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Ann-Marie Towers

Senior Research Fellow

 

I joined CHSS as a Senior Research Fellow in April 2019, after sixteen years at the Personal Social Services Research Unit (PSSRU) at the University of Kent. I am a collaborator for the NIHR Research Design Service South East, a panel member for NIHR Research for Patient Benefit (South East) and lead a programme of work to develop, test and support the Adult Social Care Outcomes Toolkit (ASCOT).
I am a mixed-methods researcher, using both qualitative and quantitative techniques. I have a special interest in how we might employ qualitative methods, such as observations, supported interviewing techniques and forms of adapted communication, to try and ascertain the views and experiences of care home residents and people with cognitive and communication difficulties. I have been the principal or co-investigator on several grants and have received funding from the Big Lottery fund, the NIHR School for Social Care Research, NIHR Health Services and Delivery, NIHR Research for Patient Benefit and most recently, from NIHR for one of the new Policy Research Units (Quality, Safety and Outcomes of Health and Social Care Research Unit).
As well as traditional research, I deliver training and consultancy in the UK and internationally to support the wider use of the Adult Social Care Outcomes Toolkit in research, policy and practice. Recent examples include:

  • Writing and delivering new ‘train the trainer’ courses in Australia to support the use of ASCOT in care planning conversations.
  • Working with the Northern Ireland Health and Social Care Board to support their use of ASCOT in the evaluation of self-directed support.
  • Training NHS England to use the ASCOT in their national evaluation of the care home vanguard sites.
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Also view these in the Kent Academic Repository

Article
Rand, S., Towers, A. and Caiels, J. (2020) "Letter to the Editor re: McEwan et al (2019) Moving on from Quality Assurance: Exploring Systems — Outcomes in Disability Services", Journal of Policy and Practice in Intellectual Disabilities. Wiley-Blackwell Publishing Ltd, pp. 376-378. doi: 10.1111/jppi.12365.

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Musa, M., Akdur, G., Hanratty, B., Kelly, S., Gordon, A., Peryer, G., Spilsbury, K., Killett, A., Burton, J., Meyer, J., Fortescue, S., Towers, A., Irvine, L. and Goodman, C. (2020) "Uptake and use of a minimum data set (MDS) for older people living and dying in care homes in England: a realist review protocol", BMJ Open. BMJ. doi: 10.1136/bmjopen-2020-040397.

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Introduction: Care homes provide nursing and social care for older people who can no longer live independently at home. In the UK, there is no consistent approach to how information about residents' medical history, care needs, and preferences are collected and shared. This limits opportunities to understand the care home population, have a systematic approach to assessment and documentation of care, identify care home residents at risk of deterioration, and review care. Countries with standardised approaches to residents' assessment, care planning and review (e.g. Minimum Data Sets (MDS)) use the data to understand the care home population, guide resource allocation, monitor services delivery and for research. The aim of this realist review is to develop a theory-driven understanding of how care homes staff implement and use MDS to plan and deliver care of individual residents. Methods and analysis: A realist review will be conducted in three research stages. Stage one will scope the literature and develop candidate programme theories of what ensures effective uptake and sustained implementation of an MDS. Stage two will test and refine these theories through further iterative searches of the evidence from the literature to establish how effective uptake of an MDS can be achieved. Stage three will consult with relevant stakeholders to test or refine the programme theory (theories) of how an MDS works at the resident level of care for different stakeholders and in what circumstances. Data synthesis will use realist logic of analysis to align data from each eligible article with possible context-mechanism-outcome (CMO) configurations, or specific elements that answer the research questions. Ethics and dissemination: The University of Hertfordshire Ethics Committee has approved this study (HSK/SF/UH/04169). Findings will be disseminated through briefings with stakeholders, conference presentations, a national consultation on the use of an MDS in UK long-term care settings, publications in peer-reviewed journals, and in print and social media publications accessible to residents, relatives, and care home staff. Review registration number: This review protocol is registered on the International Prospective Register of Systematic Reviews (PROSPERO) - CRD42020171323.
Towers, A., Killett, A., Handley, M., Almack, K., Backhouse, T., Bunn, D., Bunn, F., Dickinson, A., Mathie, E., Mayrhofer, A., Mikelyte, R. and Goodman, C. (2020) "Producing 'Top Tips' for care home staff during the COVID-19 pandemic in England: rapid reviews inform evidence-based practice but reveal major gaps", Journal of Long-term Care. International Long Term Care Policy Network.

