Needs assessment in long-term care: expression of national principles for priority setting in service allocation.

BACKGROUND: Long-term care services for older adults are characterised by increasing needs and scarce resources. Political strategies have led to the reorganisation of long-term care services, with an increased focus on "ageing in place" and efficient use of resources. There is currently limited research on the processes by which resource allocation decisions are made by service allocators of long-term care services for older adults. The aim of this study is to explore how three political principles for priority setting in long-term care, resource, severity and benefit, are expressed in service allocation to older adults. METHODS: This qualitative study uses data from semi-structured individual interviews, focus groups and observations of service allocators who assess needs and assign long-term care services to older adults in Norway. The data were supplemented with individual decision letters from the allocation office, granting or denying long-term care services. The data were analysed using reflexive thematic analysis. RESULTS: The allocators drew on all three principles for priority setting when assessing older adults' long-term care needs and allocating services. We found that the three principles pushed in different directions in the allocation process. We identified six themes related to service allocators' expression of the principles: (1) lowest effective level of care as a criterion for service allocation (resource), (2) blanket allocation of low-cost care services (resource), (3) severity of medical and rehabilitation needs (severity), (4) severity of care needs (severity), (5) benefit of generous service allocation (benefit) and (6) benefit of avoiding services (benefit). CONCLUSIONS: The expressions of the three political principles for priority setting in long-term care allocation are in accordance with broader political trends and discourses regarding "ageing in place", active ageing, an investment ideology, and prioritising those who are "worse off". Increasing attention to the rehabilitation potential of older adults and expectations that they will take care of themselves increase the risk of not meeting frail older adults' care needs. Additionally, difficulties in defining the severity of older adults' complex needs lead to debates regarding "worse off" versus potentiality in future long-term care services allocation. TRIAL REGISTRATION: Not applicable.

Service Allocators' Experiences of Ethical Dilemmas and Strategies in Long-Term Care: A Qualitative Study.

The provision of long-term care services for older adults is characterised by increasing needs and scarce resources, leading to ethical dilemmas. This qualitative study explored the ethical dilemmas experienced by healthcare professionals when allocating long-term care services to older adults and the strategies used to handle ethical dilemmas. Data from semi-structured individual interviews, focus group interviews, and observations of service allocators assessing needs and assigning long-term care services to older adults were analysed using content analysis. The overarching theme was the struggle for safe and equitable service allocation. The identified dilemmas were: (i) Struggles with A Just Allocation of Services due to Limited Time and Trust, (ii) Pressure on Professional Values Concerning Safety and Dignity, and (iii) Difficulties in Prioritising One Group Over Another. The strategies to deal with ethical dilemmas were: (i) Assessing Needs Across the Entire Municipality, (ii) Ensuring Distance to Service Recipients, (iii) Working as a Team, and (iv) Interprofessional Decision-Making. Scarce resources, organisational limitations, and political expectations drive the ethical dilemmas in long-term care service allocation. An open public discussion regarding the acceptable minimum standard of long-term care is needed to reduce the ethical pressure on service allocators.

Removal of phytotoxins in filter sand used for drinking water treatment.

Phytotoxins - toxins produced by plants - are contaminants with the potential to impair drinking water quality. They encompass a large group of toxic, partially persistent compounds that have been detected in seepage waters and in shallow wells used for drinking water production. If phytotoxins enter wells used for drinking water production, it is essential to know if the drinking water treatment processes will remove them from the water phase. However, it is currently unknown whether phytotoxins remain stable during traditional groundwater treatment using sand filters as the main treatment process. The objective of this study is to investigate removal potential of phytotoxins in biological sand filters and to asses if the removal potential is similar at different waterworks. Microcosms were set up with filter sand and drinking water collected at different groundwater-based waterworks. To be able to monitor phytotoxin removal ptaquiloside, caudatoside, gramine, sparteine, jacobine N-oxide, senecionine N-oxide and caffeine were applied at initial concentrations of 300 µg L-1, which is approx. two orders of magnitude higher than currently detected in environment, but expected to cover extreme environmental conditions. Removal was monitored over a period of 14 days. Despite the high initial concentration, all filter sands removed ptaquiloside and caudatoside completely from the water phase and at waterworks where pellet softening was implemented (pH 8.4) prior to rapid sand filtration, complete removal occurred within the first 30 min. All filter sands removed gramine and sparteine, primarily by a biological process, while jacobine N-oxide, senecionine N-oxide and caffeine were recalcitrant in the filter sands. During degradation of ptaquiloside and caudatoside we observed formation and subsequent removal of degradation products pterosin B and A. Filter sands with the highest removal potential were characterised by high contents of deposited iron and manganese oxides and hence large specific surface areas. Difference between bacterial communities investigated by 16S rRNA gene analyses did not explain different removal in the filter sands. All five investigated filter sands showed similar degradation patterns regardless of water chemistry and waterworks of origin. In drinking water treatment systems biological sand filters might therefore remove phytotoxin contaminants such as ptaquiloside, caudatoside, gramine, sparteine, while for other compounds e.g. jacobine N-oxide, senecionine N-oxide further investigations involving more advanced treatment options are needed.