Showing papers in "Primary Health Care Research & Development in 2008"

Can social prescribing provide the missing link

Abstract: Background: The voluntary sector has long been recognised as making an important contribution to individual and community health. In the UK, however, the links between primary health care services and the voluntary and community sector are often underdeveloped. Social prescribing is an innovative approach, which aims to promote the use of the voluntary sector within primary health care. Social prescribing involves the creation of referral pathways that allow primary health care patients with non-clinical needs to be directed to local voluntary services and community groups. Such schemes typically use community development workers with local knowledge who are linked to primary health care settings. Social prescribing therefore has the potential to assist individual patients presenting with social needs to access health resources and social support outside of the National Health Service. Aim: The aim of this paper is to explore the concept of social prescribing and discuss its value as a public health initiative embedded within general practice. Methods: The rationale for social prescribing and existing evidence are briefly reviewed. The paper draws on a case study of a pilot social prescribing scheme based in general practice. Data collected during the development, implementation and evaluation of the scheme are used to illustrate the opportunities and limitations for development in UK primary health care. Findings: The potential for social prescribing to provide a mediating mechanism between different sectors and address social need is discussed. The paper argues that social prescribing can successfully extend the boundaries of traditional general practice through bridging the gap between primary health care and the voluntary sector. The potential for wider health gain is critically examined. The paper concludes that social prescribing not only provides a means to alternative support but also acts as a mechanism to strengthen community–professional partnerships. More research is needed on the benefits to patients and professionals.

Effectiveness of chronic care model-oriented interventions to improve quality of diabetes care: a systematic review

Abstract: Background: The chronic care model (CCM) has been widely used in a variety of health care settings to guide system improvement for chronic illness care, including diabetes care. However, the evidence base for the specific components of the model has not been systematically reviewed. This review aimed at examining the extent to which interventions featuring the CCM components improve diabetes care and determining the relative effectiveness of different CCM components. Methods: We systematically searched MEDLINE (1966 to December 2004), the Cochrane Effective Practice and Organisation of Care and the Cochrane Controlled Trials Register to identify interventions featuring one or more system components of the CCM for diabetes care. Outcome measures included HbA1c, blood pressure and blood lipid control. We used random-effects meta-analysis and meta-regression for quantitative synthesis of data. Results: In all, 69 studies (43 randomized controlled trials and 26 controlled before‐after studies) met inclusion criteria and were included in this review. Overall, included studies reported a mean reduction of 0.46% (95% CI 0.38, 0.54) in HbA1c, mean reduction of 2.2 (95% CI 0.9, 3.5)mmHg in systolic blood pressure, mean reduction of 1.3 (95% CI 0.6, 2.1)mmHg in diastolic blood pressure and mean reduction of 0.24 (95% CI 0.06, 0.41)mmol/L in total cholesterol. For specific CCM components, interventions that addressed delivery system design reported the largest improvements in patient outcomes, followed by those employing a selfmanagement support component. Interventions involving decision support or clinical information systems reported relatively smaller effect sizes. Conclusions: Interventions featuring CCM components for diabetes care produced small-to-moderate improvements in a range of patient intermediate outcomes. The findings support the concept of the CCM in which the state of development of various aspects of primary care service systems defined in this model appear to be important factors in the quality of care provided to people with diabetes.

General practitioners’ understanding of depression in young people: qualitative study

Abstract: BackgroundDepression in young people is not necessarily self-limiting, and is frequently associated with affective disorders and impaired psychosocial functioning in adult life. Early recognition of and response to depression in teenagers could be an important task for general practitioners (GPs), but there are multiple obstacles to achieving this.ObjectivesTo explore GPs perceptions of the opportunities and difficulties of working with teenagers, and of specifically recognizing and responding to depression.Setting and participantsNine GPs who had taken part in a developmental project on diagnosing and treating depression in young people. All worked in an Inner London Medical Centre.MethodsSemi-structured interviews transcribed and analysed thematically.FindingsTwo over-arching themes that emerged from the interviews were that teenagers were perceived as being qualitatively different from adults in the ways they used general practice, and that GPs were uncomfortable with making a diagnosis of depression in young people. Within the first theme, we identified sub-themes, including failure of teenagers to engage with services, parental involvement, complex presentations and lack of time. Within the second theme, the sub-themes were surprise, normalization of depressed mood and challenge to the validity of psychiatric diagnosis in this age group.ConclusionsProfessional development in general practice that addresses this topic needs to modify two perceptions; that depressed mood is in some sense ‘normal’ in this age group, and that teenagers are so different in their use of services that the management of depression (if it is recognized at all) is problematic.

