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Previous studies of service reconfiguration in healthcare have explored the influence of power on processes and outcomes. However, in these accounts the moral agency of managers is often underemphasised. This paper draws on the theoretical tools provided by the sociology of morality to help deepen understanding of the interaction between power and moral agency in service reconfiguration in healthcare. It presents results from a qualitative study of a pan-organisational service reconfiguration in the NHS in England, involving nineteen in-depth interviews with those leading the change and the analysis of twelve programme documents. We combine concepts of the moral background and epistemic governance to interpret participants' conviction that the service change was 'the right thing to do'. The paper shows how epistemic work carried out by service change regulations shaped the moral background within which participants worked. This, in turn, channelled their moral agency – specifically their commitment to patient care – in a way that also reflected central priorities. The paper adds to sociological understandings of service reconfiguration through considering the interaction of structure, agency and power, while also developing the concept of the moral background to show how power relations can influence moral beliefs. • Managers can show strong faith in uncertain evidence for healthcare service change. • The moral background explains this in a way which considers power and moral agency. • Confidence in evidence depends on background assumption of future as predictable. • Confidence also depends on premise that finances are not open to moral evaluation. • Service change regulations carry out epistemic work on background assumptions. [ABSTRACT FROM AUTHOR]

Supporting people to 'age in place' – to live independently at home and remain connected to the community – is an international policy priority. But the process of ageing in place is mediated in a socio-cultural context where neoliberal tropes of successful ageing reproduce a pervasive model about 'ageing well' by elevating ideals of individualised choice and self-governance. Based on two waves of qualitative interviews and interim observations, we employ a Bourdieusian logic to explore the ramifications of this context on the experiences of 46 people in later older age (80+) ageing in place in North East England. All participants enacted everyday improvisatory practices to render their homes habitable. But our participants – most of whom were located in middle-class social positions – supplemented such improvisions with a strategic disposition to plan for and actively shape their ageing-in-place futures. Our participants conveyed a distinct sense of agency over their ageing futures. Underpinning their orientations to practice was an awareness of the value attached to individually 'ageing well' and a distancing from the agedness associated with the fourth age. Our analysis demonstrates the role of capital, accrued throughout the life course, in bringing such future trajectories into effect. The central argument of this paper therefore is that the embodiment of (neoliberal) ideals of successful ageing in place requires the deployment of classed capital. In sum, contrary to the individualising narratives ubiquitous in policy pertaining to ageing well, we show the importance of classed structural moorings in this process. • Regardless of class, older adults (80+) tinker to render their homes habitable. • Bourdieusian analysis shows how class shapes (successful) ageing in place. • Focusing on middle-class experiences deepens insight into ageing inequalities. • Dispositions to plan for and actively shape ageing futures requires capital. • The individualising focus of successful ageing ideals is inherently classed. [ABSTRACT FROM AUTHOR]

Major service change in healthcare – whereby the distribution of services is reconfigured at a local or regional level - is often a contested, political and poorly understood set of processes. This paper contributes to the theoretical understanding of major service change by demonstrating the utility of interpreting health service reconfiguration as a biopolitical intervention. Such an approach orients the analytical focus towards an exploration of the spatial and the population – crucial factors in major service change. Drawing on a qualitative study from 2011–12 of major service change in the English NHS combining documentary analyses of historically relevant policy papers and contemporary policy documentation (n = 125) with semi-structured interviews (n = 20) we highlight how a particular 'geography of stroke' in London was created building upon multiple types of knowledge: medical, epidemiological, economic, demographic, managerial and organisational. These informed particular spatial practices of government providing legitimation for the significant political upheaval that accompanies NHS service reconfiguration by problematizing existing variation in outcomes and making these visible. We suggest that major service change may be analysed as a 'practice of security' – a way of redefining a case, conceiving of risks and dangers, and averting potential crises in the interests of the population. • Foucault's work on biopolitics is applied to analyse major service change. • The reconfiguration of stroke services in London is explored. • Empirical and theoretical implications are discussed. [ABSTRACT FROM AUTHOR]

Abstract Health systems around the world face financial pressures that can affect sustainability and patient outcomes, and there is a vast literature devoted to the allocation of scarce health care resources. Capital spending - for example on estates, equipment and information technology - is an important but often neglected area of this literature. This study explores the constraints on the allocation of capital budgets in health care, before addressing the question: what is the role of priority setting and rationing in responses to these constraints? The paper presents findings from interviews conducted with senior finance professionals in 30 National Health Service local provider organisations across England. Findings suggest a pervasive sense of impending crisis, with capital restrictions limiting investment in buildings, infrastructure and equipment. The paper applies a conceptual classification scheme from the classic rationing literature (the forms of rationing framework) and identifies widespread practices of 'selection', 'dilution' and 'delay', with 'denial' and 'termination' comparatively rare. Practices of 'deflection' and 'deterrence' are ascribed to national actors as a means of restricting the flow of capital resources to the system. The study suggests that there is little by way of tailored support for priority setting in capital spending, and a perception that decisions are often reactive and short term. It also suggests that wider system features and dynamics can preclude or constrain priority setting at the organisational level. The authors use these findings to suggest future conceptual development of the forms of rationing framework and make recommendations for research and practice in this area. Highlights • Respondents described capital budget deficits affecting quality and safety of care. • Most had adopted rationing and/or priority setting to help deal with this. • Service dilution, delay and selection were the most cited forms adopted. • Lack of tools and the system context impeded local decision-making. [ABSTRACT FROM AUTHOR]

The recent 50th anniversary of the 1967 Abortion Act provides the opportunity to revisit what has been termed the ‘remarkable authority’ this Act ascribes to doctors. This paper does so using as its starting point a seminal commentary on this question by the renowned medical sociologist Sally Macintyre, published in this journal in 1973 as ‘The Medical Profession and the 1967 Abortion Act in Britain’. We revisit themes from that paper through an analysis of the findings of interviews with 14 doctors who, throughout lengthy careers, have provided abortions and led the development of the abortion service in England and Wales. We contrast our findings with Macintyre's, and argue that our interviews highlight the shifting meaning of medical authority and medical professionalism. We show that those doctors most involved in providing abortions place moral value on this work; uphold the authority of women (not doctors) in abortion decision-making; view nurses and midwives as professional collaborators; and consider their professional and clinical judgement impeded by the present law. We conclude that medical sociologists have much to gain by taking abortion provision as a focus for the further exploration of the shifting meaning of medical authority. [ABSTRACT FROM AUTHOR]

High quality primary care is a foundational element of effective health services. Internationally, primary care physicians (general practitioners (GPs), family doctors) are experiencing significant workload pressures. How non-patient-facing work contributes to these pressures and what constitutes this work is poorly understood and often unrecognised and undervalued by patients, policy makers, and even clinicians engaged in it. This paper examines non-patient-facing work ethnographically, informed by practice theory, the Listening Guide, and empirical ethics. Ethnographic observations (104 h), in-depth interviews (n = 16; 8 with GPs and 8 with other primary care staff) and reflexive workshops were conducted in two general practices in England. Our analysis shows that 'hidden work' was integral to direct patient care, involving diverse clinical practices such as: interpreting test results; crafting referrals; and accepting interruptions from clinical colleagues. We suggest the term 'hidden care work' more accurately reflects the care-ful nature of this work, which was laden with ambiguity and clinical uncertainty. Completing hidden care work outside of expected working hours was normalised, creating feelings of inefficiency, and exacerbating workload pressure. Pushing tasks forward into an imagined future (when conditions might allow its completion) commonly led to overspill into GPs' own time. GPs experienced tension between their desire to provide safe, continuous, 'caring' care and the desire to work a manageable day, in a context of increasing demand and burgeoning complexity. • The non-patient-facing work of general practitioners is often invisible or hidden. • Hidden work is associated with complexity and uncertainty. • Behind-the-scenes work is care work, just as direct work with patients is care work. • Doctors face tensions between completing tasks and working a manageable day. • Combining practice theory with the Listening Guide embraces multi-vocality. [ABSTRACT FROM AUTHOR]

