Biomedical subjects

Neil Small

Publications and source records attributed to Neil Small.

At least 19 recordsLinked to original sources

PubMed2006

A cost effectiveness analysis within a randomised controlled trial of post-acute care of older people in a community hospital.

OBJECTIVE: To assess the cost effectiveness of post-acute care for older people in a locality based community hospital compared with a department for care of elderly people in a district general hospital, which admits patients aged over 76 years with acute medical conditions. DESIGN: Cost effectiveness analysis within a randomised controlled trial. SETTING: Community hospital and district general hospital in Yorkshire, England. PARTICIPANTS: 220 patients needing rehabilitation after an acute illness for which they required admission to hospital. INTERVENTIONS: Multidisciplinary care in the district general hospital or prompt transfer to the community hospital. MAIN OUTCOME MEASURES: EuroQol EQ-5D scores transformed into quality adjusted life years (QALYs), and health and social service costs over six months from randomisation. RESULTS: The mean QALY score for the community hospital group was marginally non-significantly higher than that for the district general hospital group (0.38 v 0.35) at six months after recruitment. The mean (standard deviation) costs per patient of the health and social services resources used were similar for both groups: community hospital group 7233 pounds sterling (euros 10,567; 13,341 dollars) (5031 pounds sterling), district general hospital group 7351 pounds sterling(6229 pounds sterling), and these findings were robust to several sensitivity analyses. The incremental cost effectiveness ratio for community hospital care dominated. A cost effectiveness acceptability curve, based on bootstrapped simulations, suggests that at a willingness to pay threshold of 10,000 pounds sterling per QALY, 51% of community hospital cases will be cost effective, which rises to 53% of cases when the threshold is 30,000 pounds sterling per QALY. CONCLUSION: Post-acute care for older people in a locality based community hospital is of similar cost effectiveness to that of an elderly care department in a district general hospital.

Acute Disease↗

PubMed2006

Prevalence of symptoms in a community-based sample of heart failure patients.

This study explored the prevalence and burden of symptoms in a community-based sample of patients aged >60 with symptomatic heart failure. Five hundred forty-two patients were recruited from UK general practices. Participants completed the Kansas City Cardiomyopathy Questionnaire every 3 months for 2 years. Data are presented at baseline alongside findings from in-depth interviews with patients and focus groups with primary care professionals. Over half the participants experienced breathlessness and/or fatigue daily. Factors identified as predictive of symptom prevalence and burden were as follows: being female; being staged at New York Heart Association Class III or IV; having symptoms of depression; and having two or more comorbidities. Interviews identified other symptoms, including chest pain, nausea, sleep disruption, and confusion. Participants felt that symptoms restricted activities of daily living. Health professionals reported symptom control as being a concern of patients and identified their own educational needs in this area. Findings suggest that symptom prevalence and burden for this population is high. Primary care professionals should offer comprehensive assessment and treatment of symptoms.

Activities of Daily Living↗

PubMed2006

Predictors of the quality of life of older people with heart failure recruited from primary care.

BACKGROUND: Current understanding of quality of life in heart failure is largely derived from clinical trials. Older people, women and those with co-morbidities are underrepresented in these. Little is known about factors predictive of quality of life amongst older people with heart failure recruited from community settings. OBJECTIVE: To identify factors predictive of quality of life amongst older people recruited from community settings. DESIGN: prospective questionnaire survey. SETTING: General practice surgeries located in four areas of the UK: Bradford, Barnsley, East Devon and West Hampshire. SUBJECTS: A total of 542 people aged >60 years with heart failure. METHODS: Participants completed a postal questionnaire, which included a disease-specific measure (Kansas City Cardiomyopathy Questionnaire), a generic quality-of-life measure (SF-36) and sociodemographic information. RESULTS: A multiple linear regression analysis identified the following factors as predictive of decreased quality of life: being female, being in New York Heart Association (NYHA) functional class III or IV, showing evidence of depression, being in socioeconomic groups III-V and experiencing two or more co-morbidities. Older age was associated with decreased quality of life, as measured by a generic health-related quality-of-life tool (the SF-36 mental and physical health functioning scales) but not by a disease-specific tool (the Kansas City Cardiomyopathy Questionnaire). CONCLUSION: Findings from the study suggest that quality of life for older people with heart failure can be described as challenging and difficult, particularly for women, those in a high NYHA class, patients showing evidence of depression, patients in socioeconomic groups III-V, those experiencing two or more co-morbidities and the 'oldest old'. Such information can help clinicians working with older people identify those at risk of reduced quality of life and target interventions appropriately.