Factors affecting the offer of pulmonary rehabilitation to patients with chronic obstructive pulmonary disease by primary care professionals : a qualitative study

Abstract: Aim: To explore health professionals’ experiences of barriers and facilitators to referring patients for pulmonary rehabilitation in a primary care setting. Background: Pulmonary rehabilitation involves a multidisciplinary teamwork approach to improving the quality of life for people with chronic obstructive pulmonary disease. This study aimed to find out about health care professionals’ experiences when referring patients. Reports suggest that a health care professional’s attitude towards a treatment affects the willingness of patients to accept advice. Methods: Five focus group interviews were undertaken with 21 health professionals from North Midlands, UK. Data were analysed using a thematic analysis drawing on the techniques of grounded theory. Findings: Chronic disease management has been delegated to Practice Nurses in many cases leaving some nurses feeling unsupported and some General Practitioners feeling deskilled. Problems with communication, a lack of adequate and timely local service provision, a difficult referral process, time pressures and lack of information were barriers to health care professionals making an offer of pulmonary rehabilitation. An explanatory model is proposed to describe how addressing barriers to referral may improve health care professionals views about pulmonary rehabilitation and therefore may mean that they present it in a more positive manner.

Patterns of prescription and concern about opioid analgesics for chronic non-malignant pain in general practice

Abstract: Aim - The purpose of this study was to investigate the circumstances of opioid prescription among general practitioners (GPs) in the UK. Background - Prescription of opioids for chronic pain, particularly non-malignant chronic pain, remains controversial. In the midst of this controversy, patterns of actual prescription and influences on these patterns are not well understood. Method - A mail survey was posted to 1192 GPs and it was returned by 414 (35.0%). The survey addressed the frequency and reluctance in GP prescription of opioids for chronic pain. It also sampled their attitudes and concerns about opioids, including their views on appropriateness and effectiveness, adverse effects and potential social pressures presumed to impact on prescribing. Findings - Overall, 57.9% of GPs reported they sometimes, frequently, or always, prescribe strong opioids for chronic pain, which was of significantly lower frequency than for prescribing of weak opioids, non-steroidal anti-inflammatory drugs (NSAIDs) or tricyclic antidepressant medications. Similarly, 69.1% reported a reluctance to prescribe strong opioids for chronic non-malignant pain, which was a significantly greater reluctance than for cancer pain, for example. GPs who were men, younger, had fewer years experience and worked full time (as opposed to part time), were more likely to prescribe opioids. Practice guideline use was unrelated to prescribing but those with specialty training were more likely to prescribe. Interestingly, a majority of GPs (83.0%) felt that opioids are effective for chronic non-malignant pain; however, they worry about long-term commitment (such as managing dosing and repeat prescriptions), addiction and other adverse events. Conclusions - Based on multivariate analyses, both frequency of prescribing and reluctance were predicted by a combination of concerns about effects on patient behaviour, professional competency concerns and degree of belief in opioids as an effective option. These results may suggest a need for additional GP training in the management of analgesics for chronic non-malignant pain.

A qualitative study of the health experience of Gypsy Travellers in the UK with a focus on terminal illness

Abstract: Aim To understand the experience of terminal care and health care access for Gypsy Travellers, to inform palliative and primary care service provision. Background Little contemporary research of UK English Romany Gypsy Travellers is available. This ethnic group is often overlooked in ethnic minority health research. Methods Access to Gypsy Traveller communities was through non-health care channels and required the development of trust through repeated contact over time. English Romany Gypsy Travellers at two Traveller sites participated in face-to-face contacts. Data collection was through field observation and seven semistructured interviews with Gypsy Traveller women who had experience of caring for relatives who were dying. In addition, data were collected over two years through discussion in a members-only Gypsy and Traveller interest e-mail forum. Findings The culture of Gypsy Travellers is distinct but diverse. Hygiene is important as is discretion and sensitivity to the information requirements of the patient and family. Gypsy Travellers are aware that their mobility (voluntary or enforced) can negatively impact on health care. Home care for the terminally ill is often preferred to hospital care often due to poor understanding of their cultural and personal needs by health care professionals and due to an aversion to ‘bricks and mortar’. Care may be provided by the extended family. Palliative care provision should consider the needs of Gypsy Travellers including respect for their culture and support for caring at home.