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Context:The work presented in this paper was undertaken during the first three months of the COVID-19 crisis in the UK. Objectives:The project aimed to respond to questions and concerns raised by front-line care staff during this time, by producing research-based 'Top Tips' to complement emerging COVID-19 policy and practice guidelines. Methods: Eight rapid, expert reviews of published, multidisciplinary research evidence were conducted to help answer care home workers' questions about 'how' to support residents, family members and each other at a time of unprecedented pressure and grief and adhere to guidance on self-distancing and isolation. A review of the emerging policy guidelines published up to the end of April 2020 was also undertaken. Findings: The rapid reviews revealed gaps in research evidence, with research having a lot to say about what care homes should do and far less about how they should do it. The policy review highlighted the expectations and demands placed on managers and direct care workers as the pandemic spread across the UK. Implications: This paper highlights the value of working with the sector to co-design and co-produce research and pathways to knowledge with those who live, work and care in care homes. To have a real impact on care practice, research in care homes needs to go beyond telling homes 'what' to do by working with them to find out 'how'.
Rand, S., Towers, A., Razik, K., Turnpenny, A., Bradshaw, J., Caiels, J. and Smith, N. (2020) "Feasibility, factor structure and construct validity of the easy-read Adult Social Care Outcomes Toolkit (ASCOT-ER)", Journal of Intellectual and Developmental Disability. Taylor & Francis, pp. 119-132. doi: 10.3109/13668250.2019.1592126.

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Background: The ASCOT-ER is an adapted easy-read version of the ASCOT-SCT4, a selfreport measure of social care-related quality of life (SCRQoL) for social care evaluation. In this study, we investigated the instrument's feasibility, construct validity and factor structure. Method: Data were collected from 264 service users in England. Feasibility was evaluated by missing data and help to complete the questionnaire. Scale dimensionality was assessed using exploratory factor analysis. Construct validity was evaluated by hypothesis testing. Results: Convergent validity was supported by moderate to strong correlations between ASCOT-ER and personal wellbeing and overall quality of life, as well as with individual characteristics. Exploratory factor analysis indicated that the ASCOT-ER is a unidimensional scale. Low missingness indicates that the instrument is feasible; however, most respondents needed some level of support to complete the questionnaire. Conclusion: The study provides preliminary evidence of the ASCOT-ER's feasibility, unidimensionality and construct validity.
Smith, N., Towers, A., Palmer, S. and Collins, G. (2019) "Quality of life in older adult care homes: Comparing office hours with out-of-office hours", Journal of Long-Term Care.

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Context: Poorer mortality rates and quality of care in hospitals outside of office hours is well documented. The literature on adult social (long-term) care, and in particular, care homes, is much less developed. There are, however, a few studies that suggest that outside of Monday to Friday between 9.00am and 16.30pm, quality of care in care homes might be lower. Objective(s): The objective of this study was to compare the social care-related quality of life (SCRQoL) of residents in older adult care homes during office hours (0900 to 16.30) with outside of office hours (evenings and weekends). Method(s): We conducted a nested, cross-sectional study, collecting SCRQoL data using the Adult Social Care Outcomes Toolkit at two time points, office hours (Monday-Friday between 9.00 and 16.30) and outside of office hours. We did not examine nigh times in the homes. Data were collected for 99 older adult care home residents in 13 care homes (5 residential and 8 nursing) and analysed using a combination of non-parametric and parametric techniques. Findings: SCRQoL ratings were lower during the weekends and early evenings than during office hours. The differences were most pronounced in the higher order domains of social participation, occupation and control over daily life. Limitations: The study struggled to explain this variation. This work was both exploratory and small in size. We also did not collect data on levels of staffing. Implications: Further work is required to both confirm our findings and explore the reasons for the difference. Nonetheless, this study challenges the traditional model of care, in which social activities and meaningful pastimes are mostly organised during 'office hours'. We observed evenings that were very short, as residents tended to return to their room shortly after dinner, and quiet weekends and this was reflected in residents' quality of life. This is contrary to the rhetoric of care homes being people's own homes, where they would be able to choose to remain active and engaged into the evening and on the weekends, as they may have done throughout their lives.
Smith, N., Towers, A., Collins, G., Palmer, S., Allan, S. and Beecham, J. (2019) "Encouraging managers of care homes for older adults to participate in research", Quality in Ageing and Older Adults. Emerald, pp. 120-129. doi: 10.1108/QAOA-04-2019-0017.