Age Factors↗

PubMed2006

Communication in heart failure: perspectives from older people and primary care professionals.

The objective of this study was to explore the attitudes of older people and primary care professionals towards communication of diagnosis, prognosis and symptoms in heart failure. Forty-four interviews were conducted with people aged>60 years with heart failure (New York Heart Association III-IV) recruited from general practices in the UK. Ten focus groups were held with primary care professionals involved in heart failure management. Data were analysed thematically with the aid of the NUD*IST computer program. Participants reported problems with communication, including not being given enough information about their condition, or being given complex information that they did not understand. Many understood little about heart failure and the causes of, and ways to manage, their symptoms. Few participants had had discussions about the prognosis with any health professional, and this was confirmed in professional accounts. Difficulties with terminology were frequently reported: a diagnosis of 'heart failure' was rarely communicated to patients to avoid causing anxiety. Educational needs were identified by most primary care professionals in relation to heart failure management and specifically in relation to communication. In conclusion, communication was identified as being inadequate within primary care from both the patient and professional perspectives. These findings point to a need for an educational intervention tailored specifically to the need to improve the communication skills of primary care professionals in chronic heart failure.

Aged↗

PubMed2006

What does the use of a computerized checklist mean for patient-centered care? The example of a routine diabetes review.

The authors examine the interaction between nurses and patients with type 2 diabetes during routine consultations in primary care settings in the United Kingdom. Through preconsultation interviews, the authors identified the patients' expectations. The article draws on videotaped consultations with 25 patients with type 2 diabetes. Using conversation analysis, the authors examine the use of a rigid agenda, imposed via a computerized checklist, and consider how far this is able to suppress the patient's agenda. They consider the potential impact for the patient and the factors that might encourage the clinician, and the nurse specifically, to adopt a narrowly task-based approach to the consultation. They identify two potentially conflicting strands within contemporary diabetes care, patient-centered practice and an emphasis on biomedical audit, and suggest that achievement of the former might be compromised by the demands of the latter.

Adolescent↗

PubMed2006

Explanatory models of dementia: links to end-of-life care.

We will describe four models used to understand dementia: as a neurological condition; as a neuro-psychiatric condition; as a normal part of ageing; and seeing dementia from a person-centred perspective. Adopting the last of these allows an engagement with palliative care that has the potential to enrich the end-of-life experience of people with dementia, of their families and of the professional care staff who work with them. In this article, it will be argued that our perceptions of what is possible for practising person-centred care at the end of life are constrained by the paradigms we work within. There is developing evidence about how approaches to end-of-life care for people with dementia can move beyond what was, at best, therapeutic pessimism and at worst ill-treatment towards something that optimizes the capacities of those with dementia and mobilizes imaginative care practice.

Aged↗

PubMed2006

Characteristics and views of family carers of older people with heart failure.

AIMS: to explore the characteristics and views of the family carers of older people with heart failure. METHOD: 213 family carers of heart failure patients >60 years were recruited from UK general practitioner (GP) practices. Carer strain, quality of life (QOL) and service satisfaction questionnaires were completed every 3 months for 2 years, as well as 16 interviews with patients and carers, and 9 focus groups with health care professionals. RESULTS: 76% of carers were female, 70% were >60 years and 73% were spousal carers. Predictors of carer strain were symptoms of depression, age and patient NYHA. Predictors of lower QOL were: spousal carer; 2+ health conditions and symptoms of depression. Qualitative findings related to the change in circumstances, impact of responsibilities and health conditions of the family carers. CONCLUSION: carers were mainly older women, often experiencing multiple health conditions. Addressing the practical and emotional support required presents a challenge for specialist palliative care in responding to calls for increased involvement in heart failure. A shared care model with liaison between specialist heart failure nurses, cardiologists, primary care teams and hospice services is advocated.

Activities of Daily Living↗

PubMed2005

South Asians and epilepsy: exploring health experiences, needs and beliefs of communities in the north of England.