Sexual health promotion in primary care – activities and views of general practitioners and practice nurses

Abstract: Background Sexual health in Northern Ireland (NI) is poor compared with the rest of Europe with increasing incidences of sexually transmitted infections and one of the highest rates of teenage pregnancy. Traditionally, sexual health services have been provided in a fragmented way by a wide range of different providers but recent sexual health strategies have flagged sexual health as a key activity within the primary care setting.Aim The main aim of the study was to assess the sexual health promotion activities within the primary care setting across one Health and Social Services Board in NI.Methods A series of semi-structured interviews with both general practitioners (GPs) and practice nurses (PNs) was conducted to assess their views on the key issues in relation to sexual health in primary care. A questionnaire survey was also conducted with these health professionals to elicit information about sexual health promotion activities within the primary care setting.Findings The results have shown that promoting sexual health within the primary care setting is often ad hoc and often does not target the ‘at-risk’ population. As such, GPs and PNs tend not to discuss sexual health with non-heterosexual clients or those with learning disabilities due to lack of awareness and training. Health professionals feel inadequately trained to engage in effective sexual health promotion and to provide enhanced sexual health services. Personal embarrassment and lack of time were also identified as barriers for providing effective sexual health care.Conclusion Health professionals within the primary care setting require additional training to deal with the sensitive and complex issues inherent in the area of sexual health.

Developing a new response to non-urgent emergency calls : evaluation of a nurse and paramedic partnership intervention

Abstract: Original article can be found at: http://journals.cambridge.org/action/login Copyright Cambridge University Press DOI: 10.1017/S1463423608000765

Caring for the carers: the characteristics of district nursing support for family carers

Abstract: This paper presents findings from an ethnographic study that examined how qualified district nurses’ conceptualised their role in relation to family carers and how they performed this aspect of their role. A participant observational study involving fieldwork and in-depth interviews with six district nursing teams was undertaken over a 12 month period. Interview transcripts and fieldnotes were analysed by drawing upon the principles of dimensional analysis. District nurses acted on the assumption that family carers would, by choice or default, provide care. Family carer support was conceptualised as a means of promoting self-care and the patient’s independence from nursing services. The rationale for providing family carer support was based largely on service capacity rather than carer needs and preferences. Six characteristics of district nursing support for carers were identified; enabling, supporting, mediating, care substitution, crisis prevention and crisis intervention. Family carers were not recipients of district nursing support in their own right but were dependent upon the cared for person receiving nursing care. This in turn was conditional upon others (general practitioners and hospitals) making appropriate patient referrals. Family carer support was also conditional upon effective communication and family carer receptiveness. As the scope of home-based nursing continues to increase district nurses need to take a more active stance in providing family carer support and adopt a family rather than patient-focused approach in order that family carers might be supported more effectively.

The present status and future role of family doctors: a perspective from the International Federation of Primary Care Research Networks

Abstract: BackgroundHealth care systems are changing around the world; family doctors need to adapt and prepare for future challenges.AimTo consider the present status of family doctors, anticipated changes in health care systems, the challenges these will bring and possible solutions.Collection of informationCollaborative enquiry amongst members of the International Federation for Primary Care Research Networks (IFPCRN). Six strategic questions were addressed by 37 contributors from 23 countries. Responses were collated and contributors invited to further comment on the interim report.FindingsPresent status: Despite wide variability, common problems relate to delivery systems, funding and policy, lack of evidence-based medical practice, education and research. Role of family doctors: There is wide variability in roles and often poor interaction with other caregivers. Anticipated changes: An expansion of the family physician model is anticipated, alongside shortages of family doctors in the face of increased health care needs, increased complexity of problems and the shift to ambulatory care. Advances in information technology may be useful. Anticipated challenges and proposed actions: Address quality issues. This requires audit and quality assurance, promoting adaptability, promoting group practices and teamwork, coordinating care, incorporating information technology and ensuring ethical relationships with industry. Improve education and continuing professional development: Improved education and continuing professional development are needed, as are measures to prevent burnout and retain the workforce. Develop a robust research enterprise: Research in primary care is needed to develop relevant guidelines. Improve support for family doctors: Providing excellent patient care is essential for improved status and support. Achieving this requires engagement with policy makers, academic institutions and the public.ConclusionsWhile there is great variability across different countries, common themes relate to present status, anticipated changes in health systems and the responses needed from family medicine.