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Purpose: Research in care homes requires the co-operation of care home managers. Noting the challenges faced by the care home sector, this article considers ways in which research studies can encourage care home managers and their homes to participate in research. Approach: The discussion is informed by two research projects which are used to explore methods of encouraging managers of care homes to participate in research. One of the studies included interviews with care home managers to understand their reasons for taking part in research. Findings: This paper outlines and assesses three strategies for encouraging care home managers to participate in research; working in partnership, providing payment and providing personalised feedback on findings. While all the strategies have the potential to encourage care home managers' participation in research, partnership working in particular was found to be fraught with difficulties. Research implications: This paper suggests the research projects could employ any of these strategies to encourage managers of care homes to participate in research. It also suggests that proactive measures could help ameliorate the pitfalls of partnership working. Originality: This paper shows the advantages and disadvantages to using a combination of strategies for encouraging the participation of care home managers in research.The authors would like to thank all the residents, family members, staff and homes who took part in this research and the local authorities who supported it.
Malley, J., Rand, S., Netten, A., Towers, A. and Forder, J. (2019) "Exploring the feasibility and validity of a pragmatic approach to estimating the impact of long-term care: The 'expected' ASCOT method", Journal of Long-Term Care. International Long Term Care Policy Network. Available at: https://journal.ilpnetwork.org/articles/abstract/11/.

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Context: Measuring the impact of long-term Care (LTC) is essential to ensure effective allocation of limited resources. Objectives: We explored the feasibility and validity of a pragmatic approach to evaluation, known as the counterfactual self-estimation of programme participants (CSEPP). CSEPP forms part of the Adult Social Care Outcomes Toolkit (ASCOT), and is referred to as the 'expected' method since participants estimate their expected quality of life in the absence of services. Methods: We used survey data from interviews with 748 LTC users in 22 English local authorities. Questions on self- and interviewer-assessed understanding of the 'expected' questions were used to assess feasibility. Construct validity was assessed by examining hypothesised associations between the expected score and individual characteristics. Bias was assessed by comparing the expected impact estimate to one produced using Forder et al.'s (2014) instrumental variables approach on the same dataset. Findings: We found evidence that the expected method was feasible and the self-estimated counterfactual outcome score valid. There were indications that the method is less appropriate for some groups and it may slightly overestimate the impact of LTC. Limitations: Due to the opportunistic design, exploration of the method's appropriateness for people with mental health problems was limited. The assumption of the between-methods comparison that the instrumental variables estimate of the effect of LTC is unbiased is unlikely to be true. Implications: The expected method is a promising tool for the LTC context, but more research is needed to understand potential sources of bias and its feasibility with certain groups.
Towers, A., Palmer, S., Smith, N., Collins, G. and Allan, S. (2019) "A cross-sectional study exploring the relationship between regulator quality ratings and care home residents' quality of life in England", Health and Quality of Life Outcomes. BMC. doi: 10.1186/s12955-019-1093-1.

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Background: The quality of life of people receiving health and social care is an important indicator of service quality, but the relationship between patient experience and outcomes and regulator quality ratings in England is unknown. In 2013, the health and social care regulator in England, the Care Quality Commission (CQC), introduced a new ratings system and by February 2017, all social care services were inspected and awarded new quality ratings (outstanding, good, requires improvement and inadequate). This study aimed to explore whether quality ratings were associated with residents' quality of life, controlling for confounding variables.
Towers, A., Nelson, K., Smith, N. and Razik, K. (2019) "Using ASCOT in care planning conversations", Australian Journal of Dementia Care, pp. 31-35. Available at: http://journalofdementiacare.com/.

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Report on a joint UK-Australian project which trialled a new and innovative use of the ASCOT tool in residential aged care planning to help staff initiate and hold conversations with residents, including those with dementia, about their emotional and social wellbeing.
Phillipson, L., Smith, L., Caiels, J., Towers, A. and Jenkins, S. (2019) "A Cohesive Research Approach to Assess Care-Related Quality of Life: Lessons Learned From Adapting an Easy Read Survey With Older Service Users With Cognitive Impairment", International Journal of Qualitative Methods. Sage, pp. 1-13. doi: 10.1177/1609406919854961.