Background: The numbers using illicit anabolic-androgenic steroids are a cause of concern for those seeking to reduce health harms. Using the 'risk environment' as a conceptual framework to better comprehend how steroid users' practices and perspectives impact on health risks, this paper examines steroid user motivations, patterns of use, and the ways in which these practices are accounted for.Methods: As part of a wider mixed-method study into performance and image enhancing drug (PIED) use and supply in one mid-sized city in South West England, qualitative interviews were undertaken with 22 steroid users. Participants were recruited from a local safer injecting service, rather than bodybuilding gyms, in order to access a wider cross-section of steroid users. A limitation of this approach is potential sample bias towards those showing more health optimising behaviours.Results: The research findings highlight that patterns of steroid use varied according to motivation for use, experience and knowledge gained. Most reported having had little or no knowledge on steroids prior to use, with first use being based on information gained from fellow users or suppliers-sometimes inaccurate or incomplete. In accounting for their practices, many users differentiated themselves from other groups of steroid users-for example, older users expressed concern over patterns of use of younger and (what they saw as) inexperienced steroid users. Implicit in these accounts were intimations that the 'other' group engaged in riskier behaviour than they did.Conclusion: Examining social contexts of use and user beliefs and motivations is vital to understanding how 'risk' behaviours are experienced so that this, in turn, informs harm reduction strategies. This paper examines the ways in which use of steroids is socially situated and the implications of this for policy and practice. [ABSTRACT FROM AUTHOR]

Objective: To identify attitudes towards pharmacy characteristics and promotional methods for selected pharmacy public health services (lifestyle advice and screening for cardiovascular risk factors) among different sectors of the general public. Study design: Cross-sectional survey, using a previously validated questionnaire. Methods: Three survey methods were used, across 15 areas of England, to maximize diversity: face-to-face; telephone; and self-completion of paper questionnaires. Responses to closed questions regarding characteristics and promotion were quantified and differences among sub-groups explored by univariate and multivariate analysis. Results: In total, 2661 responses were available for analysis: 2047 face-to-face; 301 telephone; and 313 paper. There were strong preferences for a pharmacy near to home or doctor's surgery and for long opening hours, particularly among employed people and nonwhites. Fifty percent preferred not to use a pharmacy in a supermarket, particularly older people, the retired, those of lower education and frequent pharmacy users. Personal recommendation by health professionals or family/friends was reported as most likely to encourage uptake of pharmacy public health services, with older people and males being less likely and frequent pharmacy users more likely to perceive any promotional method as influential. Posters/leaflets were preferred over mass-media methods, with fewer than 30% perceiving the latter as potentially influential. Conclusion: Pharmacists, pharmacy companies and service commissioners should use promotional methods favoured by potential users of pharmacy public health services and be aware of differences in attitudes when trying to reach specific population sub-groups. For personal recommendation to be successful, good inter-professional working and a pro-active approach to existing customers are needed. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has disproportionately impacted ethnic minorities in the global north, evidenced by higher rates of transmission, morbidity, and mortality relative to population sizes. Orthodox Jewish neighbourhoods in London had extremely high SARS-CoV-2 seroprevalence rates, reflecting patterns in Israel and the US. The aim of this paper is to examine how responsibilities over health protection are conveyed, and to what extent responsibility is sought by, and shared between, state services, and 'community' stakeholders or representative groups, and families in public health emergencies. The study investigates how public health and statutory services stakeholders, Orthodox Jewish communal custodians and households sought to enact health protection in London during the first year of the pandemic (March 2020–March 2021). Twenty-eight semi-structured interviews were conducted across these cohorts. Findings demonstrate that institutional relations – both their formation and at times fragmentation – were directly shaped by issues surrounding COVID-19 control measures. Exchanges around protective interventions (whether control measures, contact tracing technologies, or vaccines) reveal diverse and diverging attributions of responsibility and authority. The paper develops a framework of public health relations to understand negotiations between statutory services and minority groups over responsiveness and accountability in health protection. Disaggregating public health relations can help social scientists to critique who and what characterises institutional relationships with minority groups, and what ideas of responsibility and responsiveness are projected by differently-positioned stakeholders in health protection. • COVID-19 produced diverse responses and relations around health protection in London. •Pandemic preparedness can be enhanced by mapping possible partners in localities. •Establishing public health partnerships requires adequate resources. •Public health services cannot defer responsibility entirely to local partners. •Households are key constituents of public health relations. [ABSTRACT FROM AUTHOR]

Reflecting the higher prevalence of domestic violence and abuse experienced by women, and the recognised health impacts of such abuse, studies have focused on the responses of health-care practitioners to women in heterosexual relationships. Comparatively few studies have looked at the health impacts or help-seeking of men who may be perpetrators and/or victims of abuse within intimate relationships. In this paper we report on help seeking and the health professional's role based on a survey of 1368 men attending 16 general practices in the southwest of England and 31 interviews with a sample of survey respondents. The survey had a number of questions on experience or perpetration of behaviours which could be considered abusive, on whether respondents had ever been asked about such behaviours by health-care professionals, and on whether they had ever sought formal or informal help for such behaviours. Men were most likely to seek informal support from friends or family. The next most likely source of support was the family doctor. This paper suggests that health-care practitioners in general, and family doctors in particular, have a role in asking male patients about the experience or perpetration of domestic abuse and need training to do so effectively and safely. [ABSTRACT FROM AUTHOR]

• A complex web of semi-formal groupings make accountability challenging. • Local is defined in diverse ways and at varying scales which can cause tensions. • Uncertainty in risk information enables stakeholders to support different positions. • Varied planning timescales bring clashing concerns into focus. • Negotiations at the local level struggle to resolve national issues such as housing. In England spatial planning decisions with regard to development in coastal areas at risk of flooding or erosion are largely devolved to negotiations at what is said to be the local scale. Such development is discouraged but may be allowed so long as it is possible to demonstrate wider sustainability benefits said to outweigh the risk. It is at this point a range of stakeholders, representing different organisations and concerns must come together to try and resolve the tension between new development and risk reduction. Participants must navigate an evolving, complex, multiscale risk governance network to achieve an effective risk dialogue. The paper critically examines this apparently local, collaborative method, to understand the contributions and challenges of such an approach and provide suggestions to support this process. Semi structured interviews with thirty interviewees across three coastal locations in England reveal a number of key areas of contention, centred on: the risk data, local boundaries and planning timescales. In a complex system, mixing formal and informal planning spaces, stakeholders represent diverse spaces, a variety of organisational concerns and different planning horizons. At least some local concerns have a significant influence, but the system struggles to address national and strategic issues. [ABSTRACT FROM AUTHOR]

Stories about disability are heavily shaped by the narratives offered by medicine and society. Those narratives enact an ‘anomalous’ body that is constructed as distant from the norm and therefore ‘damaged’ but also fixable. In this paper we explore how such narratives, and the practices they encompass, influence the stories disabled young people tell about their bodies and impairment. We do so by drawing on narrative qualitative interviews and visual practices carried out with seventeen disabled young people in a project funded by the Economic and Social Research Council that took place between 2011 and 2012 in the North East of England. The findings discussed here focus on how medical and societal responses to bodily difference become part of the stories disabled young people tell about their bodies, and influence the way they work with the body as something which remains ‘unfinished’ and therefore both fixable and flawed. Our conclusion is that a narrative of an unfinished body is produced, as young people manage their bodies as something that is integral to their emerging identity, but also as a potential threat that could undermine and give away their labour in making an ‘ordinary’ functioning body and life. The paper contributes to medical sociology and sociology of the body by producing new knowledge about how disabled embodiment is lived and framed by disabled young people in the context of ongoing attempts to change the body. [ABSTRACT FROM AUTHOR]

Abstract: Lay involvement in public health programmes occurs through formalised lay health worker (LHW) and other volunteer roles. Whether such participation should be supported, or indeed rewarded, by payment is a critical question. With reference to policy in England, UK, this paper argues how framing citizen involvement in health only as time freely given does not account for the complexities of practice, nor intrinsic motivations. The paper reports results on payment drawn from a study of approaches to support lay people in public health roles, conducted in England, 2007–9. The first phase of the study comprised a scoping review of 224 publications, three public hearings and a register of projects. Findings revealed the diversity of approaches to payment, but also the contested nature of the topic. The second phase investigated programme support matters in five case studies of public health projects, which were selected primarily to reflect role types. All five projects involved volunteers, with two utilising forms of payment to support engagement. Interviews were conducted with a sample of project staff, LHWs (paid and unpaid), external partners and service users. Drawing on both lay and professional perspectives, the paper explores how payment relates to social context as well as various motivations for giving, receiving or declining financial support. The findings show that personal costs are not always absorbed, and that there is a potential conflict between financial support, whether sessional payment or expenses, and welfare benefits. In identifying some of the advantages and disadvantages of payment, the paper highlights the complexity of an issue often addressed only superficially. It concludes that, in order to support citizen involvement, fairness and value should be considered alongside pragmatic matters of programme management; however policy conflicts need to be resolved to ensure that employment and welfare rights are maintained. [Copyright &y& Elsevier]

