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1.  The long shadow of work—does time since labour market exit affect the association between socioeconomic position and health in a post‐working population 
Objective
To test the effect of time since labour market exit (LME) on associations between socioeconomic position (SEP) and self‐rated health.
Methods
Retirees from the English Longitudinal Study of Ageing (ELSA) were divided into three groups on the basis of the length of time since LME. Seven different indicators of SEP were identified: socioeconomic class, income, wealth, education, tenure, area deprivation and subjective social status. Unadjusted and mutually adjusted logistic regression analyses were performed with poor self‐rated health as the outcome. The sample consisted of 2617 men (mean (SD) age 71.69 (7.04) years) and 2619 women (71.29 (8.26) years).
Results
In the unadjusted analyses, patterns of association between SEP measures and health were similar for men and women. Most SEP measures were associated with poor health, although the effects were attenuated by time since LME. In the mutually adjusted analyses, wealth was found to have a strong independent effect on health among men, especially in those groups that left the labour market ⩽20 years ago,while for women subjective social status seemed to have the most important effect on health after LME.
Conclusions
Time since LME is an important factor to consider when studying health inequalities in a post‐working population. The effect of time since LME varies according to gender and the measures of SEP used. Further work in this area should take account of age, period and cohort effects using multiple measures of SEP and more refined measures of LME.
doi:10.1136/jech.2006.051284
PMCID: PMC2465706  PMID: 17496263
2.  Understanding service user-defined continuity of care and its relationship to health and social measures: a cross-sectional study 
Background
Despite the importance of continuity of care [COC] in contemporary mental health service provision, COC lacks a clearly agreed definition. Furthermore, whilst there is broad agreement that definitions should include service users’ experiences, little is known about this. This paper aims to explore a new construct of service user-defined COC and its relationship to a range of health and social outcomes.
Methods
In a cross sectional study design, 167 people who experience psychosis participated in structured interviews, including a service user-generated COC measure (CONTINU-UM) and health and social assessments. Constructs underlying CONTINU-UM were explored using factor analysis in order to understand service user-defined COC. The relationships between the total/factor CONTINU-UM scores and the health and social measures were then explored through linear regression and an examination of quartile results in order to assess whether service user-defined COC is related to outcome.
Results
Service user-defined COC is underpinned by three sub-constructs: preconditions, staff-related continuity and care contacts, although internal consistency of some sub-scales was low. High COC as assessed via CONTINU-UM, including preconditions and staff-related COC, was related to having needs met and better therapeutic alliances. Preconditions for COC were additionally related to symptoms and quality of life. COC was unrelated to empowerment and care contacts unrelated to outcomes. Service users who had experienced a hospital admission experienced higher levels of COC. A minority of service users with the poorest continuity of care also had high BPRS scores and poor quality of life.
Conclusions
Service-user defined continuity of care is a measurable construct underpinned by three sub-constructs (preconditions, staff-related and care contacts). COC and its sub-constructs demonstrate a range of relationships with health and social measures. Clinicians have an important role to play in supporting service users to navigate the complexities of the mental health system. Having experienced a hospital admission does not necessarily disrupt the flow of care. Further research is needed to test whether increasing service user-defined COC can improve clinical outcomes. Using CONTINU-UM will allow researchers to assess service users’ experiences of COC based on the elements that are important from their perspective.
doi:10.1186/1472-6963-12-145
PMCID: PMC3437199  PMID: 22682145
Service users; Continuity of care; Health and social outcomes
3.  Achieving Continuity of Care: Facilitators and Barriers in Community Mental Health Teams 
Background
The integration of mental health and social services for people diagnosed with severe mental illness (SMI) has been a key aspect of attempts to reform mental health services in the UK and aims to minimise user and carer distress and confusion arising from service discontinuities. Community mental health teams (CMHTs) are a key component of UK policy for integrated service delivery, but implementing this policy has raised considerable organisational challenges. The aim of this study was to identify and explore facilitators and barriers perceived to influence continuity of care by health and social care professionals working in and closely associated with CMHTs.
Methods
This study employed a survey design utilising in-depth, semi-structured interviews with a proportionate, random sample of 113 health and social care professionals and representatives of voluntary organisations. Participants worked in two NHS Mental Health Trusts in greater London within eight adult CMHTs and their associated acute in-patient wards, six local general practices, and two voluntary organisations.
