The role of lawyers in supporting young people in the criminal justice system: balancing economic survival and children’s rights

Legal aid reductions have caused a crisis in the criminal justice system impacting the quality of representation and advice provided by lawyers. This paper is particularly concerned with the impact of these cuts on young people in the youth criminal justice system. The paper will examine how changes to the way in which defence lawyers are funded is having a damaging impact upon the experience of young people involved in the criminal justice system. The particular vulnerability of young people, coupled with the complexity of laws and procedures surrounding youth justice make it particularly concerning that the system is financially incentivising the provision of inadequate representation in the youth justice system. These issues will be considered in light of the standards set by the Council of Europe Guidelines on Child-Friendly Justice

Analysing the role of complexity in explaining the fortunes of technology programmes : empirical application of the NASSS framework

Background: Failures and partial successes are common in technology-supported innovation programmes in health and social care. Complexity theory can help explain why. Phenomena may be simple (straightforward, predictable, few components), complicated (multiple interacting components or issues) or complex (dynamic, unpredictable, not easily disaggregated into constituent components). The recently published NASSS framework applies this taxonomy to explain Non-adoption or Abandonment of technology by individuals and difficulties achieving Scale-up, Spread and Sustainability. This paper reports the first empirical application of the NASSS framework. Methods: Six technology-supported programmes were studied using ethnography and action research for up to 3 years across 20 health and care organisations and 10 national-level bodies. They comprised video outpatient consultations, GPS tracking technology for cognitive impairment, pendant alarm services, remote biomarker monitoring for heart failure, care organising software and integrated case management via data warehousing. Data were collected at three levels: micro (individual technology users), meso (organisational processes and systems) and macro (national policy and wider context). Data analysis and synthesis were guided by socio-technical theories and organised around the seven NASSS domains: (1) the condition or illness, (2) the technology, (3) the value proposition, (4) the adopter system (professional staff, patients and lay carers), (5) the organisation(s), (6) the wider (institutional and societal) system and (7) interaction and mutual adaptation among all these domains over time. Results: The study generated more than 400 h of ethnographic observation, 165 semi-structured interviews and 200 documents. The six case studies raised multiple challenges across all seven domains. Complexity was a common feature of all programmes. In particular, individuals’ health and care needs were often complex and hence unpredictable and ‘off algorithm’. Programmes in which multiple domains were complicated proved difficult, slow and expensive to implement. Those in which multiple domains were complex did not become mainstreamed (or, if mainstreamed, did not deliver key intended outputs). Conclusion: The NASSS framework helped explain the successes, failures and changing fortunes of this diverse sample of technology-supported programmes. Since failure is often linked to complexity across multiple NASSS domains, further research should systematically address ways to reduce complexity and/or manage programme implementation to take account of it

The Law in the Community Model of Clinical Legal Education: Assessing the Impact on Key Stakeholders

This article examines a model of clinical legal education where a university law school works in partnership with an external organisation. The partnership enables law students to attend the offices of Citizens Advice during their law degree and under the guidance and supervision of their staff, advise their service users on a range of legal issues. Using data collected from a research study involving student focus groups and semi structured interviews with the Citizens Advice supervisors, this research contributes to the understanding of whether, and how, this model impacts upon law students, Citizens Advice and the local community. This study contributes to the knowledge on the value of this model of clinical legal education from both a pedagogical and social justice perspective. The research raises questions as to how a partnership between a university and external organisation can overcome challenges, ensuring an equivalent clinical experience for all students and that effective feedback is provided to students. The results indicate that there are a clear set of pedagogical benefits to the students and benefits to Citizens Advice with regards to the service they can provide to the local community. The authors argue that this module enables students to engage in transformative and impactful work, whilst obtaining first-hand experience of the access to justice challenges (and other socio-economic issues) faced by their local community. The study will be of interest to clinics who incorporate, or intend to incorporate, an externship model in their curriculum, both in Europe and beyond

SCALS : a fourth-generation study of assisted living technologies in their organisational, social, political and policy context