This paper contributes to the international literature examining design of inpatient settings for mental health care. Theoretically, it elaborates the connections between conceptual frameworks from different strands of literature relating to therapeutic landscapes, social control and the social construction of risk. It does so through a discussion of the substantive example of research to evaluate the design of a purpose built inpatient psychiatric health care facility, opened in 2010 as part of the National Health Service (NHS) in England. Findings are reported from interviews or discussion groups with staff, patients and their family and friends. This paper demonstrates a strong, and often critical awareness among members of staff and other participants about how responsibilities for risk governance of ‘persons’ are exercised through ‘technical safety’ measures and the implications for therapeutic settings. Our participants often emphasised how responsibility for technical safety was being invested in the physical infrastructure of certain ‘places’ within the hospital where risks are seen to be ‘located’. This illuminates how the spatial dimensions of social constructions of risk are incorporated into understandings about therapeutic landscapes. There were also more subtle implications, partly relating to ‘Panopticist’ theories about how the institution uses technical safety to supervise its own mechanisms, through the observation of staff behaviour as well as patients and visitors. Furthermore, staff seemed to feel that in relying on technical safety measures they were, to a degree, divesting themselves of human responsibility for risks they are required to manage. However, their critical assessment showed their concerns about how this might conflict with a more therapeutic approach and they contemplated ways that they might be able to engage more effectively with patients without the imposition of technical safety measures. These findings advance our thinking about the construction of therapeutic landscapes in theory and in practice. [Copyright &y& Elsevier]

This paper reports on research framed by theories of therapeutic landscapes and the ways that the social, physical and symbolic dimensions of landscapes relate to wellbeing and healing. We focus especially on the question of how attributes of therapeutic landscapes are constructed in different ways according to the variable perspectives of individuals and groups. Through an ethnographic case study in a psychiatric hospital in the North of England we explore the perceived significance for wellbeing of ‘smoking spaces’ (where tobacco smoking is practiced in ways that may, or may not be officially sanctioned). We interpret our findings in light of literature on how smoking spaces are linked to the socio-geographical power relations that determine how smoking is organised within the hospital and how this is understood by different groups using the hospital building. We draw on qualitative research findings from discussion groups, observations, and interviews with patients, carers and staff. These focused on their views about the building design and setting of the new psychiatric hospital in relation to their wellbeing, and issues relating to smoking spaces emerged as important for many participants. Creating and managing smoking spaces as a public health measure in psychiatric hospitals is shown to be a controversial issue involving conflicting aims for health and wellbeing of patients and staff. Our findings indicate that although from a physical health perspective, smoking is detrimental, the spaces in which patients and staff smoke have social and psychological significance, providing a forum for the creation of social capital and resistance to institutional control. While the findings relate to one case study setting, the paper illustrates issues of wider relevance and contributes to an international literature concerning the tensions between perceived psychological and psychosocial benefits of smoking vs. physical harm that smoking is likely to cause. We consider the implications for hospital design and the model of care. [Copyright &y& Elsevier]

Abstract: This paper seeks to orientate research on local food networks more firmly towards ideas of grassroots and social niche innovations. Drawing on recent conceptual ideas from strategic niche management, this paper provides an exploratory analysis of attempts to spread grassroots social innovations through the Big Lottery Local Food programme run by the Royal Society of Wildlife Trusts in England. This £59.8 million programme aims to distribute grants to a variety of food-related projects and to make locally grown food more accessible and affordable to local communities. Insights into 29 funded projects, of varying length and scale of operation, are provided through over 150 telephone and personal interviews. While the Local Food programme is undoubtedly about bringing small, often neglected pieces of land into production and increasing access to affordable food, results show that the programme is also very much seen as a vehicle for building community capacity through facilitating community cohesion, healthy eating, educational enhancement and integrating disadvantaged groups into mainstream society and economy. The paper concludes with some reflections on the extent to which the concept of grassroots social innovations, as a form of niche innovation, can help understand the ability of local food networks to develop the capacity of communities to respond to locally identified problems and to effect more widespread, sustainable change. [Copyright &y& Elsevier]

Background: Family carers provide strong support for many older adults, often enabling older adults to remain at home. Little is known about the care recipients' perspectives of the role and contributions of family carers, particularly when hospital admissions occur as part of end of life care. Aim: This paper explores the meanings of family caring for care recipients by drawing on older adults' perspectives about the impact of hospital admission on established family caring relationships. Design: Exploratory semi-structured qualitative interviews. Key findings reported in this paper emerged from within the inductive research design. Setting: Interviews were conducted in older adults' place of residence in northwest England between June 2009 and July 2010. Participants: Participants were 27 older adults living with heart failure (n = 13) or lung cancer (n = 14), aged 69-89 years (mean 79 4.3 years) and considered by their health professionals to be in their last year of life. In 12 of the interviews, a family carer was also present and made contributions. Findings: For community-dwelling older adults, family carers are conceptualised as 'conductors'; making strong contributions to maintaining the rhythm of good care throughout the illness trajectory. Following older adults' hospital admission, family carers find themselves in the role of 'second fiddle', their ability to work with the individual and to make or influence decisions vastly reduced. Despite this, carers continue to invest considerable effort in maintaining continuity in the carer relationship to maximise the individual's wellbeing by identifying needs, filling gaps in provision and advocating on patients' behalf. Family carers act flexibly to provide continuity, support and take responsibility for older adults' wellbeing across settings. Conclusions: Nurses and family carers working together, and greater appreciation of the contribution and role of family carers by health professionals may contribute to improving the quality and continuity of care for older adults. [ABSTRACT FROM AUTHOR]

Abstract: Excessive alcohol consumption among young people in England regularly features in national media and has been a focus of recent academic research and government policy. Though the majority of young people do not regularly drink excessively, heavy sessional drinking – ‘binge’ drinking – is associated with negative health and social consequences for those who do. Alcohol-related health problems in young people are not spread consistently across England, however, and while there are significant intra-regional differences, northern regions fare worse overall than those in the south. This paper draws on an 18-month project which explored differences in the physical, social and regulatory environments (highlighted by previous research as influential) in two locations with contrasting alcohol harm profiles. The paper focuses on the lives of 15–16 year olds and examines potential differences that influence behaviour at this crucial age; and in particular issues that might presage risky and/or harmful drinking in young adulthood. The study examines evidence from young people themselves (activity diaries and interviews); stakeholder interviews; and observation analysis. The study finds social practices in the two areas to be largely similar; moreover, the collectivised and social nature of alcohol consumption suggests sources of influence from a wider context, beyond immediate family and friendship groups. However these social practices were acted out in locations with very different physical characteristics, in particular these related to the availability of non-alcohol focused leisure activities and the spatial arrangement/visibility of adult drinking culture. [Copyright &y& Elsevier]

Abstract: Pelvic radiotherapy creates physical effects and psychological responses that negatively affect the sexual health of women and couples, yet these sexual consequences are not frequently researched or clinically assessed. This focused ethnographic study explored factors that influence the clinical assessment of treatment-induced female sexual difficulties after pelvic radiotherapy within routine medical follow-up. Participant observation of follow-up clinics (n = 69) and in-depth interviews with 24 women, 5 partners and 20 health professionals were undertaken at two cancer centres in the South East of England from 2005 to 2006. Thematic analysis of interview transcripts resulted in five emergent themes, two of which are explored in detail within this paper. A social constructionist approach to human sexuality was used to explore representations of female sexuality in oncology follow-up constructed by clinicians, women and their partners. Yet neither social constructionist nor biomedical (the predominant model in medical follow-up) perspectives on human sexuality provided an adequate interpretation of these study findings. This paper argues that the comprehensive study and practice of sexual rehabilitation in oncology requires a synthesis of both biomedical and social constructionist perspectives in order to capture the complex, subjective and embodied nature of the female sexual response in both health and illness. [Copyright &y& Elsevier]

