Exploring participation: older people on discharge from hospital

ISSUES AND INNOVATIONS IN NURSING PRACTICE

Exploring participation: older people on discharge from hospital

Kathryn Roberts BA PhD

Research Fellow, Centre for Health Research and Evaluation, Ormskirk, Lancashire, UK

Submitted for publication 17 October 2001

Accepted for publication 30 July 2002

Correspondence:

Kathryn Roberts,

Centre for Health Research and Evaluation,

Edge Hill,

Ormskirk,

Lancashire L39 4QP,

UK.

E-mail: [email protected]

ROBERTS K (2002)ROBERTS K. (2002) Journal of Advanced Nursing 40(4), 413–420

Exploring participation: older people on discharge from hospital

Background and aim. User participation has been a widely researched and debated

phenomenon in the formulation and implementation of health and social care policy

and indeed wider public sector policy in the United Kingdom (UK), yet there

remains a vast array of definitions of the term and great variety in the findings of

empirical studies. The aim of this paper is to discuss the main findings of an

empirical study in order to build upon existing evidence and interpretation relating

to user participation in health and social care.

Method. The study reported here was carried out in the UK and explored the extent

to which older people were able and willing to assume an active role in the process

of using health and social care. Hospital discharge and the period shortly afterwards

was the process under investigation. This study used a multi-method approach

incorporating both quantitative and qualitative approaches; data from 260 ques-

tionnaires and 30 interviews were included.

Findings. The majority of respondents felt that they had been involved in decisions

regarding their discharge from hospital. All welcomed advice from professionals and

some preferred service providers to make decisions on their behalf.

Discussion. Arnstein’s ladder of citizen participation is drawn upon in analysing the

findings and notions of ‘partnership’, ‘relationship’, ‘communication’ and ‘pater-

nalism’ are discussed.

Keywords: participation, decision-making, hospital discharge, older people

Background and aim

Participation by potential and actual service users in the

formulation and implementation of public services policy in

the United Kingdom (UK) is certainly not a new concept

(Pateman 1970, Boaden et al. 1982, Deakin & Wright 1990,

Croft & Beresford 1992). In the provision of health and

social welfare, user-orientated care and an active role for

service users have gained greatly in prominence over the last

two decades. The Conservative government in the late 1980s

explicitly promoted the participation of service users and

informal carers in decisions about their own care provision,

along with associated concepts such as information provi-

sion, choice and simplified complaints procedures (Depart-

ment of Health 1989a, 1989b, 1991). With specific reference

to the National Health Service, the New Labour government

has placed patient and public involvement central to setting,

delivering and monitoring standards of care and to quality

improvement (Department of Health 1998) and has empha-

sized the importance of obtaining and acting upon user views

(Department of Health 2000, 2001).

The aim of this paper is to discuss the main findings of an

empirical study in order to build upon existing evidence and

interpretation relating to user participation in health and

social care. The objective of the empirical study was to

explore the views and experiences of older users (70 years

and over) of health and social care regarding service use and

decision-making with particular reference to participation.

The focus was hospital discharge and the period shortly

afterwards. The study explored the concepts of participation,

representation, access, choice, information and redress,

derived from the work of Potter (1988), Barnes et al. (1990)

� 2002 Blackwell Science Ltd 413

and Deakin and Wright (1990). In relation to the public

sector, these authors perceive these factors as necessary to

shift the balance of power towards users, as relating to user

control and as necessary for the position of users to be fully

recognized and strengthened. The concepts were used to

analyse both how far services are orientated towards users

and the extent to which users are able and willing to assume

an active role. Whilst it is acknowledged that these concepts

are inter-related to a large extent, the findings relating to

participation and representation only are reported here.

Definitions

‘Participation’ as a concept is very broad and open to

interpretation. This is acknowledged by most authors on the

subject who clarify their use of the term, for example, Boaden

et al. (1982), Richardson (1979, 1983) and Brownlea (1987).