Why GPs refer patients to complementary medicine via the NHS: a qualitative exploration

Abstract: Background. The use of complementary and alternative medicine (CAM) is increasing. Access to CAM through primary care referral is common with some of these referrals occurring through existing NHS contracts. Yet currently little is understood about General Practitioners (GPs) referrals to CAM via an NHS contract. Aim. This exploratory qualitative study was designed to explore UK GPs experiences of referring patients to CAM under an NHS contract. Method. Semistructured interviews were conducted with 10 GPs in the UK, purposively sampled, who referred patients under an NHS contract to a private CAM clinic, staffed by medically qualified CAM practitioners. Qualitative methodology making use of the framework approach was used to undertake the interviews and analysis. Findings. The decision of GPs to refer a patient to CAM through an NHS contract is complex and based on negotiation between patient and GP but is ultimately determined by the patients’ openness and motivation towards CAM. Most GPs would consider referral when there are no other therapeutic options for their patients. Various factors, including clinical evidence, increase the likelihood of referral but two overarching influences are crucial: (a) the individual GPs positive attitude to, and experience of CAM, including a trusting relationship with the CAM practitioner; and (b) the patient’s attitude towards CAM. In-depth knowledge of CAM was not a vital factor for most GPs in the decision to refer. Conclusion. A CAM referral only took place if the patient readily agreed with this therapeutic approach, and in this respect it may differ from referrals by GPs to conventional medicinal practitioners. Such an approach, then, relies on patients having a positive view of CAM and as such could result in inequity in treatment access. Increasing knowledge about and evidence for CAM will assist GPs in making appropriate referrals in a timely manner. We propose a preliminary model that explains our findings about referrals considering patients need as well as the medical process. As data saturation may not have been achieved, further investigation is warranted to confirm or refute these suggestions.

Undergraduate research in primary care: is it sustainable?

Abstract: Aim: To describe the research project component of the BSc in Primary Health Care and to discuss the issues faced by students and faculty in attempting to complete a student-led research project Background: Medical schools increasingly expect medical students to undertake research as part of intercalated BSc’s or in self-selected study modules This research has historically been laboratory based, ‘piggybacking’ onto existing projects Projects initiated by students themselves and studies in primary care or community settings are more unusual Methods: A qualitative study, based on interviews with students and examiners, triangulated with data from the peer review process and personal observations on the running of the course Setting: A London medical school, running an intercalated BSc in Primary Health Care Findings: We interviewed 24 of 26 students and two external examiners during the interview period of the study Students successfully undertook research, from initial question through to publication Overall, 90 dissertations were completed since 1997, of which half used a qualitative methodology (45/90) Ten projects have subsequently been published; there were also 16 conference presentations and 6 research letters Themes from the interview data include: the students’ strong sense of project ownership, the difficulties of being a novice researcher, the difficulties posed by the research governance hurdles, the beneficial and for some students adverse impact (stress and coping with unsuccessful projects) and finally, the impact on their careers Conclusion: Students gain considerably from this learning process, not only by undertaking their own research, but they also gain in terms of acquisition of transferable skills such as critical appraisal and improved self-directedness Project completion and publication rates suggest that programmes developing undergraduate initiated research projects can be as successful as those for other novice researchers The student-led project is a fragile endeavour, but currently is sustainable

Mapping care pathways and estimating the number and cost of musculoskeletal chronic pain patients to inform the development and implementation of a new service

Abstract: Background Patients living with chronic pain are typically resource intensive, their care requirements are long term and referral to secondary care is not always expeditious. To provide more appropriate, accessible and cost-effective care, Tower Hamlets Primary Care Trust reviewed the needs of the patients, their current care and the numbers requiring treatment for non-malignant chronic pain, initially starting with musculoskeletal pain. Method We estimated the number of people with chronic pain being treated outside general practice by the NHS in Tower Hamlets. A working group established set criteria to define a chronic pain patient. We surveyed appropriate clinicians to determine the approximate number of patients who fitted our inclusion criteria, the approximate number of follow-up appointments they required and their care pathways. Secondly, we estimated the cost of care for chronic pain patients using NHS national tariff and reference cost data. We also took a convenience sample of chronic pain patients and recorded their history of care. Findings The routes and pathways of care are complex and multiple. We estimate between 4.0% and 5.5% of new patients in rheumatology, orthopaedics, occupational therapy and musculoskeletal physiotherapy and up to 90% in the pain clinic are people living with chronic pain. The cost of this care ranged from £296 for a course of physiotherapy to £1911 for a patient seen in physiotherapy, orthopaedic and the pain clinics. Conclusion There is no facility in current management information services that identifies people being treated for non-specific chronic pain; therefore, estimating both the numbers and costs for treating these people is difficult. National tariff and notional cost data provide estimates only, of an ‘average patient’; the real cost of these patients is unknown.