There is limited literature on the processes of choice-making in families of young people with learning disabilities. This paper examines the factors considered by parents of young people with learning disabilities when deciding their own and their child's role in a range of significant choices (health, social care and education) about their child's life. The paper reports data collected from a sub-sample of 14 parents recruited from 11 families participating in a longitudinal (2007–2010) qualitative study based in England. The parents all had children with learning disabilities and participated throughout the study. Data were collected over three semi-structured interviews. Parents' accounts demonstrated a continuum of parental involvement ranging from young people being unaware a choice was taking place to young people being fully involved in choice-making. Parents did not always adopt the same approach to choice-making; different approaches to their own and their son/daughter's level of involvement emerged when parents discussed different choices. Five choice-making factors are presented. These factors were used by parents to guide their own and their child's level of involvement. Although young people's level of understanding was considered, it was not always the most important factor. Other factors were important and, at times, could be considered more important by parents. The other factors were: parents' views on the nature of the choice, protecting their child, parents' personal attitudes/beliefs and confidence in practitioner knowledge. Insights from these factors highlight some important practice issues when practitioners work with families of young people with learning disabilities making significant life-choices. [Copyright &y& Elsevier]

Abstract The aim of this paper is to explore eleven year old children's understanding of well-being through their completion of Well-Being Maps and subsequent interviews on their content. The children were asked to describe the people, places and things which they viewed as important to their sense of well-being. The subsequent interviews explored their rationalisations for their choices. Ninety-two eleven year old children attending four schools with varying levels of deprivation and ethnic diversity took part in the study. This is the first section of an English study which is a part of the Multi-National Children's Understanding of Well-Being Study involving 26 countries which aims to explore how children conceptualise and experience well-being from a comparative and global perspective. Commonalities and divergences in the English children's responses were explored. Across the entire sample of 92 children, there were clear commonalities. Relationships with family, predominantly parents, were viewed as very important. The reasons provided were consistent love and affection; constant support, encouragement and protection; fun to be with. The duration of this quality of parent-child interaction appeared to be the key. Trust and a sense of security were the result. Relationships with friends were deemed important by over two thirds of the children. The qualities of these relationships mirrored those with the parents with a sense of trust and security being present. Where places and activities were included on their maps, they were often linked to important relationships. Activities appeared to be important in acknowledging the relationship but also maintaining it. Activities were also valued by the children for skill development. There were some differences across the sample with relationships with friends and grandparents being more reported as important in the two areas of high deprivation, irrespective of ethnic diversity. The level of material possessions and holidays abroad were much more frequently reported in the school serving the low deprivation area. At times, the explanations for differences appeared to be an interplay of socio-economic factors and religious and cultural traditions. Suggestions for further research on children's perspectives on factors important to their well-being are made. Highlights • Children's understanding of well-being is a critical component of conceptual development in the field. • Close relationships with family and friends are identified by 11 year old children as central to their well-being. • It is predominantly through relationships that children attach importance to places and activities. [ABSTRACT FROM AUTHOR]

Abstract: This paper explores the notion of genetic responsibility, i.e. the responsibility to know and manage one’s own genome for oneself and the sake of others, focusing particularly on responsibilities to family and kin. It also considers wider ideas about the emergence of new forms of biological subjectivities with which the concept of genetic responsibility is associated. The paper draws on a UK-based study concerned with lay constructions of familial hypercholesterolaemia (FH), a treatable inherited form of high cholesterol, which involved qualitative interviews with 31 people with the condition recruited through a specialist outpatient clinic. The paper is an attempt to open out discussions about the significance of genetic responsibility and biological subjectivity. I argue that in this study, FH was not associated with a notable family narrative of illness or a strongly defined specific disease community, and no clear sense emerged of obligations to kin or others derived through genetic risks or genetic connections. While responsibilities concerned with the welfare of oneself and one’s existing offspring were enunciated, obligations to other potential or actual kin, e.g. to tell and encourage kin to manage their risks, were much less clearly defined. Drawing on these findings, I start to address questions about the pervasiveness of genetic responsibility and genetic identity and the contexts in which they might be significant. [Copyright &y& Elsevier]

Sight impairment is experienced by approximately 253 million people worldwide, including people of all generations, at all life course stages. Caught between past and present embodiments of the world, people often express feelings of loss with the onset of sight impairment. This paper examines the role of nonhuman nature encounters as a contingent resource amongst individuals navigating these emotional transitions. It responds to recent calls to attend to the life course in both critical disability studies and the growing body of work linking nonhuman nature relations to human wellbeing. The paper draws on findings from a qualitative study that combined in-depth narrative interviews with in situ go-along interviews to explore how 31 people with sight impairment in England describe and experience a sense of wellbeing (or otherwise) with nature across their everyday lives and life trajectories. The data were analysed using inductive narrative thematic analysis. While nonhuman nature encounters were valued by many participants in promoting a sense of freedom, relatedness, pleasurable sensory immersion, opportunities for exploration and 'skilling up', this paper cautions against generalised or overly Romantic tropes of what nonhuman nature can 'do' through key sight loss junctures, and for whom. It highlights the value of providing timely and sensitive social scaffolding and nurturing creativity to open up meaningful opportunities to engage with nonhuman nature and to counter feelings of loss exacerbated by identity-limiting life course narratives and disability stereotypes. Informed by the stories shared by participants to chart and situate their experiences of sight loss, we call for a new identity politics within and beyond the growing movement to 'connect' people to nonhuman nature for wellbeing; a politics that affirms diverse forms of more-than-human embodiment, recognising how and why such relations may weave into – and indeed out of – people's varied, interdependent life course trajectories. • Disabling life course norms can exacerbate feelings of loss with sight impairment. • Care is needed in generalising benefits of nature through transitions of sight loss. • Social scaffolding and creativity can enable supportive nonhuman encounters. • A more inclusive identity politics is needed in nature-wellbeing policy & practice. [ABSTRACT FROM AUTHOR]

Abstract In the United Kingdom student nurses spend approximately half of their education programme in a practical setting commonly referred to as the Clinical Learning Environment (CLE). The significant amount of time student nurses spend in CLEs, combined with reports of negative experiences, indicate that it is important to consider the challenges of learning within this environment. Nurse Link Lecturers spend up to 20% of their teaching time supporting student nurses in CLEs. Link lecturers' proximity to the CLE means that they are well-placed to articulate the challenges facing student nurses in this context. This paper reports on a study that used interviews and focus groups to collect experienced adult field Link Lecturers' views on the challenges facing student nurses in CLEs. Link Lecturers reported that students often find themselves in polarised positions of either 'fitting in' with the pressures of the environment and thereby potentially gaining 'access to learning' opportunities or 'falling out' and merely 'learning to get through' their placement. Mentors were thought to have a significant influence on student nurses' negotiation of learning. This insight is timely due to the changes in supervisory and assessment arrangements required by the new Nursing and Midwifery Council Standards (NMC, 2018). Highlights • The Clinical Learning Environment may be a challenging environment to learn in (for students) and to teach in (for mentors). • Mentors are responsible for delivering patient care in addition to supporting student learning. • Students may 'fit in' and potentially gain 'access to learning' opportunities or 'fall out' and merely 'learn to get through'. • It is timely to reconsider supervisory and assessment arrangements in practice. [ABSTRACT FROM AUTHOR]

Background The predicted demographic changes internationally have implications for the nature of care that older people receive and place of care as they age. Healthcare policy now promotes the implementation of end-of-life care interventions to improve care delivery within different settings. The Gold Standards Framework in Care Homes (GSFCH) programme is one end-of-life care initiative recommended by the English Department of Health. Only a small number of care homes that start the programme complete it, which raises questions about the implementation process. Aim To identify the type, role, impact and cost of facilitation when implementing the GSFCH programme into nursing care home practice. Design A mixed-methods study. Setting Nursing care homes in south-east England. Participants Staff from 38 nursing care homes undertaking the GSFCH programme. Staff in 24 nursing care homes received high facilitation. Of those, 12 also received action learning. The remaining 14 nursing care homes received usual local facilitation of the GSFCH programme. Methods Study data were collected from staff employed within nursing care homes (home managers and GSFCH coordinators) and external facilitators associated with the homes. Data collection included interviews, surveys and facilitator activity logs. Following separate quantitative (descriptive statistics) and qualitative (template) data analysis the data sets were integrated by ‘following a thread’. This paper reports study data in relation to facilitation. Results Three facilitation approaches were provided to nursing home staff when implementing the GSFCH programme: ‘fitting it in’ facilitation; ‘as requested’ facilitation; and ‘being present’ facilitation. ‘Being present’ facilitation most effectively enabled the completion of the programme, through to accreditation. However, it was not sufficient to just be present. Without mastery and commitment, from all participants, including the external facilitator, learning and initiation of change failed to occur. Implementation of the programme required an external facilitator who could mediate multi-layered learning at an individual, organisational and appreciative system level. The cost savings in the study outweighed the cost of providing a ‘being present’ approach to facilitation. Conclusions Different types of facilitation are offered to support the implementation of end-of-life care initiatives. However, in this study ‘being present’ facilitation, when supported by multi-layered learning, was the only approach that initiated the change required. [ABSTRACT FROM AUTHOR]