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New or adapted methods and tools are needed to ensure the voices of older people with cognitive impairment and dementia are included in evaluations of care services which aim to support their quality of life (QoL). In this study, cognitive interviewing practices were used with a group of 26 older service users with cognitive impairment from two service providers in New South Wales, Australia, to test and modify the Adult Social Care Outcomes Toolkit Easy Read (ER) survey to improve its suitability for this cohort. We used Antonovsky's "sense of coherence" framework to describe our research approach and how it was adapted to provide a manageable, meaningful, and comprehensible experience for our participants. While the modified ER format made the survey more comprehensible and meaningful, it was the techniques of cognitive interviewing that made the research approach manageable. We argue that while ER does support the research process for older service users with cognitive impairment, combining ER pictorials with the qualitative interactions with the researcher, in particular cognitive interviewing strategies, is needed to support a cohesive approach to assess care-related QoL in this vulnerable group.
Smith, N., Towers, A., Palmer, S., Beecham, J. and Welch, E. (2018) "Being Occupied: Supporting 'meaningful activity' in care homes for older people in England", Ageing and Society. Cambridge University Press, pp. 2218-2240. doi: 10.1017/S0144686X17000678.

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The benefits of meaningful activity in later life are well documented. Studies show that being occupied contributes to both physical and mental health as well as quality of life. Research also suggests that activity may be beneficial to people residing in care homes, including people living with dementia. This paper presents findings from a study which used the Adult Social Care Outcomes Toolkit (ASCOT) to measure quality of life in six care homes located in the south-east of England. The study found, like previous ones, that care home residents' days were characterised by a lack of activity. Drawing on observations, interviews and focus groups with residents and staff from these homes, this paper attempts to understand why care homes residents do not engage in meaningful activities. We reject the idea that these low levels of activity are a natural part of the ageing process or that they can be explained by notions of resident choice. Instead the findings point to both insufficient funding and working practices within care homes as more substantive explanations. These explanations inform a discussion of how the low levels of engagement in meaningful activity could be addressed and residents' quality of life improved.
Rand, S., Malley, J., Towers, A., Netten, A. and Forder, J. (2017) "Validity and test-retest reliability of the self-completion Adult Social Care Outcomes Toolkit (ASCOT-SCT4) with adults with long-term physical, sensory and mental health conditions in England", Health and Quality of Life Outcomes. BioMed Central. doi: 10.1186/s12955-017-0739-0.

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Background: The Adult Social Care Outcomes Toolkit (ASCOT-SCT4) is a multi-attribute utility index designed for the evaluation of long-term social care services. The measure comprises eight attributes that capture aspects of social care-related quality of life. The instrument has previously been validated with a sample of older adults who used home care services in England. This paper aims to demonstrate the instrument's test-retest reliability and provide evidence for its validity in a diverse sample of adults who use publicly-funded, community-based social care in England. Methods: A survey of 770 social care service users was conducted in England. A subsample of 100 services users participated in a follow-up interview between 7 and 21 days after baseline. Spearman rank correlation coefficients between the ASCOT-SCT4 index score and the EQ-5D-3L, the ICECAP-A or ICECAP-O and overall quality of life were used to assess convergent validity. Data on variables hypothesised to be related to the ASCOT-SCT4 index score, as well as rating of individual attributes, were also collected. Hypothesised relationships were tested using one-way ANOVA or Fisher's exact test. Test-retest reliability was assessed using the intra-class correlation coefficient for the ASCOTSCT4 index score at baseline and follow-up. Results: There were moderate to strong correlations between the ASCOT-SCT4 index and EQ-5D-3L, the ICECAP-A or ICECAP-O, and overall quality of life (all correlations ? 0.3). The construct validity was further supported by statistically significant hypothesised relationships between the ASCOTSCT4 index and individual characteristics in univariate and multivariate analysis. There was also further evidence for the construct validity for the revised Food and drink and Dignity items. The testretest reliability was considered to be good (ICC=0.783; 95% CI: 0.678-0.857). Conclusions: The ASCOT-SCT4 index has good test-retest reliability for adults with physical or sensory disabilities who use social care services. The index score and the attributes appear to be valid for adults receiving social care for support reasons connected to underlying mental health problems, and physical or sensory disabilities. Further reliability testing with a wider sample of social care users is warranted, as is further exploration of the relationship between the ASCOT-SCT4, ICECAP-A/O and EQ-5D-3L indices.
Welch, E., Palmer, S., Towers, A. and Smith, N. (2016) "Why are relatives of care home residents reluctant to 'rock the boat'? Is there a culture of acceptance?", Working with Older People. Emerald, pp. 124-132. doi: 10.1108/WWOP-10-2016-0030.