The difficulties in doing so, and yet the reason why further

exposition is required, are suggested by Croft and Beresford

(1992), who begin their article on the politics of participation

by claiming participation to be ‘one of those contentious

words…which can seem to mean everything and nothing’

(p. 20). Also of note is the plethora of similar and related

terms which are often used interchangeably or alongside

participation (Arnstein 1969, Croft & Beresford 1992, Jewell

1996a, 1996b; Cahill 1998) including involvement, consul-

tation, collaboration and partnership. Ashworth et al. (1992)

contend that involvement, collaboration and partnership do

not necessarily mean genuine participation. Cahill (1996),

however, in formulating a concept analysis of patient

participation, placed these terms in a hierarchy rising from

involvement/collaboration through participation and finally

to partnership. Arnstein (1969), in her ‘ladder’ of citizen

participation, which rises from manipulation to citizen

control, denotes consultation as ‘tokenism’ yet partnership

as indicative of ‘citizen power’. The study reported here

explored involvement and consultation as indicative of

participation and users assuming an active role.

The study focused on individuals playing an active role in

decisions relating to their own personal care, that is, direct

participation or interaction with service providers or

decision-makers on an individual basis. This contrasts to

collective and indirect participation in the formulation of

policy. Similarly, representation was defined as the direct

involvement of informal third parties (mainly family and

friends) in relation to individual care decisions. Barnes et al.

(1990) group participation and representation together,

broadly defining the terms as enabling the user’s views to

be heard, and discuss the roles of family members and

advocates. Jewell (1994) discusses the involvement of family

or a carer as an element of participation.

For older service users, playing a role in the discharge

process and decision-making has been suggested to produce

greater satisfaction and better adjustment (Coulton et al.

1989, Abramson 1990, Jewell 1996b, Bull et al. 2000). These

positive factors perhaps provide the rationale for user

participation in health care delivery generally, and in hospital

discharge as an important individual element. The role of

nurses in promoting and facilitating an active user role, both

as a professional group and as part of the multidisciplinary

team, cannot be disputed.

Less benevolent motives for encouraging user participation

have also been identified, for example, gaining support for

decisions already taken (Brownlea 1987) and how an

impression of encouraging participation may simply be

tokenism (Arnstein 1969) or may actually lessen user power

and influence (Clayton 1988) and legitimize that of the

professional (Richardson 1979).

The study

Objective

The objective of the study was to explore the views and

experiences of older users (70 years and over) of health and

social care regarding service use and decision-making with

reference to how far they were willing and able to assume an

active role.

Method

All people aged 70 years and over discharged from one

District General Hospital in UK to a private address over a

5-month period in 1997 (n ¼ 518) were sent a questionnaire

in the month following their return home. Two hundred and

sixty completed questionnaires were returned, representing a

response rate of 50%. Table 1 shows the demographic

characteristics of respondents.

Male Female 70–77 years 78 years and over Lives alone* Lives with others*

125 135 131 129 103 152

48% 52% 50% 50% 40% 60%

*Five missing cases.

Table 1 Characteristics of Questionnaire

respondents (n ¼ 260)

K. Roberts

414 � 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 40(4), 413–420

Data collection and consent

Questionnaires contained mainly questions requiring closed

responses and a small number of open-ended questions. A

comprehensive covering letter was enclosed explaining the

purpose of the study, how names had been selected and

assurances regarding confidentiality. Seventeen statements

addressing the discharge process and subsequent use of

welfare provisions were listed to be answered on a ‘yes/

unsure/no’ scale. The statements were devised on the basis of

policy documentation relating to hospital discharge and

subsequent care and addressed the six factors indicating user

influence or control (participation, representation, access,

choice, information and redress), for example, involvement

of themselves and their carer(s) in needs assessment and

decision-making, provision of information and choice, and

ability to express their wishes.

Piloting the survey instrument

The questionnaire and covering letter were piloted in face-

to-face encounters at two local day centres with service users

of 70 years and over and recently discharged from hospital.

Three pilot phases in total were carried out, with each of the

three versions of the questionnaire being piloted with three or

four individuals. The changes made in each case were to

vocabulary and terminology.

Sampling for subsequent interview

Respondents were asked to indicate on the questionnaire if

they would be willing to take part in an interview. Ques-

tionnaire respondents were purposively sampled (Patton

1990, Mason 1996) on the basis of age, gender and house-

hold composition for inclusion in in-depth semi-structured

interviews (n ¼ 30) (Table 2). Random sampling may not

have yielded a sufficiently broad range of these general

characteristics. Mason (1996) discusses how purposive

sampling enables meaningful comparisons to be made in

relation to the research questions, theory and type of

explanation sought. However, no claims to representative-

ness can be made. Interviews were conducted until saturation

was reached, i.e. no new information was generated.