Background Ever-growing demands on care systems have increased reliance on healthcare support workers. In the UK, their training has been variable, but organisation-wide failures in care have prompted questions about how this crucial section of the workforce should be developed. Their training, support and assessment has become a policy priority. Objectives This paper examines: healthcare support workers’ access to training, support and assessment; perceived gaps in training provision; and barriers and facilitators to implementation of relevant policies in acute care. Design and settings We undertook a qualitative study of staff caring for older inpatients at ward, divisional or organisational-level in three acute National Health Service hospitals in England in 2014. Participants 58 staff working with older people (30 healthcare support workers and 24 staff managing or working alongside them) and 4 healthcare support worker training leads. Methods One-to-one semi-structured interviews included: views and experiences of training and support; translation of training into practice; training, support and assessment policies and difficulties of implementing them. Transcripts were analysed to identify themes. Results Induction training was valued, but did not fully prepare healthcare support workers for the realities of the ward. Implementation of hospital policies concerning supervision and formal assessment of competencies varied between and within hospitals, and was subject to availability of appropriate staff and competing demands on staff time. Gaps identified in training provision included: caring for people with cognitive impairment; managing the emotions of patients, families and themselves; and having difficult conversations. Access to ongoing training was affected by: lack of time; infrequent provision; attitudes of ward managers to additional support workforce training, and their need to balance this against patients’ and other staff members’ needs; and the use of e-learning as a default mode of training delivery. Conclusions With the current and unprecedented policy focus on training, support and assessment of healthcare support workers, our study suggests improved training would be welcomed by them and their managers. Provision of training, support and assessment could be improved by organisational policy that promotes and protects healthcare support worker training; formalising the provision and availability of on-ward support; and training and IT support provided on a drop-in basis. Challenges in implementation are likely to be faced in all international settings where there is increased reliance on a support workforce. While recent policies in the UK offers scope to overcome some of these challenges there is a risk that some will be exacerbated. [ABSTRACT FROM AUTHOR]

• Survey respondents had their first suicidal thoughts, on average, at 13.6 years. • Forms of suicidal thoughts were passive, active and chronic suicidal ideation. • During and after leaving care, suicidal thoughts can re-occur and intensify. • English and German samples show similar occurrences of suicidal thoughts. • English participants judge their care experience to affect their attitude towards life. This paper investigates the range of suicidal ideation among people with care experience. People who grew up in care have an elevated risk of suicidal ideation, behavior and dying by suicide compared to people without care experience. However, a comprehensive and in-depth understanding of when suicidal ideation occurs and how care-experienced people experience suicidal thoughts, especially when leaving care in England and Germany, is currently not available but would help to inform suicide prevention tailored to care-experienced people across different ages. Aiming to address this gap, the current study applied a mixed-methods approach, combining an online survey and semi-structured interviews with young adults with care experience from England and Germany. The survey included 45 adults with care experience, age 18–40, and interviews were conducted with 13 care-experienced young adults from both countries. Descriptive statistical and significance tests were conducted to analyze the survey data with SPSS. Framework analysis was used to analyze the interviews. The findings show that many participants experienced suicidal thoughts from a young age and at different times up to adulthood. A range of suicidal thoughts and trajectories are identified with an increased risk of suicide for young people with care experience, especially during transitions such as when leaving care in early adulthood. The study underlines the need for a stronger recognition of suicide prevention in social work and the (leaving) care system across different countries. [ABSTRACT FROM AUTHOR]

This paper examines how people living in two socially contrasting areas of Stockton on Tees, North East England experience, explain, and understand the stark health inequalities in their town. Participants displayed opinions that fluctuated between a variety of converging and contrasting explanations. Three years of ethnographic observation in both areas (2014–2017) generated explanations which initially focused closely on behavioural and individualised factors, whilst 118 qualitative interviews subsequently revealed more nuanced justifications, which prioritised more structural, material and psychosocial influences. Findings indicate that inequalities in healthcare, including access, the importance of judgemental attitudes, and perceived place stigma, would then be offered as explanations for the stark gap in spatial inequalities in the area. Notions of fatalism, linked to (a lack of) choice, control, and fear of the future, were common reasons given for inequalities across all participants. We conclude by arguing for a prioritisation of listening to, and working to understand, the experiences of communities experiencing the brunt of health inequalities; especially important at a time of austerity. [ABSTRACT FROM AUTHOR]

Objectives: Tuberculosis (TB) is a highly stigmatised disease. This paper sought to explore the experiences and meanings of stigma among African men with a previous TB diagnosis. Study design: Qualitative approach with ten men recruited from a community based organisation offering health support to the men. Methods: In-depth semi-structured interviews. Results: Men were unable to recognise TB symptoms and subsequently made late clinical presentation when they were also diagnosed with HIV. A few were diagnosed when in immigration detention centres. The experience of late diagnosis informed their understanding of the word stigma. The link between HIV and TB compounded experiences of stigma which led to depression and compromised HIV confidentiality. Conclusion: TB late diagnosis among the men has implications for population health. Multidisciplinary teams supporting ongoing TB education programmes should include African men's organisations, due to the close supportive links such organisations have with African men. [ABSTRACT FROM AUTHOR]

Housing is a significant determinant of health and substandard housing is a public health issue. East London has long had a shortage of social and affordable housing, worsened in recent years by a combination of stressors. In one of East London's most deprived boroughs, Newham, changes brought about by the 2011 Localism Act and the unique demands of being the host Olympic borough in 2012 have brought considerable pressures to bear on social infrastructure. This paper examines how these pressures were experienced by local residents via their narratives of social housing and health. The data reported here are from a qualitative study comprising two waves of data collection. Narrative family interviews and go-along interviews were conducted with 40 Newham residents at wave one and 28 at wave two. A narrative analysis with a Bakhtinian interpretation was undertaken. This revealed that residents framed experiences of social housing in terms of an inherent system-level ideology based on notions of need and waiting. A particularly striking feature of this ideology was the extent to which descriptions of ill health and impairment were implicated in constructions of housing need; participants directly attributed a range of health complaints to their housing predicaments, including stress, depression, cancer scares, panic attacks and loss of sleep. Understanding the contested ideology of social housing can illuminate both the dynamic processes of social exclusion and the ways in which its subjects seek to resist it. [ABSTRACT FROM AUTHOR]

Background: In 2014, the annual report of the Her Majesty's Chief Inspector of Prisons (HMIP) for England and Wales raised concerns regarding New Psychoactive Substance (NPS) use in custody, specifically the consumption of synthetic cannabinoids. To date, however, the use of these substances in prison populations, and the markets that have emerged to facilitate it, have been under-researched.Methods: Our research was conducted in an English adult male prison using multi-method techniques. These included: in-depth interviews and focus groups with prison staff and prisoners; observations of prisoner-led focus groups, workshops and restorative justice circles involving discussion of synthetic cannabinoid use and markets; and analysis of routinely collected prison data measuring drug seizures, incidents of violence and incidents of self-harm.Results: The findings highlight: (1) the scale and nature of synthetic cannabinoid markets in a custodial setting and the motivations for establishing them; (2) the nature and motivations for synthetic cannabinoids use in prison; and (3) the impact synthetic cannabinoid markets in this setting have upon prisoners, the prison system and the wider criminal justice system. The policy implications of the stated motivations for use and reported problems are discussed in relation to both prison and community settings, and the recently implemented Psychoactive Substance Act (2016).Conclusion: The paper concludes that the rise in synthetic cannabinoid use in custody and the size of the drug market are posing significant challenges to the management of offenders; including healthcare, appropriate detection techniques, license recall and sanctions for both use and supply. We argue that the primary motivation for consumption in this setting is the avoidance of drug use detection, and that this is likely to supersede other motivations for consumption in the future. We propose a revision of the use of mandatory drug tests (MDTs) both in prisons and in the management of offenders in the community. [ABSTRACT FROM AUTHOR]