School nurse management of children's questions when they are involved in primary school sex education: an exploratory study

Abstract: Aim The aim of this paper is to explore school nurses’ experiences of teaching Sex and Relationships Education (SRE) as part of the primary school curriculum. In particular it focuses on the questions that the children ask during the lessons and the strategies which the nurses employ in managing those questions. Background School based Sex and Relationship Education (SRE) is an important aspect of children’s education. However, it is a highly politicised and controversial area which is a matter of concern to a wide number of stakeholders. In the primary school setting, school nurses are commonly involved in delivery of the programme. Their input is particularly valued because they are ‘specialist outsiders’ who create an environment which is conducive to discussion of sensitive topics. To date there is little understanding of the skills that they employ in managing the educational needs of primary school children within the confines of a pre-agreed school curriculum. Methods Semi-structured focus group interviews were conducted with small groups of school nurses from a single geographical location in the Midlands region of England. Data were analysed using a thematic analysis approach. Findings Data identified the ways in which the nurses viewed and responded to the children’s agenda which was realised in the form of questions. In particular it focuses on what they deemed to be inappropriate questions and the basis upon which this label was applied. Five strategies for managing these inappropriate questions were identifiable from the data. Their deployment is explored in relation to the tensions implicit in the realisation of sexualised realities in a classroom setting.

How has primary health care progressed? Some observations since Alma Ata

Abstract: Original article can be found at: http://journals.cambridge.org/action/ Copyright Cambridge University Press 2008 doi:10.1017/S1463423608000753

General practitioners’ coronary risk assessments and lipid-lowering treatment decisions in primary prevention : Comparison between two European areas with different cardiovascular risk levels

Abstract: Aim: To investigate whether general practitioners (GPs) in countries with different levels of cardiovascular risk would make different risk estimates and choices about lipid-lowering treatment when ...

A survey of primary and specialised health care provision to prisons in England and Wales.

Abstract: Background Prison health care in England, including primary care, is now incorporated into the National Health Service; the impetus for the change is in part due to concern about standards of health care within prisons. The demographic characteristics and health status of patients within prisons are relatively well understood, as are the problems faced by health care professionals. Less is known about current health care provision. Aims To describe the organisation of primary health care and specialised services in prisons and compare services available to different types of prison. Method A piloted questionnaire was sent to the governors of all prisons in England and Wales for completion by the health care manager. Findings Completed questionnaires were received from 122 (89%) of 138 prisons. The survey showed a low use of information technology (IT). Problems were reported with the recruitment and retention of general nurses in more than 50% of prisons. Prisoners in category A/B (higher security) prisons had available to them a greater range of health care services compared with those in other prisons. The results suggest that provision of services for chronic diseases and improvements in IT are needed. Problems with the recruitment and retention of general nurses need addressing. The reasons why lower-security prisoners are receiving a narrower range of specialised health care services compared with higher-security prisoners need justifying.

Sickness certification in general practice: a comparison of electronic records with self-reported work absence

Abstract: Background Reports of work absence usually come from self-report or company absence records; however, these records are limited to just one company. Electronic recording of sickness certification in primary care medical records may provide an alternative source of data, but its relation to other sources of sickness absence information is unknown. Comparing general practitioner electronic sickness certification records with self-reported work absence would enable the comparability of these electronic records to be established. Aim To investigate the comparability of electronic medical records of sickness certification in primary care, with self-reported work absence. Methods Analysis included 292 primary care low-back pain consulters who consented to medical record review. A within-group design was used to match electronic records of sickness certification with self-reported sickness absence. Findings Overall 95% of the electronic medical records of sickness certification matched with self-reported absences; 96% in employed consulters and 95% in unemployed consulters. In all, 94% of employed participants were a direct match, 2% a consistent match and 4% a mismatch. Including consistent matches increased matching to 97% in employed consulters and to 100% in unemployed consulters. Electronic records of sickness certification in general practice are a useful method of analysing sickness absence in the population, as they are comparable with other sources of data. Additionally, electronic records of sickness certification will allow the investigation of sickness absence where data from one company are too limited and self-report is not available or unreliable. To facilitate the use of electronic medical records of sickness certification, data need to be accurately recorded and evaluated or audited to ensure completeness and validity. Furthermore, methods should be developed to ensure straightforward linkage between sickness certification records and other data held on the electronic medical record.

The need for wider public understanding of health care research

Abstract: In recent years several factors have affected the public’s relationship with health care research: increased data protection legislation and the resultant consent requirements; access to unforeseen levels of both information and misinformation through mass media; and a growing culture of personal choice which may have eroded the perceived importance of activities whose benefits are societal rather than personal. This article considers these factors and their implications and highlights the need for health care researchers to engage more effectively with the public in order to ensure its continued support.