Interview schedule

The interview schedule was semi-structured according to the

six aspects of user influence and control and addressed ways

in which policy documentation advocated an active role for

users of health and social care. The questions related to

specific aspects of hospital discharge and the subsequent use

of welfare provisions, and aimed to expand on the responses

gained to the postal survey.

In addition to gaining service users’ detailed responses of

service use, interviews also attempted to ascertain their ability

and willingness to assume an active role in the use of health

and social care. An interview setting was felt to be most

appropriate to questioning about attitudes, providing the

opportunity to explore issues in greater depth rather than

reducing them to single statements. The interview schedule

was piloted with three questionnaire respondents; no changes

were required.

During analysis the data from questionnaires and inter-

views were used to complement one another, an approach

discussed in a growing body of literature (Brannen 1992,

Weinholtz et al. 1995, Pearson 1997).

Ethical considerations

Ethical approval was gained from the relevant Local

Research Ethics Committee. Robson (1993) believes a major

ethical consideration to be whether respondents can ration-

ally, knowingly and freely give informed consent. Informed,

voluntary, written consent (Polit & Hungler 1993) was

gained from service users before interviews commenced and

following detailed verbal explanation. Respondents were

assured regarding confidentiality. It was also made clear that

any questions they had would be answered and that they

were free to withdraw at any stage without providing a reason

and with no detrimental effect on their care. Interviews were

conducted in respondents’ homes for their convenience. They

were tape-recorded, with respondents’ consent, transcribed

and the tape destroyed within 6 weeks of the interview.

Identification of questionnaires and interview transcripts was

by means of a number and this was kept completely separate

from respondents’ identifying information.

Data analysis

Quantitative data from the questionnaires was analysed using

SPSS (version 7Æ0). Content and thematic analyses were per-

formed (Patton 1990, Silverman 1993, Miles & Huberman

1994) on the qualitative data. All transcripts were read

thoroughly and analytical categories (Miles & Huberman

1994) were developed.

Table 2 Characteristics of interviewees

(n ¼ 30)Male Female 70–77 years 78 years and over Lives alone Lives with others

14 16 17 13 15 15

Issues and innovations in nursing practice Exploring participation

� 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 40(4), 413–420 415

Findings

Findings relating to participation and representation only are

reported here.

Table 3 summarizes the perceptions of questionnaire

respondents regarding involvement in needs assessment and

decision-making about the care they would receive when they

returned home from hospital.

Of those questionnaire respondents who felt that they

had been involved in decisions regarding care (164 of 260),

most felt that their views had been taken into considera-

tion. Comments included ‘not much’ (eight respondents);

‘satisfactorily’ or ‘adequately’ (16); ‘quite good’ or ‘fairly

well’ (15); ‘considerably’ or ‘very much’ (26) and ‘com-

pletely’ (11).

Although these findings are not based on any objective data

or observation, they suggest relatively high levels of involve-

ment of both service users and their family/friends.

The following comments indicate the seemingly advanta-

geous position of respondents who have family or friends (as

representatives) to articulate on their behalf or otherwise help

or provide support in their contacts with care professionals:

Not sure, social worker liaised with [friend] on my behalf. (female,

82 years, lives alone)

Very much, my wife and I were told exactly what was happening and

what after care treatment was available. (male, 72 years, lives with

wife)

Everyone listened to what I wanted and discussed it with my family.

(female, 81 years, lives with husband)

My views were openly discussed when my wife was present. (male,

71 years, lives with wife)

Perceptions of family or friends’ involvement in decision-

making (Table 3) were that 50% (n ¼ 260) had been

involved. This demonstrates the potential role of informal

carers in discharge planning and reinforces the value of

examining participation of third parties (as representation)

alongside the participation of service users.

Reinforcing the questionnaire findings, most interviewees

reported having been consulted, or at least spoken with,

about their discharge from hospital. Interviews provided the

opportunity to collect more in-depth data. Most (22 of 30)

had spoken with a social worker or other front line worker

before or very shortly after discharge about their perceived

needs and service requirements. One man succinctly gave

what appeared a widespread perception of what ‘involve-

ment’ could entail as follows:

I think I have been pretty well involved. They’ve told me what they

were going to do, and they’ve done it. (male, 74 years, lives alone)

The extent to which service users assumed a proactive,

reactive or passive role was sought at interview. Seven

interviewees (7 of 30), all of whom rated their health

positively, felt that they had initiated the discharge process

or at least asked when they could expect to return home and

expressed an unprompted desire to do so. Perhaps unsurpris-

ingly, all waited for ‘permission’ from a doctor or consultant

before leaving inpatient care.

