and evidence about domestic violence than those of the community. The research also examined variations in the attitudes and beliefs of the child protection workforce according to practitioner characteristics, finding variations by gender. The implications for the fields of child protection and social work are discussed.     

Reconciling Cash and Care: Home Care Charges and Benefit Checks in Social Services

Correspondence to Pete Alcock, Health and Community Studies, Sheffield Hallam University, Collegiate Cresent, Sheffield S10 2BP Summary This article contains the report of a small research projecton the development of welfare rights checks for home care clientsin social services departments. Welfare rights take-up activityhas become an important feature of provision by local authoritysocial services departments, frequently targeted on particulargroups of clients known to experience problems in claiming fullbenefit entitlement. Users of home care services are such aclient group. Take-up work with home care clients is also, however,a product of the impact of community care policy changes andof financial pressures on local authority social services. Thesehave resulted in the introduction of charges for home care servicesby many authorities, and the use of rebates from such chargesto protect low income service users. Welfare rights work hasthus become an important feature of the reconciliation of thesenew charging policies with the continued service needs of poorhome care clients. The research examined a successful take-upinitiative, linked to home care charges, in Sheffield and contrastedthis with similar activities in other authorities throughoutthe UK. The conclusion is reached that levels of non-take-upof social security benefits are particularly low amongst homecare clients and that benefit checks can secure significantadditional income for them, which may also have the indirecteffect of increasing the income to social services departmentsfrom the charges for home care services.     

The impact of globalization and financial development on India’s income inequality

This paper empirically examines the combined effects of globalization and financial development on income inequality in a unified framework for an emerging economy. Using annual data for the Indian economy over the period 1980–2014, we show that the perceived benefits of globalization and financial development have not trickled down; rather, has aggravated income inequality. Our results also indicate that while inflation aggravates income inequality, education seems to alleviate the differential effect. Proactive measures in providing access to financial services, creating equitable employment opportunities, and improving the quality of education are required to offset the negative impacts of globalization and financial development on income disparity.     

Nursing Homes in England and their Capacity to Provide Rehabilitation and Intermediate Care Services

The numbers of older people living in residential and nursing home care in the UK have risen exponentially since the early 1980s when the closure of long–stay geriatric wards and changes in social security funding of care home places led to a rapid expansion of the care home industry. While the implementation of the 1990 National Health Service (NHS) and Community Care Act shifted the responsibility for the commissioning and funding of these services to local authority social services departments, the provision of most health services (such as general practitioner care, physiotherapy and specialist nursing services) to nursing home residents remains the responsibility of community–based NHS practitioners. Recently, the attention of policy–makers in the UK has been focused on the need to improve the throughput of the acute sector. Older people who have received treatment but are not yet able to return to their own homes are to be transferred into intermediate care facilities, often by using nursing home beds, with the aim of supporting short–term rehabilitation outside of the acute sector. This paper presents evidence from a study of health service provision to older people living in nursing homes in England. It examines whether nursing homes have the capacity to fulfil the rehabilitation and intermediate care function envisaged by policy–makers. It concludes that shortfalls in the provision of NHS services to nursing homes and difficulties faced by nursing homes in paying for health services themselves may hinder the rehabilitation potential of intermediate care placements in nursing homes.     

Means Testing and the Heterogeneity of Housing Assets: Funding Long-Term Care in Spain

The access to publicly funded long‐term care (LTC) in Spain has been traditionally rationed through the use of means tests based on individuals’ current income and needs. However, individuals’ wealth, primarily housing assets, is progressively taken into account. Parallel to this feature, the responsibilities for the organization of LTC services have been devolved to region‐states – autonomous communities (ACs), giving rise to some regional heterogeneity, though limited evidence has been reported on the underlying determinants. This paper examines the current role of housing assets in determining public and private funding for long‐term care in Spain. Secondly, we present a qualitative and quantitative examination of the regional heterogeneity in the provision and public funding criteria determining eligibility for public support for LTC. Finally, we report survey evidence on the individual's willingness to sell (WTS) their housing assets in order to either totally or partially finance the access to LTC. Our findings suggest that housing assets are the main source of wealth accumulation at old age. Yet there is significant regional heterogeneity in the access to LTC resulting from regional differences in the means testing criteria. Progressively, all ACs are considering housing assets in their means testing criteria. Interestingly, individuals’ willingness to sell their housing assets declines with age and is more common among less skilled and widowed individuals.     