Identifying the strengths and weaknesses of epilepsy care in general practice – a case note review

Abstract: AimTo suggest how to improve primary epilepsy care by assessing the strengths and weaknesses of epilepsy care in general practice by reviewing practice records in relation to qualities and outcomes framework (QOF) indicators and epilepsy guidelines.BackgroundConcerns have been raised about epilepsy care in the UK. The general practice QOF indicators offered the first opportunity to take on structured epilepsy care in the UK. The QOF includes targets for this condition and national guidelines list key priorities to improve care. This study explores how general practice systems are delivering this care.MethodsA case notes review in 27 practices in the north-east of England. Adults with epilepsy were identified from practice morbidity registers and a READ code search. Data from 1333 patients were collected on the frequency and location of epilepsy review, type of epilepsy and classification of seizures, epilepsy medication ordering, and individual and practice demographic data. The data were entered into SPSS for frequency analysis and grouped for further analysis: Primary Care Trust (PCT), age and medication ordering groups (satisfactory, moderate or poor).FindingsOf the patients, 24% did not have a record of type of epilepsy and about a third of patients had no seizure classification recorded. One-fifth of patients were not reviewed in the previous year but of those who were, the majority were seen in general practice. Seizure frequency was not recorded in the last 12 months in one-quarter of patients. Adherence and recording of seizure information were related to age of patient. Epilepsy registers were inaccurate. The findings suggest that epilepsy care can be improved by using review and monitoring systems to ensure a complete and accurate epilepsy register and appropriate annual clinical and medication review.

Virtual standardized patients: an interactive method to examine variation in depression care among primary care physicians.

Abstract: BACKGROUND: Some primary care physicians provide less than optimal care for depression (Kessler et al., Journal of the American Medical Association 291, 2581-90, 2004). However, the literature is not unanimous on the best method to use in order to investigate this variation in care. To capture variations in physician behaviour and decision making in primary care settings, 32 interactive CD-ROM vignettes were constructed and tested. AIM AND METHOD: The primary aim of this methods-focused paper was to review the extent to which our study method - an interactive CD-ROM patient vignette methodology - was effective in capturing variation in physician behaviour. Specifically, we examined the following questions: (a) Did the interactive CD-ROM technology work? (b) Did we create believable virtual patients? (c) Did the research protocol enable interviews (data collection) to be completed as planned? (d) To what extent was the targeted study sample size achieved? and (e) Did the study interview protocol generate valid and reliable quantitative data and rich, credible qualitative data? FINDINGS: Among a sample of 404 randomly selected primary care physicians, our voice-activated interactive methodology appeared to be effective. Specifically, our methodology - combining interactive virtual patient vignette technology, experimental design, and expansive open-ended interview protocol - generated valid explanations for variations in primary care physician practice patterns related to depression care.

Patients, general practitioners, diseases and health problems in urban general practice: a cross-sectional study on electronic patient records

Abstract: Background Statistics from primary health care in Sweden, as well as from other Nordic countries, have been sparse. The electronic patient records (EPR) will be an increasingly important source of ...

Making the shift from hospital to the community: lessons from an evaluation of a pilot programme

Abstract: AimTo analyse the experience of a pilot programme designed to shift care from hospital to the community.BackgroundThe white paper, Our Health, Our Care, Our Say, published in England in 2006, set out a vision for the future of primary care and community services. A key component of this vision is to provide care closer to home. The NHS Institute for Innovation and Improvement established a pilot programme in five field test sites to explore the scope for bringing about shifts in care from hospital to the community. This paper reports the results of the evaluation of the programme.MethodsA comparative case study design was used including interviews with key stakeholders at different points during the pilot programme, participation in discussion groups, documentary analysis, and collation of activity and output statistics. By comparing evidence drawn from 14 projects in the five field test sites, the evaluation was able to identify the impact of different factors on the progress of the projects.FindingsAll of the projects made some progress in taking forward their plans to shift care, although there were wide variations in what had been achieved at the end of the test and learn phase. Key factors influencing progress were the existence of a receptive context for change, project focus, organisational leadership, project management, stakeholder analysis, clinical engagement and leadership, overcoming barriers to change, aligned incentives, training and support, measuring and monitoring progress, and the timescale for change. A critical requirement in programmes of this kind is ‘getting the basics right’ through dogged attention to project and change management. Also important is ensuring that the evidence on change management and quality improvement is acted on by those leading change programmes.