Attitudes towards participating were also explored at

interview. Understandably, service users felt that advice from

professionals was valuable and many were content for them

to take decisions on their behalf. The following comments are

examples:

I left it entirely to them. They ask you what you want…and I said

‘Well you know more about it than I do’. (female, 72 years, lives

alone)

It was just decided that [the district nurses] would come, I wasn’t

consulted, but I didn’t want to be. (male, 70 years, lives with wife)

Comments such as ‘They’re the experts’, ‘They know best’,

‘It’s naturally better to take their advice’ and ‘I haven’t

sufficient knowledge’ were typical, demonstrating why ser-

vice users may not wish for an active role. Eighteen

interviewees (18 of 30) made specific comments, when

questioned, regarding wishing to be involved in decisions

about their care, whilst seven (7 of 30) definitely did not wish

to be, largely on the grounds of poor health.

Respondents’ ability to express their wishes was viewed as

central to how far they were able or willing to be involved in

decision-making. Over half of interviewees (16 of 30) felt

that, if asked, they would express an opinion to care

Involved in needs

assessment*

Involved in

decision-making

Family/friends involved

in decisions

Yes 161 (63%) 164 (63%) 129 (50%)

No 60 (24%) 85 (33%) 109 (42%)

Unsure 34 (13%) 11 (4%) 22 (8%)

*Five missing cases.

Table 3 Perceptions of involvement

in needs assessment and decision-making,

questionnaire respondents (n ¼ 260)

K. Roberts


professionals. The majority of these rated their health

positively; three (3 of 30) specifically cited ill health as a

reason for not expressing an opinion.

Communication with care professionals more generally

was explored as a fundamental aspect of participation

(Table 4) and indeed a central element of care provision.

Although taken together, these responses suggest that most

people felt quite able to express their wishes to professionals,

of more concern is the sizeable minority who were unsure of

this ability. The statistically significant association between

these two findings (P < 0Æ05) reveals how almost 20% of

questionnaire respondents (50 of 260) felt unable to express

their wishes to hospital or social work personnel.

At interview, a distinction was made between doctors or

consultants and other front-line workers in terms of

communication. Only 10 interviewees (10 of 30) felt able

to communicate with doctors or consultants, compared with

19 (19 of 30) feeling able to communicate with other front-

line workers. This obviously has implications for involve-

ment in decision-making regarding discharge and subsequent

care provision in terms of the professionals who may have

a role.

Study limitations

It was not possible to limit the sampling process by medical

condition in order to focus the study more specifically. Also

data were not available about service users’ actual involve-

ment to verify self-reports. This would have added an

interesting dimension. However patients’ self-reports and

perceptions regarding participation are important to consider

in the provision of care.

Discussion

Recent and current UK policy advocates user participation,

and studies have shown positive outcomes for older people

having a role in decision-making (Coulton et al. 1989,

Abramson 1990, Jewell 1996b, Bull et al. 2000). The

complexity yet importance of hospital discharge and planning

has been well established (Waters 1987, Victor & Vetter

1988, Jewell 1993, Tierney & Closs 1993, Chapman & Jack

1996, Bull & Roberts 2001), with the involvement of users

and informal carers representing an important dimension.

The findings presented here and discussion with reference to

previous studies examining participation and involvement

therefore have important implications for the nursing role.

The findings of previous studies of older people’s partici-

pation around hospital discharge vary in how much patients

have been involved or wish to be involved in decisions. For

example, studies show that many older patients are consulted

or involved in decisions and care planning (Waters 1987,

Coulton et al. 1989, Fairhurst et al. 1996), whilst many do

not feel they are adequately involved (Jewell 1993, Congdon

1994, Bull & Roberts 2001). Other studies have found that

older people do not wish for an active role (Beisecker 1988,

Jewell 1996b) and that older users’ views are subordinate to

those of family members or professionals (Abramson 1988,

Jewell 1996a).