Introduction: Research to date into assisted living technologies broadly consists of 3 generations: technical design, experimental trials and qualitative studies of the patient experience. We describe a fourth generation paradigm: studies of assisted living technologies in their organisational, social, political and policy context. Fourth-generation studies are necessarily organic and emergent; they view technology as part of a dynamic, networked and potentially unstable system. They use co-design methods to generate and stabilise local solutions, taking account of context. Methods and analysis: SCALS (Studies in Co-creating Assisted Living Solutions) consists (currently) of 5 organisational case studies, each an English health or social care organisation striving to introduce technology-supported services to support independent living in people with health and/or social care needs. Treating these cases as complex systems, we seek to explore interdependencies, emergence and conflict. We employ a co-design approach informed by the principles of action research to help participating organisations establish, refine and evaluate their service. To that end, we are conducting in-depth ethnographic studies of people’s experience of assisted living technologies (micro level), embedded in evolving organisational case studies that use interviews, ethnography and document analysis (meso level), and exploring the wider national and international context for assisted living technologies and policy (macro level). Data will be analysed using a sociotechnical framework developed from structuration theory. Ethics and dissemination: Research ethics approval for the first 4 case studies has been granted. An important outcome will be lessons learned from individual co-design case studies. We will document the studies’ credibility and rigour, and assess the transferability of findings to other settings while also recognising unique aspects of the contexts in which they were generated. Academic outputs will include a cross-case analysis and progress in theory and method of fourth-generation assisted living technology research. We will produce practical guidance for organisations, policymakers, designers and service users

Speaking with Listening: Art Therapy and Poetic Practice

Poems written in response to art therapy sessions may be less of interest for their artistic value than for their contribution to reflection on art therapy practice. Spontaneous poetry is often an intensely honest and inclusive way of recording a relationship or process & provides a vivid record of what is noticed. It may also indicate transpersonal, peripheral and ”˜field’ effects during sessions, which may have been contributing to the therapy in ways which need acknowledgement and understanding. Poems may work as mini-oracles, bringing subliminal perceptions and pre-cognitions to the surface, serving as a helpful contribution to self-supervision and the therapeutic work. Similar mind states are involved in art therapy and poetry; primarily an awake, compassionate ”˜presence’ and a willingness to connect with, and witness, ”˜otherness’ and our shared world. Such core therapeutic skills can always be enhanced and refined.The author proposes that poetry becomes more openly recognised as a medium for and respected form of, reflection on art therapy practice in our professional literature. This may further extend what is accepted as ”˜professional’ discourse to include more ”˜thick’ descriptions of our work and enable it to be more artistically communicated. It may then become less charged to ask clients/patients about publication, just as it has become easier for medical and social work staff to ask patients for permission to publicise their intimate verbal accounts of medical experiences to help other patients and practitioners.The article includes quotations from several writers and extracts from the authors ”˜poem-notes’ and poems.Key Words: Poetry, art therapy, skills, transpersonal, Buddhis

Patient-initiated cardiovascular monitoring with commercially available devices: how useful is it in a cardiology outpatient setting? Mixed methods, observational study

Background: The availability, affordability and utilisation of commercially available self-monitoring devices is increasing, but their impact on routine clinical decision-making remains little explored. We sought to examine how patient-generated cardiovascular data influenced clinical evaluation in UK cardiology outpatient clinics and to understand clinical attitudes and experiences with using data from commercially available self-monitoring devices. Methods: Mixed methods study combining: a) quantitative and qualitative content analysis of 1373 community cardiology clinic letters, recording consultations between January–September 2020 including periods with different Covid-19 related restrictions, and b) semi-structured qualitative interviews and group discussions with 20 cardiology-affiliated clinicians at the same NHS Trust. Results: Patient-generated cardiovascular data were described in 185/1373 (13.5%) clinic letters overall, with the proportion doubling following onset of the first Covid-19 lockdown in England, from 8.3% to 16.6% (p < 0.001). In 127/185 (69%) cases self-monitored data were found to: provide or facilitate cardiac diagnoses (34/127); assist management of previously diagnosed cardiac conditions (55/127); be deployed for cardiovascular prevention (16/127); or be recommended for heart rhythm evaluation (10/127). In 58/185 (31%) cases clinicians did not put the self-monitored data to any evident use and in 12/185 (6.5%) cases patient-generated data prompted an unnecessary referral. In interviews and discussions, clinicians expressed mixed views on patient-generated data but foresaw a need to embrace and plan for this information flow, and proactively address challenges with integration into traditional care pathways. Conclusions: This study suggests patient-generated data are being used for clinical decision-making in ad hoc and opportunistic ways. Given shifts towards remote monitoring in clinical care, accelerated by the pandemic, there is a need to consider how best to incorporate patient-generated data in clinical processes, introduce relevant training, pathways and governance frameworks, and manage associated risks