Increasing systemic capacity to respond to child and adolescent mental health needs using reciprocal knowledge transfer with parents

Abstract: Background: Knowledge is recognized as a crucial organizational resource, which it has been suggested, increases in value through use. However, tensions exist between applying generalized scientific and academic knowledge to practice and incorporating local, experiential and tacit understanding in our knowledge base for practice. Knowledge management and transfer are frequently advocated as the means to increase service capacity within existing resource levels. In the NHS knowledge management and transfer tends to adopt a social constructivist approach, which favours the application of scientific evidence to practice, consequently the tacit and experiential knowledge of practitioners and service users is often excluded from formal knowledge-transfer processes. Aim: This paper describes a systematic process that was used to formalize tacit nursing knowledge in child and adolescent mental health (CAMH) and link it into the pre-existing scientific and academic literature. Method: The paper goes on to describe how this process was modified and transferred to work with parents of children referred to CAMH services. Findings: The paper illustrates the differing strands of pre-existing scientific and academic knowledge valued by nurses and parents. It highlights how involving service users in identifying scientific and academic knowledge that they find useful can focus attention on strands of pre-existing knowledge previously overlooked by professionals and service providers and thus enhance the value of this knowledge as an organizational resource. The paper also demonstrates how the tacit and experiential knowledge of nurses and services users can be transformed into more formalized knowledge, which can then be incorporated into organizational knowledge-transfer processes.

Evidence-based primary health care and local research: a necessary but problematic partnership

Abstract: Background: Front-line NHS staff undertake small research projects to answer questions about local patients and services, but these projects often face considerable challenges. This paper reports on one such project. Aims and methods of study:The study used structured interviews in order to find out about the knowledge of nutrition among Bangladeshis using an NHS Walk-in Centre. Development of the study: Time constraints posed considerable difficulties in progressing and completing the study; flaws in the methodology emerged; and underpinning assumptions about health promotion and ethnic minority health beliefs were open to challenge. Learning from the study: Despite this, some findings were valuable and have considerable potential as a stimulus to critical thinking among practitioners about their own attitudes, as well as raising issues that future research would find it useful to address.

The impact on health services utilization in a replication study of two self-management programmes for osteoarthritis of the knee and hip

Abstract: Aim As part of a replication study after the randomized controlled trial (RCTs) in the Netherlands, the impact was assessed on health services utilization and expenditure of two self-management programmes for older adults with osteoarthritis (OA) of the knee and hip. Background Evidence-based patient education and exercise programmes, developed and tested in RCTs, are often insufficiently diffused among practitioners and primary healthcare providers and tend to have a modest reach in the population. Large-scale adoption in primary healthcare can be improved if programmes are feasible and effective in real life. Methods The programmes were conducted in real-life conditions by primary healthcare providers (local health centres, home-care providers, physical therapy centres). Pre-test/post-test data were collected for consultation of the general practitioner (GP), medical specialist, physical therapist, and for the use of OA medication, as well as for the expenditure for physical therapy and OA medication. Findings In total, 20 Knee and 20 Hip programmes were carried out by 18 providers. The Knee programmes were attended by 204 participants and the Hip programmes by 169 participants. Physical therapy and use of OA medication for both programmes and consultation of the medical specialist for the Hip programme decreased. No effect was observed for consultations of the GP. Expenditure for physical therapy and use of OA medication could not be assessed, due to difficulties to obtain sufficient reliable data from participating health insurers. Both programmes produced similar outcomes in real-life conditions compared to their RCTs. The implications are discussed as to accurate data collection on OA expenditure, future cost-utility and cost-effectiveness studies, and the large-scale implementation of the programmes in the Dutch primary healthcare system.

Case management for elderly patients at risk of hospital admission: a team approach

Abstract: AimTo evaluate an approach to multidisciplinary case management that is embedded in primary health care.BackgroundCase management has been advocated in order to coordinate health and social care for vulnerable elderly people and avoid unnecessary hospital admissions. However, it is unclear who should undertake this.MethodsThis case study reports on an approach developed in a semi-rural general practice in Cambridgeshire, UK, and later adopted locally. Data evaluated included practice records, minutes of project meetings over a three-year period and comments from members of the primary care team.FindingsKey elements of the approach were a register of vulnerable people, regular inter-disciplinary meetings and administrative support to follow-up decisions. Practitioners from a range of health and social services participated. Of the 937 people aged 75 and over, 54 (5.8%) were registered as vulnerable, along with five who were younger. After initial efforts to identify those at risk, new registrations fell. Of these 59 patients, 39 (66%) were admitted to hospital over the three years and practitioners believed that the project had prevented admissions. The monthly meetings also enabled professionals from different services to share information, coordinate their work and learn about local services.ConclusionsBy adopting a systematic approach to sharing intelligence about those at risk, extended primary care teams are able to provide case management for the vulnerable elderly. This integrated approach also provides a forum for practitioners to learn about local services. However it involves a significant time commitment. There is a need for further research to assess the cost-effectiveness of the approach in preventing avoidable admissions and improving health and quality of life for older people.