Results
Team leadership, decision making, and experiences of teamwork support were facilitators for cross boundary and team continuity; face-to-face communication between teams, managers, general practitioners, and the voluntary sector were facilitators for information continuity. Relational, personal, and longitudinal continuity were facilitated in some local areas by workforce stability. Barriers for cross boundary and team continuity were specific leadership styles and models of decision making, blurred professional role boundaries, generic working, and lack of training for role development. Barriers for relational, personal, and longitudinal continuity were created by inadequate staffing levels, high caseloads, and administrative duties that could limit time spent with users. Incompatibility of information technology systems hindered information continuity. Flexible continuity was challenged by the increasingly complex needs of service users.
Conclusions
Substantive challenges exist in harnessing the benefits of integrated CMHT working to deliver continuity of care. Team support should be prioritised in terms of IT provision linked to a review of current models of administrative support. Investment in education and training for role development, leadership, workforce retention, and skills to meet service users' complex needs are recommended.
doi:10.1186/1748-5908-6-23
PMCID: PMC3073925  PMID: 21418579
4.  Dignity in the care of older people – a review of the theoretical and empirical literature 
BMC Nursing  2008;7:11.
Background
Dignity has become a central concern in UK health policy in relation to older and vulnerable people. The empirical and theoretical literature relating to dignity is extensive and as likely to confound and confuse as to clarify the meaning of dignity for nurses in practice. The aim of this paper is critically to examine the literature and to address the following questions: What does dignity mean? What promotes and diminishes dignity? And how might dignity be operationalised in the care of older people?
This paper critically reviews the theoretical and empirical literature relating to dignity and clarifies the meaning and implications of dignity in relation to the care of older people. If nurses are to provide dignified care clarification is an essential first step.
Methods
This is a review article, critically examining papers reporting theoretical perspectives and empirical studies relating to dignity. The following databases were searched: Assia, BHI, CINAHL, Social Services Abstracts, IBSS, Web of Knowledge Social Sciences Citation Index and Arts & Humanities Citation Index and location of books a chapters in philosophy literature. An analytical approach was adopted to the publications reviewed, focusing on the objectives of the review.
Results and discussion
We review a range of theoretical and empirical accounts of dignity and identify key dignity promoting factors evident in the literature, including staff attitudes and behaviour; environment; culture of care; and the performance of specific care activities. Although there is scope to learn more about cultural aspects of dignity we know a good deal about dignity in care in general terms.
Conclusion
We argue that what is required is to provide sufficient support and education to help nurses understand dignity and adequate resources to operationalise dignity in their everyday practice. Using the themes identified from our review we offer proposals for the direction of future research.
doi:10.1186/1472-6955-7-11
PMCID: PMC2483981  PMID: 18620561
5.  Ethical principles and the rationing of health care: a qualitative study in general practice 
Background
Researching sensitive topics, such as the rationing of treatments and denial of care, raises a number of ethical and methodological problems.
Aim
To describe the methods and findings from a number of focus group discussions that examined how GPs apply ethical principles when allocating scarce resources.
Design of study
A small-scale qualitative study involving purposive sampling, semi-structured interviews and focus groups.
Setting
Twenty-four GPs from two contrasting areas of London: one relatively affluent and one relatively deprived.
Method
Initial interviews asked GPs to identify key resource allocation issues. The interviews were transcribed and themes were identified. A number of case studies, each illustrative of an ethical issue related to rationing, were written up in the form of vignettes. In focus group discussions, GPs were given a number of these vignettes to debate.
Results
With respect to the ethical basis for decision making, the findings from this part of the study emphasised the role of social and psychological factors, the influence of the quality of the relationship between GPs and patients and confusion among GPs about their role in decision making.
Conclusion
The use of vignettes developed from prior interviews with GPs creates a non-threatening environment to discuss sensitive or controversial issues. The acceptance by GPs of general moral principles does not entail clarity of coherence of the application of these principles in practice.
PMCID: PMC1463218  PMID: 16105371
decision making; ethics; focus groups; healthcare rationing

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