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Purpose - The purpose of this paper is to explore whether relatives of care home residents are best placed to act as 'champions' or advocates for their family members, as is often the expectation. Design/methodology/approach - Focus groups and interviews were conducted with 25 relatives of residents in four care homes for older people in the South East of England. Two rounds of focus groups were held in each participating care home: the first was to discuss any issues arising from the care received, or concerns about the home itself; the second was to enable a deeper exploration of the key themes that arose from the first round and explore why relatives, in this case, failed to complain. Findings - Thematic analysis revealed a complex range of emotions experienced by relatives that contributed to a conflict between what they believed to be the correct response and how they behaved in reality, which led to a culture of acceptance. Analysis revealed some relatives were reluctant to 'interfere' for fear of possible negative repercussions, thus they downplayed issues in an attempt not to 'rock the boat'. Originality/value - This paper discusses the flaws in the policy emphasis on personalisation and the reliance on family members as advocates, and concludes with suggestions on how care homes may foster an environment where relatives, and indeed residents, feel comfortable to raise issues and concerns.
Towers, A., Smith, N., Palmer, S., Welch, E. and Netten, A. (2016) "The acceptability and feasibility of using the Adult Social Care Outcomes Toolkit (ASCOT) to inform practice in care homes", BMC Health Services Research. BioMed Central. doi: 10.1186/s12913-016-1763-1.

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Background: The Adult Social Care Outcomes Toolkit (ASCOT) measures social care related quality of life (SCRQoL) and can be used to measure outcomes and demonstrate impact across different social care settings. This exploratory study built on previous work by collecting new inter-rater reliability data on the mixed-methods version of the toolkit and exploring how it might be used to inform practice in four case study homes. Method: We worked with two care home providers to agree an in-depth study collecting SCRQoL data in four case-study homes. Data was collected about residents' age, ethnicity, cognitive impairment, ability to perform activities of daily living and SCRQoL in the four homes. Feedback sessions with staff and managers were held in the homes two weeks after baseline and follow-up data collected three months later. Interviews with managers explored their views of the feedback and recorded any changes that had been made because of it. Results: Participant recruitment was challenging, despite working in partnership with the homes. Resident response rates ranged from 23 to 54 % with 58 residents from four care homes taking part in the research. 53 % lacked capacity to consent. Inter-rater reliability for the ASCOT ratings of SCRQoL were good at time one (IRR = 0.72) and excellent at time two (IRR = 0.76). During the study, residents' ability to perform activities of daily living declined significantly (z = -2.67, p < .01), as did their expected needs in the absence of services (z = -2.41, p < .05). Despite these rapid declines in functionings, residents' current SCRQoL declined slightly but not significantly (Z = -1.49, p = .14). Staff responded positively to the feedback given and managers reported implementing changes in practice because of it. Conclusion: This exploratory study faced many challenges in the recruitment of residents, many of whom were cognitively impaired. Nevertheless, without a mixed-methods approach many of the residents living in the care homes would have been excluded from the research altogether or had their views represented only by a representative or proxy. The value of the mixed-methods toolkit and its potential for use by providers is discussed.
Monograph
Razik, K., Turnpenny, A., Bradshaw, J., Rand, S., Towers, A., Caiels, J. and Smith, N. (2019) ASCOT Easy Read: usability evaluation of an electronic adaptation. PSSRU, University of Kent.

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Conference or workshop item
Towers, A. and Greenwood, R. (2019) "Trials methodology meets social care research: issues and opportunities", in 5th International Clinical Trials Methodology Conference. 5th International Clinical Trials Methodology Conference.

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Debate
Collins, G., Towers, A., Smith, N., Palmer, S., Naick, M. and Babaian, J. (2018) "Engaging with care home managers", in British Society of Gerontology Conference. British Society of Gerontology Conference.