CASH,CUSTOMERS, AND CARE: THE EXPERIENCE AND MEANING OF DIFFERENTIAL PAYMENT FOR HIGH CARE PLACES IN AGED CARE FACILITIES

The introduction of new asset/income tested charges for high care residents was the 1997–98 Commonwealth government policy response to concerns about financing residential aged care. This in‐depth study of residents, families, staff and managers in three aged care facilities explores issues of equity, access and empowerment arising when some residents pay more for the same level of care and amenity. The study reports little evidence of financial contributions affecting access to high care places and the delivery of care, the potential for differential access to amenities such as single rooms linked to the extra payments, and no evidence of a sense of empowerment linked to payment of the new charges. The complexity of current financial arrangements, access to appropriate financial advice at the time of entry, and the potential for an informal two tier system in relation to the allocation of amenities are identified as developing policy issues.     

The impact of health insurance cost-sharing method on healthcare utilisation in China

In current Chinese health insurance programmes, there are two types of cost-sharing methods: the time-of-service copayment policy and the reimbursement policy. In contrast to the copayment participants, reimbursement participants need to pay for all medical expenses in advance. We study the effect of the reimbursement policy on the utilisation of healthcare services in China. The theoretical analysis indicates that the medical consumption of low income households will be less than the optimal consumption level when enrolled in a reimbursement programme instead of a copayment programme. Empirically, using data from the China Health and Retirement Longitudinal Study (CHARLS), we find that the total inpatient expenditure of the reimbursement participants is 12.7% lower than that of copayment enrolees, and the reimbursement arrangement negatively impacts low-income and rural populations. Therefore, reimbursement participants, those who are financially constrained, are more likely to suffer the up-front payment burden and finally reduce their healthcare needs.     

Enablers of help‐seeking for deaf and disabled children following abuse and barriers to protection: a qualitative study

Research internationally has highlighted the increased vulnerability of deaf or disabled children to abuse and the frequently inadequate response of services. However, first‐hand accounts of deaf or disabled children have rarely been sought. This paper reports selected findings from one of the first studies exploring experiences of deaf and disabled children regarding help‐seeking following maltreatment. Innovative and sensitive research methods were employed to support 10 deaf or disabled people (children and adults) to take part in guided conversations. The study identifies three enablers of help‐seeking of deaf or disabled children: the capacity of adults to detect abuse and respond to disclosures, supportive relationships or circumstances which facilitate disclosure and for Deaf children, access to registered interpreters. Barriers to protection related to these are also discussed. Recommendations directed at policy makers, practitioners and families include education and awareness raising amongst practitioners, children, parents and carers; addressing isolation of deaf and disabled children; providing comprehensive support services that address the needs of the child holistically; ensuring that the voice of the child is heard; routine access to registered interpreters for Deaf children within mainstream and specialist services and measures to address disablism at local and institutional levels.     

Low‐Income Students and College Attendance: An Exploration of Income Expectations*

Objectives. Some have hypothesized that unrealistic expectations regarding their futures may explain the weak link between expectations and realizations among low‐income (particularly minority) youth. Unfortunately, there is little evidence characterizing students' expectations around the time that they make college decisions that would allow one to study this hypothesis. Methods. In this exploratory article, I analyze data on income expectations from a small sample of low‐income minority high school seniors in Baltimore City, MD; and use data from Dominitz and Manski's sample of higher‐income white students in Madison, WI, and the NELS88 for comparisons. Results. I find little evidence that the income expectations of lower‐income minority students are so different from those of higher‐income students. Rather, the expected returns to postsecondary education appear similar between the two samples of high school seniors. Analysis of a nationally representative sample of high school seniors suggests that lower‐income students do not place less weight on expected economic returns to college when making their plans than do more advantaged students, although low‐income students are less able to translate their college plans into actual college attendance. Conclusions. These results suggest that differing income expectations do not explain the weaker relationship between expectations and educational attainment among low‐income students.     

Social Exclusion and Civil Law: Experience of Civil Justice Problems among Vulnerable Groups

Combating social exclusion has become a priority target for many governments and was a key factor in the establishment of the Legal Services Commission (LSC) and the Community Legal Service (CLS) in England and Wales in April 2000. This study aims to assess whether socially excluded groups within the general population are more likely to suffer justiciable problems (problems for which there is a potential legal remedy) and whether such groups differ in their problem resolution strategies and advice‐seeking behaviour. We draw upon a large‐scale survey of 5,611 people representative of the population of England and Wales, and a further survey of 197 people in temporary accommodation. Five vulnerable groups are extracted: survey respondents with a long‐term illness or disability, young and elderly respondents, low‐income respondents and those living in temporary accommodation. We identify how some of these vulnerable groups have a high likelihood of experiencing justiciable problems. We also examine advice‐seeking strategies among our vulnerable groups and, where contact was made, which advisers were typically contacted. The findings demonstrate the potentially crucial role of access to justice and advice and legal services in tackling social exclusion.     