In this discussion, general issues around the definition and

interpretation of participation are highlighted and implica-

tions for the nursing role explored. A number of the ‘rungs’ of

Arnstein’s ladder of citizen participation (1969) (Figure 1) are

relevant to the provision of welfare and can be applied to the

findings presented. Arnstein can be argued to be seeking to

demonstrate the many dimensions of participation rather

Table 4 Ability to express wishes to professionals, questionnaire

respondents (n ¼ 260)

Able to express wishes

when in hospital

Able to express wishes

to social workers

Yes 192 (74%) 153 (59%)

No 50 (19%) 57 (22%)

Unsure 18 (7%) 50 (19%)

Figure 1 Arnstein’s ladder of citizen participation. [Reprinted by

permission of the Journal of the American Planning Association,

1969, 35(4)].



than aiming to define it. Importantly, she demonstrates that

participation does not exist on only one level.

The most applicable ‘rungs’ are those in the middle range,

denoted ‘degrees of tokenism’ that ‘allow the have-nots to

hear and to have a voice’ (p. 217), that is, informing,

consultation and placation. These tokens all suggest a passive

role for participants in being informed, consulted or placated.

Only through consultation, which was apparent in this study

and which can further be promoted by nurses, do the degrees

of tokenism imply any opportunity for activity on the part of

service users. This level of participation can be argued to be

compatible with the definitions of participation given by

Maxwell and Weaver (1984) and by Brownlea (1987), that is,

involvement in the decision-making process or being one of a

number of people consulted on an issue or matter. McEwen

et al. (1983), however, believe that individuals must be active

to be defined as participating.

The top rungs in Arnstein’s model – partnership, delegated

power and citizen control, collectively denoted ‘degrees of

citizen power’ – suggest a much greater shift in the balance of

power towards service users than any ‘degrees of tokenism’.

Partnership is perhaps the most realistic concept to apply

to welfare provision. It could be argued that if individual

service users, or their representatives, participate in any way

in decision-making surrounding their discharge, they have

been a partner in the process. This is consistent with

Arnstein’s belief that partnership is apparent when citizens

‘negotiate and engage in trade-offs with traditional power-

holders’ (p. 217). Bull et al. (2000) show positive outcomes

of a professional-older patient partnership model for dis-

charge planning.

Whilst the perception of Cahill (1996) of participation

meaning involvement in some phase of the health care

process is applicable to the findings of this study, her

perception of partnership as equal control for service users

and providers at all phases was not in evidence. Cahill (1996)

discusses how a relationship with decision-makers is neces-

sary for patient participation to take place. As with partner-

ship, the fact that the majority of respondents in this study

had been consulted or felt that they had been involved

suggests that a relationship existed. Representatives who

became involved may also be interpreted as forming a

relationship with decision-makers. However the definition

of relationship is obviously crucial. Ashworth et al. (1992)

discuss the inequalities which may be present in the relation-

ship and how participation is dependent on meaningful

interaction whereby individuals have the right to speak and

to be listened to. Boaden et al. (1982) similarly define

participation as the right of people to make representations

and express their views. It appeared in this study that

meaningful interaction may have taken place, as most

respondents felt that their views had been taken into

consideration.

Ease of communication and interaction must be seen as key

factors in determining the nature of any relationship or

partnership which is established between service users and

service providers (West & Frankel 1991, Bull 1994, Clark

1996) and as crucial for effective discharge planning (Jewell

1993, Bull & Roberts 2001). The fact that the majority of

questionnaire respondents had felt able to express their

wishes to both hospital and social work personnel, whether

this was unprompted or when invited to do so, suggests the

possibility that meaningful interaction had taken place. For

almost 20% of questionnaire respondents (50 of 260),

however, this was not the case, perhaps suggesting the

requirement for representation from family members or

friends.

It was clear that respondents with family or friends who

became involved in their care or were available to be

informed, consulted or to become a partner in the discharge

process were in a stronger position in terms of being involved

themselves than those with no such representatives. How-

ever, potential conflict between older people and their

representative(s) can adversely affect user participation in

discharge planning (Abramson 1990, Dill 1995, Jewell

1996a, Bull & Roberts 2001) and is an important factor to

be considered by nurses when seeking input from family or

friends. No such conflict was revealed by this study.