Evaluation of the antibiotic prescribing of nurse practitioners trained to prescribe in primary care

Abstract: AimTo evaluate the antibiotic prescribing of prescriber-trained nurse practitioners in a primary care setting.BackgroundAs of 1st May 2006, legislation was introduced extending the prescriptive powers of appropriately trained nurses and nurse practitioners to nearly equal that of fully registered doctors. Following this increase, we believe that it is important to ensure that these new powers are being used judiciously. In this paper, we focus on a particular aspect of prescribing: that of antibiotics in a primary care setting. We examine how the prescriber-trained nurse practitioners’ prescribing of antibiotics compares with the practice guidelines on prescribing.MethodsAn audit of all consultations for six months following 1st May 2006 by the three nurse practitioners trained to prescribe was conducted. Where an antibiotic was prescribed, the anonymous clinical detail was compared with the appropriate practice guideline. The antibiotic-prescribing habits of doctors were identified from a literature search using Medline, by using UK-wide data provided by the Prescriptions Pricing Authority and from the practice Primary Medical Services review.FindingsThe nurse practitioners were found to prescribe antibiotics in a total of 1296 out of 3211 consultations at an average monthly rate of 41 per 100 consultations. The most common antibiotics prescribed in descending order of frequency were as follows: amoxicillin; flucloxacillin; erythromycin; pencillin V; cefalexin and trimethoprim. Of the antibiotics prescribed during this period, 1065 were found to adhere to practice guidelines and 200 did not. A further 31 were deferred prescriptions. Off-guideline prescribing was accompanied by clear clinical indication as to the reason for the prescription identified in the medical record. Overall prescribing rates in this study of 80 per 100 consultations (including items other than antibiotics) are comparable with those published in the literature.

Preventing and managing chronic disease through primary health organizations: the example of ‘Heartbeat Tararua’

Abstract: BackroundPrimary health care service delivery in New Zealand is in an exploratory phase as primary health organizations determine new models of service delivery to reduce the incidence and impact of chronic disease. As organizations have restructured from predominantly primary care providers, the incorporation of a population approach to practice is welcomed but has provided some challenges for providers and funders alike as they reorient and extend practice parameters and determine the most effective methods of service delivery.AimTo describe and critically examine the underpinning assumptions of a new service delivered through a primary health organization to reduce the impact and burden of chronic disease with a focus on lifestyle risk factors, acting on obesity, nutrition, physical activity and smoking.Approach‘Heartbeat Tararua’ is a community-based lifestyle change programme focusing on the issues of obesity, nutrition, exercise and smoking and provides both clinical care for high-risk clients as well as operating a community-based prevention programme. The simplistic health education–behaviour change model was identified as problematic in the population approach and the high-risk service alone was unable to address all clients who expressed an interest. A revised population approach was sought that encompassed the existing community capacity and encouraged sustainable change in the community. Drawing from the public health evidence base a revised framework was recommended with a set of strategies based on social–psychological and ecological models with participatory and empowerment approaches. The work demonstrates a skilled practice team well able to reflect on practice, willing to seek advice and work towards establishing new models of primary health care service delivery.

Characteristics that identify Hispanic women likely to be ill informed about heart attack and stroke symptoms: An analysis of 2003–2005 Behavioral Risk Factor Surveillance Survey data

Abstract: AimThe research question for this study was: Are there within-group disparities in Hispanic women’s knowledge of heart attack and stroke symptomology?BackgroundHispanics constitute the fastest growing group in the US and have surpassed other racial and ethnic groups to become the largest US minority. Hispanics make up about one-third of the US population, and hence are a group of significant interest for health care providers. Few studies have examined heart attack and stroke symptom awareness among adult Hispanic women, a group at high risk for delays in treatment. Research is needed to elucidate their knowledge of warning symptoms for these vascular events.MethodsBehavioral Risk Factor Surveillance Survey data from states using the 2003–2005 Heart and Stroke module were examined by multivariate techniques. To maximize the representativeness of the sample, three years of survey data (2003–2005) were amalgamated into a single dataset. If a given state administered the Heart and Stroke module in multiple years, only the data from the most recent year were included in the merged dataset. In the final analysis, data from 23 states, one territory and the District of Columbia were included in the combined 2003–2005 database. The unweighted sample size for the population of interest for the years 2003–2005 was 3146. For analysis these data were weighted to represent 2 641 024 Hispanic women aged 18 years and older who answered questions about heart attack and stroke symptoms.FindingsAdult Hispanic women earning low scores on the heart attack and stroke knowledge questions were more likely to have less than a high school education, be uninsured, live in a household with an annual income of <$35 000 and not have a primary care provider.DiscussionThese results suggest that strategies to educate Hispanic women on signs and symptoms of heart attack and stroke might benefit from targeting women in these groups.