An extended role being explored globally is the advanced clinical practitioner (ACP). In England this is an extended role for allied health professions, nurses and midwives in a range of settings. This paper focuses on three research questions: 1) What is the role of ACPs in England? 2) What are the barriers and facilitators to implementing the role? and 3) What is the contribution of ACPs to health services in England? A qualitative, exploratory study to explore perspectives on the ACP role in a range of clinical settings. We recruited 63 stakeholders, including 34 nurses, working in a ACP role or ACP education. A purposive snowball sampling technique identified participants meeting inclusion criteria. One-to-one semi-structured interviews throughout 2020, recorded and transcribed verbatim, anonymised and thematically analysed. The ACP role in England was undertaken in a broad range of clinical contexts. In England 'advanced clinical practitioner' was not a protected title. There were high levels of variability and ambiguity of understanding and deployment of the ACP role in England. Facilitators to the implementation process included training and education, clinical supervision and organisational support. Lack of protection for the role and variances in experience were barriers. Employer support facilitated development of the ACP role, however where support was limited, at either an individual or organisation level, this was a barrier. Our study highlighted the wide range of ways the ACP role benefitted patient outcomes and workforce development. This study outlines the contribution that ACPs can make to health services, contributing factors and key barriers and facilitators to implementing this role. The work showed the positive contribution ACPs can make to service redesign, workforce development and patient outcomes, whilst accepting there is much work to do to ensure protected status and parity across all professions and clinical contexts [ABSTRACT FROM AUTHOR]

Recent decades have witnessed a significant rise in the use and ‘misuse’ of pharmaceutical medicines. Without significant behavioural change, the adverse health and environmental impacts resulting from medicine misuse will be most felt by today's young people. Yet despite real concerns surrounding pharmaceutical sustainability, insights into the ways that understandings of, and expectations to take medicines are communicated to, and taken up by young people remain limited. This paper draws on research focused around everyday home and school settings, to examine how understandings and norms relating to medicine use become embedded within the lives of young people. Between May 2014–January 2015, fifty students (aged 11–14) from one secondary school in England participated in focus groups and forty-three in interviews. Two focus groups were held with parents (n = 10). Findings demonstrate that attitudes towards medicine use were bound up with notions of parental responsibility, risk, peer governance and social acceptability, labour-related expectations, and processes of regulation within the school. Indeed, it was clear that medication use was often a compromised solution in response to wider structural pressures and demands and that such thinking was embedded at an early stage in the life course. The study found that few opportunities arose for open and informed discussion relating to responsible medicine use. Such circumstances demonstrate that any attempts to change medicine-related attitudes and behaviours should be considered within the wider social and structural contexts that govern their use. [ABSTRACT FROM AUTHOR]

This paper investigates how the concepts of clinical specialisation and evidence influence the jurisdictional power of doctors, nurses and therapists involved in stroke care in Sweden, England and Poland. How stroke care has become a distinct specialism across Europe and the role that evidence has played in this development are critically analysed. Five qualitative case studies were undertaken across the three countries, consisting of 119 semi-structured interviews with a range of healthcare workers. The informants were purposively selected and their perspectives of evidence-based practice (EBP) within stroke care were explored. The data were analysed through thematic content analysis. The two key themes that emerged from the data were the health professionals' degrees of EBP and specialisation. The results illustrate how the two concepts of clinical specialisation and evidence are interrelated and work together to influence the different professions' degree of professional jurisdiction. It is concluded that doctors' professional dominance gives them full jurisdiction in stroke care and that nurses' and therapists' degrees of jurisdiction is dependent on their ability to specialise. [ABSTRACT FROM AUTHOR]

Public Health England (2013) survey data indicates that while the place of death is geographically uneven across England, given a choice, many older people nearing end of life would prefer to die at home. There is, however, a growing critique that policies designed to support home death fail to understand the needs and preferences of older people and the impact on family carers. Such policies also make assumption about within whose home the home death takes place. Hence, there are major gaps in our understanding of firstly, where and how care work undertaken by family members within domestic settings takes place; and secondly, how it can create tensions between home and care that fundamentally disrupt the physical and socio-emotional meaning of home for family carers, impacting on their sense of home post-death. This can have consequences for their own well-being. In this paper we draw on interview data from our 'Unpacking the Home' study to elicit an in-depth understanding of how facilitating a home death can create an ambiguity of place for family carers, where the issues faced by them in caring for a dying older person at home, and the home death itself, can fundamentally reshape the meaning and sense of home. [ABSTRACT FROM AUTHOR]

Background The English National Health Service Institute for Innovation and Improvement designed a series of programmes called The Productive Series. These are innovations designed to help healthcare staff reduce inefficiency and improve quality, and have been implemented in healthcare organisations in at least 14 different countries. This paper examines an implementation of the first module of the Productive Community Services programme called ‘The Well Organised Working Environment’. Objective The quantitative component aims to identify the quantitative outcomes and impact of the implementation of the Well Organised Working Environment module. The qualitative component aims to describe the contexts, mechanisms and outcomes evident during the implementation, and to consider the implication of these findings for healthcare staff, commissioners and implementation teams. Design Mixed methods explanatory sequential design. Settings Community Healthcare Organisation in East Anglia, England. Participants For the quantitative data, participants were 73 staff members that completed End of Module Assessments. Data from 25 services that carried out an inventory of stock items stored were also analysed. For the qualitative element, participants were 45 staff members working in the organisation during the implementation, and four members of the Productive Community Services Implementation Team. Methods Staff completed assessments at the end of the module implementation, and the value of items stored by clinical services was recorded. After the programme concluded, semi-structured interviews with staff and a focus group with members of the Productive Community Services implementation team were analysed using Framework Analysis employing the principles of Realist Evaluation. Results 62.5% respondents ( n = 45) to the module assessment reported an improvement in their working environment, 37.5% ( n = 27) reported that their working environment stayed the same or deteriorated. The reduction of the value of items stored by services ranged from £4 to £5039 across different services. Results of the qualitative analysis suggests explanations for why the programme worked in some contexts and not others, for instance due to varying levels of management support, and varying levels of resources allocated to carrying out or sustaining the improvement work. Conclusions Quantitative analysis of data generated during healthcare improvement initiatives can give an impression of the benefits realised, but additional qualitative analysis also provides opportunity for learning to improve future implementations. Targets set by commissioners for innovation should focus on sustaining improvement rather demonstrating one-off benefits, and implementation teams should not let their preconceptions of what will and what will not work prevent them from trying interventions that may benefit staff. [ABSTRACT FROM AUTHOR]

Since the earliest days of the HIV/AIDS epidemic, talking about the virus has been a key way affected communities have challenged the fear and discrimination directed against them and pressed for urgent medical and political attention. Today, HIV/AIDS is one of the most prolifically and intimately documented of all health conditions, with entrenched infrastructures, practices and technologies – what Vinh-Kim Nguyen has dubbed ‘confessional technologies’ – aimed at encouraging those affected to share their experiences. Among these technologies, we argue, is the semi-structured interview: the principal methodology used in qualitative social science research focused on patient experiences. Taking the performative nature of the research interview as a talking technology seriously has epistemological implications not merely for how we interpret interview data, but also for how we understand the role of research interviews in the enactment of ‘life with HIV’. This paper focuses on one crucial aspect of this enactment: the contemporary ‘normalisation’ of HIV as ‘just another’ chronic condition – a process taking place at the level of individual subjectivities, social identities, clinical practices and global health policy, and of which social science research is a vital part. Through an analysis of 76 interviews conducted in London (2009–10), we examine tensions in the experiential narratives of individuals living with HIV in which life with the virus is framed as ‘normal’, yet where this ‘normality’ is beset with contradictions and ambiguities. Rather than viewing these as a reflection of resistances to or failures of the enactment of HIV as ‘normal’, we argue that, insofar as these contradictions are generated by the research interview as a distinct ‘talking technology’, they emerge as crucial to the normative (re)production of what counts as ‘living with HIV’ (in the UK) and are an inherent part of the broader performative ‘normalisation’ of the virus. [ABSTRACT FROM AUTHOR]