The difference in ease of communication with doctors or

consultants compared with other front line workers, revealed

amongst interviewees and reflecting previous studies

(Beisecker 1988, Jewell 1994, Jewell 1996b), gives a further

insight into the extent to which meaningful interaction is a

possibility. A minority of interviewees felt able to commu-

nicate with doctors or consultants (reported in greater detail

in Roberts 2000) suggesting that a relationship was not

always established. However, social workers or other front

line workers were the professionals cited by interviewees who

felt that they had been consulted regarding their discharge

and after care. This suggests that, although service users are

likely to interact with doctors and consultants during the

course of a hospital stay, they are not the professionals with

whom discharge arrangements are discussed.

The nature of the nursing role and the close contact with

service users, coupled with the discussion around service

users establishing a ‘partnership’ or ‘relationship’ and ease of

communication, may indicate that front line nurses are

ideally placed to encourage and facilitate an active role for

service users. With the importance of multi-disciplinary

teamwork in discharge planning, it may even be questioned

K. Roberts


whether individual patients should be viewed as part of the

team.

The bottom rungs of Arnstein’s ladder, ‘therapy’ and

‘manipulation’, actually classed as nonparticipation, can be

defined as methods employed by those in authority, under the

guise of enhancing participation, but which actually have the

opposite effect. Evidence of neither of these could be gleaned

from the findings reported here, which relate only to user

views and experiences.

The existence of three types of people in relation to

participation can be identified from this study: those who

expressed their views and opinions or stated their preferences

with no prompting, those who expressed their views and

opinions or stated their preferences when invited to do so and

those who accepted the decisions that were made. The first of

these, that is, interviewees who expressed an unprompted

desire to return home, were obviously those who displayed

the greatest willingness to participate. Even so, they still

preferred ‘experts’ to have the final say. People falling into the

second category could be both users wishing to play an active

role and those simply responding to the role that they felt was

expected of them, as found by Waterworth and Luker (1990).

The last scenario was revealed amongst a number of

interviewees who, having been offered the opportunity to

participate, preferred professionals to act on their behalf.

This may be interpreted as because of lack of specialized

knowledge, difficulty in making the link between need and

appropriate care (Leavey et al. 1989), fear of making the

wrong decision, or it may be indicative of a traditional role

for nurses and patients whereby ‘nurse knows best’ (Jewell

1996a). All these factors appeared related to participation in

this study and can equally be related to expectations of

patient and practitioner roles arising from past experience.

Unlike previous studies (Waterworth & Luker 1990, Jewell

1996a) these findings suggest that patients did not ‘toe the

line’ and participate just because they felt they should when

provided with opportunities to do so.

At the extreme, users preferring professionals to act on

their behalf could be interpreted as a wish for paternalistic

care, whereby professionals take decisions in the best

interests of the patient. Indeed, although the majority of

service users felt that they had been involved in decision-

making, all perceived an important role for professional input

in such processes, a feature of both paternalistic and

consumerist care (Beisecker & Beisecker 1993, Hogg 1994).

Explicitly advocated in recent years in official policy in UK,

user participation at a basic level may be viewed as

demonstrating respect for the views and wishes of service

users and for them to be informed and to play a role

regarding their own care. These are all important elements of

nursing care in any context and it must be acknowledged that

the nursing approach taken may influence the participation of

service users and informal carers in needs assessment and

decision-making. However, the diversity of views and

experiences within even a small sample of service users has

been highlighted, reinforcing that each person must be

treated as an individual and their ability and willingness to

play an active role at different stages throughout their care

taken into consideration.

Conclusion

The discussion here aims to contribute to existing evidence

and interpretation around user participation in the provision

of health and social care and around different ways in

which users may be defined as playing an active role with

specific reference to older people and hospital discharge.

Implications for nursing have been addressed. There remains

much scope for further investigation in this area. Remaining

with the individual user, future research could further

explore specific reasons behind the level of involvement

users may wish to have in decisions about their care and

could aim to build on studies comparing experience and

behaviour across age groups and by medical condition.

Looking at the role for patients and the public beyond their

own individual care, the structures and organizations

currently being established will warrant investigation once

fully implemented, for example, the operation of Patients’

Forums and the Patient Advice and Liaison Service at

National Health Services (NHS) trust and primary care trust

level and ‘Voice’ at Strategic Health Authority level

(Department of Health 2001).

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Documents

Exploring participation: older people on discharge from hospital