PURPOSE: To examine the beliefs and experiences of South Asians with epilepsy and the extent of provision of appropriate information and accessible services for them by health professionals. METHODS: Qualitative interviews with 30 South Asians with epilepsy, 16 carers and 10 health professionals. In addition, two focus groups were held with 16 South Asians without epilepsy recruited from community centers. The interview sample was divided by religious groupings (Hindus, Sikhs and Muslims). Fieldwork was conducted in Bradford and Leeds (England). RESULTS: Beliefs that epilepsy is caused by spirit possession (Muslims) or attributable to sins committed in a past life (Sikhs and Hindus) were reported as being widely held among South Asians living both in the UK and the Indian subcontinent, although few informants themselves subscribed to such views. Compliance with conventional medication was high; however, those who experienced seizures most often were most likely to turn to traditional South Asian therapies. Most informants used both treatments simultaneously. The main issues regarding the provision of services were: lack of appropriate information and advice; language and communication barriers; problems in interaction with health professionals. Also discussed were the potential merits of attending support groups. Greatest dissatisfaction was expressed in relation to primary care, whereas the highest praise was reserved for specialist epilepsy nurses. CONCLUSIONS: Our findings show both similarities and differences between participants' experiences, where gender, age or other aspects of personal biography can be as important as religion, culture or country of origin. Furthermore, the impact of being diagnosed with epilepsy can be exacerbated by structural impediments to accessing information and appropriate services.

Adolescent↗

PubMed2005

'She would help me from the heart': an ethnography of Egyptian women in labour.

This article reports an ethnographic study of the intrapartum care of women who were expecting normal births in an Egyptian hospital. The study involved observations of labouring women, and interviews with them shortly after they had given birth. The data were synthesised into three themes: the epistemology of hospital care, characterised by 'technical touch'; women's experience of hospital childbirth, which was contrasted unfavourably with home birth experiences; and women's epistemology of birth, which was characterised by 'helping from the heart'. This latter concept expresses the participants' preferred way of doing birth. We describe the impact of the paradigm clash experienced by these women, and propose an approach to the provision of childbirth care in Egypt and beyond which combines the clinical safety of evidence based and experientially developed technical skills with the emotional safety of trusting, respectful, loving relationships. We have termed this 'skilled help from the heart'.

Adult↗

PubMed2005

Effects of locality based community hospital care on independence in older people needing rehabilitation: randomised controlled trial.

OBJECTIVE: To determine the effects on independence in older people needing rehabilitation in a locality based community hospital compared with care on a ward for elderly people in a district general hospital. DESIGN: Randomised controlled trial. SETTING: Care in a community hospital and district general hospital in Bradford, England. PARTICIPANTS: 220 patients needing rehabilitation after an acute illness that required hospital admission. INTERVENTIONS: Patients were randomly allocated to a locality based community hospital or to remain within a department for the care of elderly people in a district general hospital. MAIN OUTCOME MEASURES: Primary outcomes were Nottingham extended activities of daily living scale and general health questionnaire 28 (carer). Secondary outcomes were activities of daily living (Barthel index), Nottingham health profile, hospital anxiety and depression scale, mortality, destination after discharge, satisfaction with services, carer strain index, and carer's satisfaction with services. RESULTS: The median length of stay was 15 days for both the community hospital and the district general hospital groups (interquartile range: community hospital 9-25 days; district general hospital 9-24 days). Independence at six months was greater in the community hospital group (adjusted mean difference 5.30, 95% confidence interval 0.64 to 9.96). Results for the secondary outcome measures, including care satisfaction and measures of carer burden, were similar for both groups. CONCLUSIONS: Care in a locality based community hospital is associated with greater independence for older people than care in wards for elderly people in a district general hospital.

Activities of Daily Living↗

PubMed2005

Establishing a welfare advice service in family practices: views of advice workers and primary care staff.