Blood pressure measurement: a call to arms

Our hard-pressed workforce may view the linked article by Clark and colleagues with a mixture of interest and trepidation. Their systematic review builds on earlier work to estimate the prevalence of inter-arm difference (IAD) in blood pressure (BP) in populations relevant to primary care. Pooled estimates of prevalence for systolic IAD of ≥10 mmHg were 11% in patients with hypertension, 7% for those with diabetes, and just under 4% in the general adult population. GPs are masters of distilling from their training and experience the shortest route to a clinical decision. This does not generally involve checking BP in both arms. Yet, paradoxically, this new evidence could reduce workload, because accurate identification of IAD in a minority of patients, and the exclusion of this condition in the majority, might inform a more rational and streamlined approach to blood pressure management in both groups

Why Are Outcomes Different for Registry Patients Enrolled Prospectively and Retrospectively? Insights from the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF).

Background: Retrospective and prospective observational studies are designed to reflect real-world evidence on clinical practice, but can yield conflicting results. The GARFIELD-AF Registry includes both methods of enrolment and allows analysis of differences in patient characteristics and outcomes that may result. Methods and Results: Patients with atrial fibrillation (AF) and ≥1 risk factor for stroke at diagnosis of AF were recruited either retrospectively (n = 5069) or prospectively (n = 5501) from 19 countries and then followed prospectively. The retrospectively enrolled cohort comprised patients with established AF (for a least 6, and up to 24 months before enrolment), who were identified retrospectively (and baseline and partial follow-up data were collected from the emedical records) and then followed prospectively between 0-18 months (such that the total time of follow-up was 24 months; data collection Dec-2009 and Oct-2010). In the prospectively enrolled cohort, patients with newly diagnosed AF (≤6 weeks after diagnosis) were recruited between Mar-2010 and Oct-2011 and were followed for 24 months after enrolment. Differences between the cohorts were observed in clinical characteristics, including type of AF, stroke prevention strategies, and event rates. More patients in the retrospectively identified cohort received vitamin K antagonists (62.1% vs. 53.2%) and fewer received non-vitamin K oral anticoagulants (1.8% vs . 4.2%). All-cause mortality rates per 100 person-years during the prospective follow-up (starting the first study visit up to 1 year) were significantly lower in the retrospective than prospectively identified cohort (3.04 [95% CI 2.51 to 3.67] vs . 4.05 [95% CI 3.53 to 4.63]; p = 0.016). Conclusions: Interpretations of data from registries that aim to evaluate the characteristics and outcomes of patients with AF must take account of differences in registry design and the impact of recall bias and survivorship bias that is incurred with retrospective enrolment. Clinical Trial Registration: - URL: http://www.clinicaltrials.gov . Unique identifier for GARFIELD-AF (NCT01090362)

Long-Term Conditions Questionnaire (LTCQ): initial validation survey among primary care patients and social care recipients in England

The aim of this study was to validate a new generic patient-reported outcome measure, the Long-Term Conditions Questionnaire (LTCQ), among a diverse sample of health and social care users in England.Cross-sectional validation survey. Data were collected through postal surveys (February 2016-January 2017). The sample included a healthcare cohort of patients recruited through primary care practices, and a social care cohort recruited through local government bodies that provide social care services.1211 participants (24% confirmed social care recipients) took part in the study. Healthcare participants were recruited on the basis of having one of 11 specified long-term conditions (LTCs), and social care participants were recruited on the basis of receiving social care support for at least one LTC. The sample exhibited high multimorbidity, with 93% reporting two or more LTCs and 43% reporting a mental health condition.The LTCQ's construct validity was tested with reference to the EQ-5D (5-level version), the Self-Efficacy for Managing Chronic Disease scale, an Activities of Daily Living scale and the Bayliss burden of morbidity scale.Low levels of missing data for each item indicate acceptability of the LTCQ across the sample. The LTCQ exhibits high internal consistency (Cronbach's α=0.95) across the scale's 20 items and excellent test-retest reliability (intraclass correlation coefficient=0.94, 95% CI 0.93 to 0.95). Associations between the LTCQ and all reference measures were moderate to strong and in the expected directions, indicating convergent construct validity.This study provides evidence for the reliability and validity of the LTCQ, which has potential for use in both health and social care settings. The LTCQ could meet a need for holistic outcome measurement that goes beyond symptoms and physical function, complementing existing measures to capture fully what it means to live well with LTCs

Identifying and managing non-complex fractures

Clinical opinion piece on the role of the nurse in identifying and managing non-complex fractures