Embodied health movements work on the boundary between lay and expert knowledge. Consumer groups, depending on their goals, may increase or decrease pharmaceuticalization. This paper reports a small case study about the retrospective evaluation of a specific second line treatment for type 2 diabetes by an existing patient involvement group. The group is part of a research collaboration between academia and the health service in England, and shares some characteristics of embodied health movements. We used the case study to explore whether an institutionally funded non activist patient group can make a more balanced contribution to drug licensing decisions than that made by either access-oriented or injury-oriented consumer groups, without being co-opted by an institutional agenda. The questions we wished to address were how this group evaluated existing mechanisms for licensing drugs; how they balanced scientific and lay knowledge; how they made their decisions; and how they viewed their experiences as panel members. The five panel members were interviewed before and after the panel discussion in July 2013. They were critical of current licensing processes, and used their own embodied experiences of medicines to evaluate expert knowledge. Their decisions on the panel were informed either by a balancing of benefits and harms, or by trust in experts. The case study suggests that such a group may have the potential both to balance the pro-pharmaceuticalization impact of access-oriented groups and to influence forms of pharmaceutical governance. [ABSTRACT FROM AUTHOR]

The paper investigates whether, how and in what circumstances boundary blurring or boundary maintenance is productive or destructive of sense in collaborative research based on a case study involving researchers from two universities and two principal organisational stakeholders in a local healthcare system in England between 2009 and 2012. Adopting a narrative method, using meeting observation, document analysis and interviews, we describe two key sets of activities in the evolution of collaboration, which allows us to tackle the question at two levels. Studying the production of documents and their use as boundary objects in project management meetings, we show how these were used to enable cooperation by establishing a truce between worldviews, giving participants a better feel for the game and a clearer perception of its stakes. Studying how the partnership expanded to take in other organisations besides the two formal partners, we show how the project accommodated pre-existing organisational interests but thereby sacrificed its experimental ethos. In showing how actors needed to subvert their experimental script to enact collaborative partnership, we argue for understanding and evaluating the latter as the co-produced outcome of disputes and co-orientations towards a practical ideal, not as an organisational format for knowledge co-production. [ABSTRACT FROM AUTHOR]

Healthcare decision-makers have always faced the challenge of allocating finite resources, but the global economic downturn places extra pressure on health systems to meet rising demands. The National Institute for Health and Care Excellence (NICE) and UK government have therefore called on commissioners to consider opportunities for ‘disinvestment’— the cessation or restriction of health-care practices, and subsequent shift of resources to higher value care. However, there are no clear guidelines on how to approach disinvestment, and little is known about how this is tackled in practice. This paper presents results from a study that used ethnographic methods to investigate how disinvestment is understood and enacted. Eight routine local-level commissioning meetings where resource allocation decisions were discussed were observed over one year in two demographically contrasting regions of England. 28 interviews accompanied observations, conducted with purposefully-sampled professionals who were involved in, or potentially impacted by, disinvestments. Analysis of interviews/meeting recordings was undertaken using constant comparison methods, complemented by observational field notes. We found variation in informants' reported definitions of disinvestment, and an absence of disinvestment decision-making in observed meetings. Observations and interviews showed evidence of practical and ideological barriers to disinvestment, including an absence of tools and capacity, difficulties in collaboration and communication, a reluctance to engage in explicit rationing, and a perceived lack of central/political support. These findings support the need for the development of methods to encourage and guide disinvestment, including a clear definition of what ‘disinvestment’ entails. Crucially, disinvestment needs to be a collaborative effort, involving health-care providers and commissioners in decision-making processes. [ABSTRACT FROM AUTHOR]

Many public health systems in high- and middle-income countries are under increasing financial pressures as a result of ageing populations, a rise in chronic and non-communicable diseases and shrinking public resources. At the same time the rise in patient mobility and concomitant market in medical tourism provides opportunities for additional income. This is especially the case where public sector hospitals have a reputation as global centres of excellence. Yet, this requires public sector entrepreneurship which, given the unique features of the public sector, means a change to professional culture. This paper examines how and under what conditions public sector entrepreneurship develops, drawing on the example of international patients in the UK NHS. It reports on a subset of data from a wider study of UK medical tourism, and explores inward flows and NHS responses through the lens of public entrepreneurship. Interviews in the English NHS were conducted with managers of Foundation Trusts with interest in international patient work. Data is from seven Foundation Trusts, based on indepth, semi-structured interviews with a range of NHS managers, and three other key stakeholders ( n = 16). Interviews were analysed using a framework on entrepreneurship developed from academic literature. Empirical findings showed that Trust managers were actively pursuing a strategy of expanding international patient activity. Respondents emphasised that this was in the context of the current financial climate for the NHS. International patients were seen as a possible route to ameliorating pressure on stretched NHS resources. The analysis of interviews revealed that public entrepreneurial behaviour requires an organisational managerial or political context in order to develop, such as currently in the UK. Public sector workers engaged in this process develop entrepreneurship – melding political, commercial and stakeholder insights – as a coping mechanism to health system constraints. [ABSTRACT FROM AUTHOR]

Governments world-wide have attempted to use market mechanisms and privatisation to increase the quality and/or reduce the cost of healthcare. England's Health and Social Care Act 2012 is an attempt to promote privatisation through marketisation in the National Health Service (NHS). While the health policy literature tends to assume that privatisation follows from private-sector entry points, we argue that this is more likely if firms expect to make a profit. This paper examines the link between privatisation and marketisation in England drawing on 32 semi-structured interviews with private-sector and public-sector respondents, campaigners, and other experts conducted 6–10 months after the implementation of the 2012 Act. By generating a theoretical framework on the conditions of profitability we seek a better understanding of the conditions under which marketisation leads to privatisation. We find that significant barriers to profit-making remain after the reforms, including a top-down squeeze on prices, uncertainty in market rules, state dominance of funding and provision, and failures to depoliticise the market. These factors restrict private-sector involvement by frustrating profit-making. Where profits are made they are through reduced unit costs and high volumes by a longstanding incumbent in a particular market segment. This, however, restricts marketisation by reinforcing entry barriers. [ABSTRACT FROM AUTHOR]

COVID-19 was identified as a pandemic by the World Health Organisation (WHO) in December 2020. Advanced Clinical Practitioners (ACPs) in England working with older people with frailty, experienced their clinical role changing in response to the emergency health needs of this complex population group. In contrast to other countries, in England Advanced Clinical Practitioners are drawn from both nursing and allied health professions. Whilst much of the literature emphasises the importance of ensuring the sustainability of the Advanced Clinical Practitioners' role, the pandemic threw further light on its potential and challenges. However, an initial review of the literature highlighted a lack of research of Advanced Clinical Practitioners' capabilities working with uncertainty in disaster response situations. To capture the lived experience of how English Advanced Clinical Practitioners working with older people adapted their roles in response to the COVID-19 pandemic (October 2020–January 2021). A qualitative research design was used. Following ethical approval, 23 Advanced Clinical Practitioner volunteer participants from across England with varied health professional backgrounds were recruited from Advanced Clinical Practitioners' professional and social media networks on Twitter using a snowballing technique. Depending on preference or availability, 23 participants (nurses (18), physiotherapists (2), paramedics (2) and a pharmacist (1)) were interviewed singularly (n = 9) or as part of 3 focus groups (n = 14) using Zoom video communication. Audio recordings were transcribed and using qualitative data analysis software, NVivo 12 pro, coded for an essentialist thematic analysis of Advanced Clinical Practitioners' responses using an inductive approach. 27 codes were identified and collated into five themes. For the purposes of this paper, four themes are discussed: experiencing different work, developing attributes, negotiating barriers and changing future provision. Advanced Clinical Practitioners successfully transferred their advanced practice skills into areas of clinical need during the pandemic. Their autonomous and generic, high level of expertise equipped them for management and leadership positions where speed of change, and the dissolution of traditional professional boundaries, were prioritised. Barriers to progress included a lack of knowledge of the Advanced Clinical Practitioner role and friction between Advanced Clinical Practitioners and physicians. The study demonstrated the successful adaption of the Advanced Clinical Practitioner role to enable more creative, personalised and sustainable solutions in the care of older people living with frailty during the pandemic. The potential of Advanced Clinical Practitioner development is in a juxtaposition to the threat of pandemic services being dismantled once the emergency nature of care has passed. Healthcare organisations have a vital part to play in considering the enablers and barriers of Advanced Clinical Practitioner capability-based practice when responding to uncertainty. [ABSTRACT FROM AUTHOR]