BACKGROUND: The placement of welfare advice services in family practice to assist patients with health-related social and economic issues (e.g. disability benefits) has gathered momentum over the last decade in the UK. This expansion of primary care raises a number of issues for practices hosting these services. OBJECTIVES: To gain the views of advice workers and primary care staff about the issues raised in hosting a welfare advice service across 30 practices in inner city Bradford. METHODS: Views were obtained through focus groups with six advice workers, and primary care staff in 14 practices. A questionnaire was also posted to all practice managers asking their opinions about the service. RESULTS: The focus groups highlighted a number of advantages for patients, including improvements in health and quality of life through increased income and reduced stress from social and economic issues. For practice staff, the service provided a resource to refer patients for welfare advice, reducing the time spent dealing with welfare issues, thereby reducing workload. This was confirmed in the questionnaire to practice managers where 72% said the service had saved time for GPs and reception/office staff. The advice workers raised concerns about the perceived level of commitment to the service from some staff at some practices. Practice staff were particularly concerned about the need for feedback about referrals. CONCLUSION: Providing welfare advice in family practice can act as a valuable resource for primary care staff helping to address their patients health-related social and economic needs.

Counseling↗

PubMed2005

A hermeneutic science: health economics and Habermas.

PURPOSE: Mainstream health economics labours under a misleading understanding of the nature of the topic area and suffers from a concomitant poverty of thinking about theory and method. The purpose here is to explore this critical position and argue that health economics should aspire to being more than a technical discipline. It can, and should, engage with transformative discourse. DESIGN/METHODOLOGY/APPROACH: It is argued that the hermeneutic sciences, emphasising interpretation not instrumentality or domination, offer a route into the change to which one seeks to contribute. The article specifically focuses on the way Habermas provides insights in his approach to knowledge, reason and political economy. How he emphasises complexity and interaction within cultural milieu is explored and primacy is given to preserving the life-world against the encroachments of a narrow rationalization. FINDINGS: The argument for a critical re-imagining of health economics is presented in three stages. First, the antecedents, current assumptions and critical voices from contemporary economics and health economics are reviewed. Second, the way in which health is best understood via engaging with the complexity of both the subject itself and the society and culture within which it is embedded is explored. Third, the contribution that hermeneutics, and Habermas' critical theory, could make to a new health economics is examined. ORIGINALITY/VALUE: The paper offers a radical alternative to health economics. It explores the shortcomings of current thinking and argues an optimistic position. Progress via reason is possible if one reframes both in the direction of communication and in the appreciation of reflexivity and communality. This is a position that resonates with many who challenge prevailing paradigms, in economics and elsewhere.

Economics, Medical↗

PubMed2005

Providing welfare advice in general practice: referrals, issues and outcomes.

General practices in the UK are increasingly hosting welfare advice services on their premises to address patients' social and economic needs. In this paper, the authors present the outcomes of a service providing welfare advice across 30 general practices in inner-city Bradford. A retrospective study of all patients referred for advice during the initial 24 months of the project was conducted. The following information was collected: patient demographics, source of referrals, advice issues raised and income generated through benefit claims. The advice workers saw 2484 patients dealing with over 4000 welfare advice issues. Demand for the service varied widely across practices, reflecting practice list size and engagement with the service by practice staff. The main source of referrals was general practitioners (28%), and disability-related welfare benefits constituted the largest category of advice issues. Sixty-nine per cent of patients seen for advice were of south Asian ethnic origin. The advice workers raised pound sterling 2,389,255 in welfare benefit claims for patients, primarily through disability-related benefits. Approximately one in four patients referred for advice benefited financially. It is concluded that the service is an excellent strategy by which primary care organisations address the social, economic and environmental influences on the health of their population.

Adolescent↗

PubMed2005

Alternative futures for health economics: implications for nursing management.

As nursing has been subject to successive waves of 'managerialism' there has been a drive on the part of government and elements within the profession to enhance the science base and promote cost-effective health care interventions. This has generated new interest in the 'economics of nursing' as efficiency and 'value for money' are viewed as necessary precondition for the provision of a high quality nursing service. As an academic subject health economics has brought an elegant set of theories to bear on the topic of health and health care. However, mainstream health economics is premised on a series of simplifying assumptions that, if applied uncritically, can induce a range of unintended and adverse consequences. This paper asks how ideas developed in one sphere (health economics) can be become influential in another (nursing management and practice) and it seeks explanations in the theories of Michel Foucault, specifically in his exploration of the reciprocal relationship between power and knowledge. How are our assumptions about what is possible and desirable shaped, how far do mechanisms of surveillance and self-subjugation extend? A range of alternative economic approaches have been developed which challenge many mainstream health economics assumptions. Some of these are better suited to the complex social environment present within health care. Nurses, nurse managers and researchers should question the assumptions of dominant economic models and explore a range of economic frameworks when planning services and evaluating their practice.