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The challenges of engaging care homes in health and social care research is well reported (Bower et al., 2009; Patel et al., 2003). Managers and owners have competing pressures on their time (e.g. providing high quality and compassionate care, recruiting and retaining staff, complying with the requirements of the regulator, commissioners and their own auditing systems, liaising with family members and supporting informal carers). It is understandable that under these conditions, research is not always a priority. Mechanisms are being set up in the UK to help care homes become 'research ready' and guidelines for best practice are becoming available to facilitate engagement as much as possible (ENRICH website/reports). However, recruitment remains a significant challenge for many studies (Bower et al., 2009). Since 2015, the Measuring Outcomes in Care Homes Study (MOOCH) has successfully recruited 34 care homes (including nursing homes) and 293 residents, including those lacking the capacity to consent. The project faced numerous challenges early on, including local authority partners withdrawing from the research due to restructuring within their organisation. This paper shares our learning, reflecting on which strategies worked and which did not (and why), including; research ready homes, partnership working, payment to care homes, presenting at provider events, having support from CQC and local commissioning teams and providing care homes with feedback reports. We will also present the results from our care home manager debrief interviews, where managers were asked their motivations for taking part in the study and their experiences of being research participants.
Collins, G., Towers, A., Smith, N., Palmer, S., Naick, M. and Babaian, J. (2018) "MOOCH Symposium: Engaging with care home managers", in BSG Conference 2018. BSG Conference 2018.

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The challenges of engaging care homes in health and social care research is well reported (Bower et al., 2009; Patel et al., 2003). Managers and owners have competing pressures on their time (e.g. providing high quality and compassionate care, recruiting and retaining staff, complying with the requirements of the regulator, commissioners and their own auditing systems, liaising with family members and supporting informal carers). It is understandable that under these conditions, research is not always a priority. Mechanisms are being set up in the UK to help care homes become 'research ready' and guidelines for best practice are becoming available to facilitate engagement as much as possible (ENRICH website/reports). However, recruitment remains a significant challenge for many studies (Bower et al., 2009). Since 2015, the Measuring Outcomes in Care Homes Study (MOOCH) has successfully recruited 34 care homes (including nursing homes) and 293 residents, including those lacking the capacity to consent. The project faced numerous challenges early on, including local authority partners withdrawing from the research due to restructuring within their organisation. This paper shares our learning, reflecting on which strategies worked and which did not (and why), including; research ready homes, partnership working, payment to care homes, presenting at provider events, having support from CQC and local commissioning teams and providing care homes with feedback reports. We will also present the results from our care home manager debrief interviews, where managers were asked their motivations for taking part in the study and their experiences of being research participants.
Towers, A., Smith, N., Palmer, S. and Collins, G. (2018) "Measuring the outcomes of care homes", in British Society of Gerontology 47th Annual Conference. British Society of Gerontology 47th Annual Conference.

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Symposium
Towers, A., Palmer, S., Smith, N. and Collins, G. (2018) "The relationship between regulator quality ratings and care home residents' care-related quality of life", in International Long-term Care Policy Network (ILPN) Conference. International Long-term Care Policy Network (ILPN) Conference.

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Parallel session on Quality of Long-Term Care: Regulators' and Consumers' Perspectives
Towers, A., Palmer, S., Smith, N. and Collins, G. (2018) "CQC Quality Ratings and Care Home Residents' Quality of Life", in British Society of Gerontology 47th Annual Conference. British Society of Gerontology 47th Annual Conference.

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Towers, A. (2018) "Developing and testing a Talking Mats symbol set to support conversations about social care related quality of life with care home residents", in NIHR School for Social Care Research Annual Conference. NIHR School for Social Care Research Annual Conference.

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Smith, N., Towers, A., Collins, G., Naick, M. and Palmer, S. (2017) "Engaging care home managers in research", in NIHR School for Social Care Research Annual Conference. NIHR School for Social Care Research Annual Conference.

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Towers, A. (2016) "Measuring the outcomes of social care: an overview of the Adult Social Care Outcomes Toolkit (ASCOT)", in Arts Health Institute. Arts Health Institute.

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Towers, A. (2016) "Measuring the outcomes of social care: why and how?", in Arts Health Institute Conference. Arts Health Institute Conference.

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Applied health research, health and social care evaluation, vulnerable groups, complex health needs, long term care of older people, integrated care, mixed methodology, qualitative research, children's hospices, European research, health visiting

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Last Updated: 11/10/2019