Background: An implementation gap exists between policy aspirations for provision and the delivery of self-management support in primary care. An evidence based training and support package using a whole systems approach implemented as part of a randomised controlled trial was delivered to general practice staff. The trial found no effect of the intervention on patient outcomes. This paper explores why self-management support failed to become part of normal practice. We focussed on implementation of tools which capture two key aspects of self-management support - education (guidebooks for patients) and forming collaborative partnerships (a shared decision-making tool). Objectives: To evaluate the implementation and embedding of self-management support in a United Kingdom primary care setting. Design: Qualitative semi-structured interviews with primary care professionals. Settings: 12 General Practices in the Northwest of England located within a deprived inner city area. Participants: Practices were approached 3-6 months after undergoing training in a selfmanagement support approach. A pragmatic sample of 37 members of staff - General Practitioners, nurses, and practice support staff from 12 practices agreed to take part. The analysis is based on interviews with 11 practice nurses and one assistant practitioner; all were female with between 2 and 21 years' experience of working in general practice. Methods: A qualitative design involving face-to-face, semi-structured interviews audio- recorded and transcribed. Normalisation Process Theory framework allowed a systematic evaluation of the factors influencing the work required to implement the tools. Findings: The guidebooks were embedded in daily practice but the shared decision- making tools were not. Guidebooks were considered to enhance patient-centredness and were minimally disruptive. Practice nurses were reluctant to engage with behaviour change discussions. Self-management support was not formulated as a practice priority and there was minimal support for this activity within the practice: it was not auditable; [ABSTRACT FROM AUTHOR]

Background: Control of infection and prevention of healthcare associated infections is an ongoing issue worldwide. Yet despite initiatives and strategies to reduce the burden that these infections cause, healthcare workers' practice is still reported as suboptimal and these infections persist. Much of the research to date has primarily focused on predicting infection prevention behaviours and factors associated with guideline compliance. While this has given valuable insight, an investigation aiming to understand and explain behaviours that occur in everyday practice from the perspective of the actors themselves may hold the key to the challenges of effecting behaviour change. This study questioned ''How can nurses' infection prevention behaviour be explained?'' This paper presents one of three identified themes 'Rationalising dirt-related behaviour'. Design: This interpretative qualitative study uses vignettes, developed from nurses' accounts of practice, to explore nurses' reported infection prevention behaviours. Participants: Registered nurses working in an acute hospital setting and had been qualified for over a year. They were recruited while studying part-time at a London University. Methods: Twenty semi-structured interviews were undertaken using a topic guide and vignettes. Interviews were transcribed verbatim and analysed using the framework method. Results: The findings demonstrate that participants were keen to give a good impression and present themselves as knowledgeable practitioners, although it was evident that they did not always follow procedure and policy. They rationalised their own behaviour and logically justified any deviations from policy. Deviations in others were criticised as irrational and explained as superficial and part of a 'show' or display. However, participants also gave a presentation of themselves: a show or display that was influenced by the desire to protect self and satisfy patient scrutiny. Conclusions: This study contributes to the identification and explanation of nurses' infection prevention behaviours which are considered inappropriate or harmful. Behaviour is multifaceted and complex, stemming from a response to factors that are outside a purely 'scientific' understanding of infection and not simply understood as a deficit in knowledge. This calls for educational interventions that consider beliefs, values and social understanding of dirt and infection. [ABSTRACT FROM AUTHOR]

Abstract: Clinical practice guidelines produced by NICE – the National Institute for Health and Care Excellence – are seen as key mechanisms to regulate and standardise UK healthcare practice, but their development is known to be problematic, and their adoption and uptake variable. Examining what a guideline or health policy means to different audiences, and how it means something to those communities, provides new insight about interpretive discourses. In this paper we present a micro-analysis of the response of healthcare professionals to publication of a single NICE guideline in 2009 which proposed a re-organisation of professional services for chronic non-specific low back pain. Adopting an interpretive approach, we seek to understand both the meaning of the guideline and the socio-political events associated with it. Drawing on archived policy documents related to the development and publication of the guideline, texts published in professional journals and on web-sites, and semi-structured interview data from professionals associated with the debate, we identify a key discourse that positions the management of chronic non-specific low back pain within physician jurisdiction. We examine the emergence of this discourse through policy-related symbolic artifacts taking the form of specific languages, objects and acts. This discourse effectively resisted and displaced the service reorganisation proposed by the guideline and, in so doing, ensured medical hegemony within practice and professional organisations concerned with the management of non-specific low back pain. [Copyright &y& Elsevier]

Abstract: Much has been written on the beneficial, restorative qualities of ‘natural’ (non-built) rural or urban ‘green’ space, including woodland, in promoting mental and physical health when accessed for leisure, sport and education. In contrast, with the exception of rural health studies, there is relatively little debate about the health benefits of ‘green space’ as work place, especially in woodland and forests. In the developed world, this apparent gap in the literature may be partly due to an assumption of the forest work place as inherently healthy, and also the invisibility of a tiny percentage of the workforce now employed in forestry. However, in the UK and parts of Europe over recent years there has been a small, though significant, increase in opportunities to train and work in woodlands using traditional, sustainable management such as coppicing, and an exploration of health issues of woodland work is timely. This paper reports on findings from a secondary narrative analysis of oral history interviews selected from two phases of the Woodland Recollections Project and newsletters written by local people historically and currently engaged in coppicing and woodland work in North West England. Perceptions of healthy working in green space are examined by applying key concepts of Attention Restoration Theory (ART). Findings suggest that woodland work environments involve many counter-restorative factors that can render the ‘green idyll’ detrimental to health and wellbeing. To benefit from restorative elements requires drawing on a high level of specialist skills that empower individuals to manage and maintain healthy working practices in these diverse and challenging environments. [Copyright &y& Elsevier]

Abstract: The paper discusses the possibilities technology provides for (re-)shaping healthcare professionals. Drawing upon critical studies of technology and the sociology of professionals, we present findings from a longitudinal study into the introduction of the Electronic Prescription Service (EPS) in Community Pharmacies in England conducted between June 2009 and July 2011. Our case illustrates the conditions that allow technology to shape healthcare professionals and the potential consequences of such shaping. The data collected, which consisted of qualitative interviews and document analysis, and their analysis rests on predictions of future directions and developments of the pharmacy profession through EPS. Specifically, we show that technology has the potential to shape fundamental aspects of pharmacy work such as its nature and values, professional roles, the degree of power professionals can exercise, their jurisdictions and professional boundaries. Drawing upon these changes and on their implications, we argue that the introduction of technology in a healthcare setting does not determine consequences but opens up a field in which processes of de-professionalisation and re-professionalisation occur simultaneously. Their implications for healthcare professionals in the future, remains an open, yet worth exploring, question for the present. [Copyright &y& Elsevier]

Abstract: This paper aims to examine the relationship between parental socio-economic status (SES) and adolescent substance use. The central question posed in the title is approached in two stages. First, theoretical and empirical research in this area is reviewed. Second, data from an ongoing longitudinal study of young people in England (the Peterborough Adolescent and Young Adult Development Study – PADS+) are used to highlight the nature of this relationship in one city. Results from discrete-time event history analyses show that when examining what predicts initiation of substance use, familial and demographic factors emerge as important predictors, but SES does not appear to be relevant. The concluding discussion focuses on whether support is found for hypotheses derived from the existing literature and implications for future research. [Copyright &y& Elsevier]

Abstract: Assisted conception involving donor insemination challenges cultural idioms of parenthood and family; there is now a growing body of work exploring how women and couples negotiate becoming a family in this way. But sperm donation also raises questions on the more intimate levels of sex, sexuality and sexual bodies, and these have received little sustained attention in the literature. Lesbian couples in the UK increasingly negotiate access to medicalised donor insemination, but many also conceive in informal arrangements with donors where they themselves negotiate proximity and contact with donors when retrieving donor sperm. I explore in this paper how lesbian couples manage and perceive sperm donations, how they seek to negotiate their intimate, sexual and bodily overtones, and how the medical and non-medical settings enable them to do this in different ways. I draw on empirical data from an interview study conducted from 2006 to 2009 in England and Wales comprising 25 lesbian couples. I suggest that sperm donation raises dilemmas of intimacy for lesbian couples, and that couples try to resolve such dilemmas by carefully and intentionally choreographing donation events through managing patterns of movement and action. The different institutional, medical and regulatory frameworks governing clinical and non-clinical sperm donation shape that management in significant and different ways. I argue that sperm donation choreographies enable couples to negotiate the private, sexual and intimate tensions surrounding sperm donations, and also the subjectivity of the sperm donor. [Copyright &y& Elsevier]