Attitude to Health↗

PubMed2005

Evidence of cultural hybridity in responses to epilepsy among Pakistani muslims living in the UK.

OBJECTIVES: To examine how people from Bradford's Pakistani Muslim community experience living with epilepsy. Specifically, the paper addresses social interactions and negotiations with care providers and considers how different understandings of epilepsy are integrated. METHODS: Interviews were conducted with a sample of Bradford's Pakistani Muslim community (n = 20). Interviews were analysed to identify themes and significant areas of shared concern. RESULTS: This paper identifies popular, professional and folk sectors contributing to an individual's 'health system'. Where sectors overlap, zones of hybridity are created: that is, a person might simultaneously seek help from a doctor and from a religious healer, or might offer explanations for seizures that include neurological and spiritual components. DISCUSSION: While there are many similarities between the experiences of these minority ethnic community members and published work on the lived experience of epilepsy in other communities, there are also important differences that service providers need to recognize and respond to. Differences include forms of cultural expression and specific language needs. Improving communication between professionals and persons with epilepsy needs to be prioritized.

Access to Information↗

PubMed2005

Recruiting older people into a large, community-based study of heart failure.

This paper highlights some of the challenges encountered when recruiting older people with heart failure into longitudinal, community-based research. It draws on the experience gained in a study to provide insights into the palliative care needs of older people with heart failure and the timing and need for service interventions. Five hundred and forty-two people with heart failure (New York Heart Association (NYHA) stages II-IV) and 213 of their informal carers were recruited from primary care practices in four areas of the UK. Ethical issues arising around gate-keeping, terminology and participant burden are discussed along with challenges faced during the recruitment process. Strategies to increase general practitioner and patient recruitment are provided. The paper concludes that prospective longitudinal studies are of particular relevance to chronic illness, and the complexity of setting up such research must be acknowledged and appropriately resourced.

Caregivers↗

PubMed2005

Religious beliefs about causes and treatment of epilepsy.

BACKGROUND: It has been acknowledged that religious and complementary therapies are commonly used among South Asian communities in the UK. However, little is known about their religious beliefs in relation to epilepsy and the type of South Asian therapies that they use to treat the condition. AIM: To explore the influences of spiritual and religious beliefs on explanation of the cause of epilepsy, and the choice of treatment in people of South Asian origin who have epilepsy. DESIGN OF STUDY: Qualitative study using interviews with patients, carers, health professionals, and focus groups of people from minority ethnic communities. SETTING: Bradford and Leeds. METHOD: Semi-structured individual interviews with 20 Muslims, six Sikhs, and four Hindus with epilepsy; 16 nominated carers (family members, friends); 10 health professionals (specialist GPs, neurologists, specialists nurses, social workers, community GPs); and two focus groups with a total of 16 South Asians without epilepsy. RESULTS: It was found that over half of responders attributed their illness to fate and the will of God, or as punishment for sins of a past life. Some patients had experienced prejudice from people who believed that their epilepsy was contagious. A strong network of traditional healers was found, providing a parallel system of health care in the UK and on the Indian subcontinent. People turned to religiospiritual treatments in desperation for a cure, often under the influence of their families after the perceived failure of Western medicine. Such treatments were viewed as complementary rather than as an alternative to Western medication. Younger people in particular expressed considerable scepticism about the effectiveness of these traditional South Asian treatments. CONCLUSIONS: In this study's South Asian sample, patients commonly turned to traditional healers in search of better health. Health professionals should be aware of the belief systems of these patients and understand the types of treatments in common use. Although these treatments might potentially compete with Western health care, they are used as an adjunct rather than a substitute. Patients have a 'healthy' scepticism about the effectiveness of such treatments, and adherence to medical therapy does not appear to be affected.

Adolescent↗

PubMed2003

Teaching primary care trusts. In a class of their own.

The first three teaching primary care trusts, which came into operation in April 2001, have increased recruitment of GPs and practice staff. Sunderland PCT has reduced practice list sizes as a result of the initiative. Salford teaching PCT has tripled the number of training practices. Eighteen GPs have been recruited in Bradford.

Education, Medical, Continuing↗