Mental Health and Domestic Violence: 'I Call it Symptoms of Abuse'

Correspondence to Dr Cathy Humphreys, School of Health and Social Studies, University of Warwick CV4 7AL, UK. E-mail: c.f.Humphreys{at}warwick.ac.uk Summary Research evidence now clearly shows a direct link between women'sexperiences of domestic violence and heightened rates of depression,trauma symptoms, and selfharm. A research project based in Women'sAid outreach services provides further evidence of women's experiencesof severe emotional distress. However, their experiences ofmental health services were often found to be negative. A numberof practices within the medical model of mental health wereunhelpful including: the lack of recognition of trauma or provisionof trauma services; making the abuser invisible through focusingon the woman's mental health reified from her experiences ofabuse; blaming the victim; offering medication rather than counsellingsupport; the negative, consequent effects on child contact andchild protection proceedings if the woman is labelled with mentalhealth problems. Alternatively, women found services, oftenin the voluntary sector, helpful when they provided the followinginterventions: helping women name domestic violence; activelyasking about the abuse; attending to safety planning; respondingto women's specialist needs; and actively working with womento recover from abuse experiences. Support for her childrenwas also seen as very helpful. Implications for practice includethe commissioning of further services in the voluntary sector,addressing the inadequate response within the medical model,and increasing the sensitivity of responses to women's emotionaldistress across all sectors.     

Inequality and Service Access

Health care in the United States is of crucial concern to citizens and government officials as well as academicians. This study reviews the literature concerning stratification and inequality. The delivery of medical services is investigated as a component of social inequality as well as one component of models of change in inequality. The data used in this analysis were collected in four upstate New York counties. Interviews were done to obtain information concerning household use of various medical specialties. Socioeconomic data were also collected for the households in the sample. The inequality of medical service delivery was investigated by comparing the distribution of medical service utilization at different levels of socioeconomic status. The degree of inequality of medical service utilization is considered a function of how strongly related utilization is to various measures of socioeconomic status. Multiple regression revealed that education of head of house, family income, level of living, family size, and place of residence are all related to the use of medical services.     

Informal Carers of Adolescents and Adults with Learning Difficulties from the South Asian Communities: Family Circumstances, Service Support and Carer Stress

Corrrespondence to Chris Hatton, Research Fellow, Hester Adrian Research Centre, University of Manchester, Manchester M13 9PL, UK. Summary On the basis of a total identification survey in two metropolitanboroughs, 54 people from the south Asian communities caringfor people with learning difficulties aged 14 or over were interviewedregarding family circumstances, service supports and levelsof stress. In general, families were living in circumstancesof material disadvantage and reported a high need for services,due to a lack of informal support and the considerable supportneeds of many of the people with learning difficulties. Carerawareness and receipt of specialist intellectual disabilityservices were, however, low. A lack of information and staffwith appropriate language skills, coupled with a general neglectof the cultural and religious needs of service users and carers,appeared to result in low service uptake and low levels of satisfactionwith services. Eight per cent of carers reported levels of stressindicative of psychiatric problems, and also reported high levelsof contact with health services. There was some evidence thatservices were not allocated according to need; carers with lowhousehold incomes reported higher levels of stress, but carerswith higher household incomes received a wider range of services.The implications of these findings for services are discussed.     

Eligibility Criteria and Entitlements: Defining Need for NHS Continuing Care

The 1995 guidance HSG(95)8 "NHS Responsibilities for Meeting Continuing Health Care Needs" required health authorities to develop local policies and eligibility criteria for a range of continuing care services. The role of criteria in defining health need, and the potential effect on open-ended rights to NHS care, need to be considered in light of the prior erosion of rights associated with changes in continuing care provision. This paper examines whether the development of eligibility criteria has led to a loss of entitlements to NHS care. Analysis of empirical evidence from a study of the policies and criteria of six health authorities found that criteria for fully funded care were generally well defined and restricted access to those with very intense and specialist needs, thereby constituting a loss of rights. In contrast, the criteria for community-based services left eligibility dependent on professional discretion but often failed to clarify the relationship between individual need and levels of service provision. The research found that resource limits are likely to remain a factor in the allocation of services and this will affect the status of the criteria as potential entitlements.