A mixed-method evaluation of a general practice paediatric education programme, using Moore’s outcomes framework for continuing medical education

BackgroundIn this study we explored the challenges to establishing a community of practice (CoP) to address standards in general practice. We focused on the issue of improving referral letters which are the main form of communication between general practitioners (GPs) and specialists. There is evidence to suggest that the information relayed to specialists at the time of referral could be improved.MethodsWe aimed to develop a community of practice consisting of GPs in Western Australia to improve the quality of referral letters to six specialty clinics. Three phases included: establishing the CoP, monitoring the progress of the CoP and sustaining and managing the CoP. The CoP's activity centred on referral letters to each of six selected specialties. A local measure for the quality of the referral letters was developed from a survey of participants about specific items of history and weighted for their perceived importance in the referral letter. Referral letters by participants written before and after the benchmarking exercise were scored for quality based on the standards set by the CoP. Feedback to participants regarding the 'quality' of their individual referrals was provided by a nominated member of the CoP, including a comparison of before and after scores.Results15 GPs were recruited. Only five GPs submitted referral letters both before and after benchmarking. The five GPs that participated in both study phases submitted a total of 102 referral letters (53 before and 49 after). There was a 26 point (95% CI 11–41) improvement in the average scores of the second set of letters after taking clustering by speciality into account, indicating the quality of referral letters improved substantially after feedback.ConclusionThere are many challenges to forming a CoP to focus on improving a specific issue in general practice. However we were able to demonstrate that those practitioners who participated in all aspects of the project substantially improved the quality of their referral letters. For recruitment it was important to work with a champion for the project from within the practice. The project took several months to complete therefore some GPs became disengaged. Some were very disappointed by their performance when compared to colleagues. This reaction may be an important motivation to change, however it needs to be sensitively handled if participants are not to become disillusioned or disheartened.

The Patients Association Nutrition Checklist (Checklist) is a simple tool that can be used to identify older adults who may be at risk of malnutrition at an early stage and provide simple advice and signpost to additional support. The Scottish Borders Council, in partnership with the Eat Well Age Well Charity, have been implementing the Checklist across health and social care organisations since Autumn 2021. Aims: To see if it was possible to use the Checklist in 12 organisations that work with older adults in the community, and to understand what the impact of the Checklist is for older adults and the staff who use it. Methods: Information regarding how the Checklist was used and the experiences of staff who work in the organisations was collected using online surveys. Organisation staff and the Checklist trainer (Eat Well Age Well) were interviewed about their experiences of using the Checklist.

Falls prevention education between older adults and healthcare providers during transition from hospital to community-living

Recent Australian trends indicate that shave biopsies for diagnosing lesions suspicious of melanoma are increasing, yet reasons for this remain relatively unknown. We sought to understand which factors influence Australian clinicians' use of shave biopsy for managing thin lesions suspicious of melanoma in sites of low cosmetic sensitivity. We used a convergent, exploratory mixed-methods design, with a cross-sectional online survey (n = 59) and semi-structured qualitative interviews (n = 15). We recruited clinicians working in skin cancer medicine across Australia, mostly general practitioners (> 80%) with some dermatologists (n = 7 survey and n = 1 interview participant). Survey participants indicated how frequently they used shave biopsies and rated the importance of factors when considering the use of a shave biopsy. Interview participants elaborated on the motivating factors for using different biopsy techniques. Qualitative data were professionally transcribed and analysed with content analysis. Most survey participants (95%) reported that identifying fewer signs of locally advanced melanoma was 'very important' for using shave biopsy. Fifty per cent of survey participants also reported that faster procedure speed and greater convenience were 'very important' reasons for using shave biopsy. Procedure speed was particularly important for using shave biopsy among clinicians self-identifying as time-poor. Interview participants noted (a) the risk of transecting the lesion base or (b) incomplete lesion removal from shave biopsies as reasons against their use. The relative speed and convenience of shave biopsies in clinical practice are strong motivators for their use. Further evidence on patient outcomes with widespread use of shave biopsy is required to inform clinical guidelines.

BackgroundGeneral practice is often recommended as an ideal setting to initiate advance care planning (ACP), but uptake of ACP in this setting is low. ACP-GP is a complex intervention to facilitate ACP for patients with chronic, life-limiting illness in Belgian general practice. It aims to increase patient ACP engagement and general practitioner (GP) ACP self-efficacy. In a cluster-randomized controlled trial, the intervention was not superior to control in increasing these outcomes. A parallel process evaluation aimed to enhance understanding of how the intervention was implemented, and which factors might have influenced trial results.MethodsWe conducted a mixed-methods process evaluation following the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. Data sources include recruitment and implementation monitoring, questionnaires for patients and GPs, and semi-structured (focus group) interviews with patients and GPs. Questionnaire data were analyzed descriptively. Qualitative data were first analyzed inductively; themes were then assigned deductively to RE-AIM dimensions.ResultsThirty-five GPs and 95 patients were recruited to the trial; GP reach was low. Sixteen GPs and 46 patients provided questionnaire data at 3 months post-baseline; qualitative data were transcribed for 14 GPs and 11 patients. Adoption of intervention components was moderate to good, with the exception of the documentation template for GPs. Interviews revealed varying patient attitudes towards ACP, but patients nonetheless emphasized that conversations made them feel reassured. GPs especially valued a positive framing of ACP. When adopted, the intervention was well-implemented and participant satisfaction was high. However, intention for maintenance was moderate, with GPs raising questions of how to sustainably implement ACP conversations in the future.ConclusionsImplementing the complex ACP-GP intervention in general practice is feasible, and can be successful. However, the implementation process is challenging and the sustainability is suboptimal. Our findings will guide future research and recommendations for facilitating and implementing ACP in general practice.Trial registrationISRCTN12995230; prospectively registered on 19/06/2020.

Background and Purpose of the Research The purpose of the research reported in this thesis was to explore the challenges of managing the 2009/A/H1N1 influenza pandemics in primary care in Australia, Israel and England. The influenza pandemic 2009/A/H1N1 was less devastating than originally anticipated; however, its burden on the health systems of many countries was substantial. It affected 214 countries and territories disproportionally afflicting young children and pregnant women. During this influenza pandemic, the main burden of the pandemic response fell on primary care services, and General Practitioners (GPs) were the ones who diagnosed and treated most of the patients. The prominent role of GPs in the 2009/A/H1N1 influenza pandemic presented an excellent opportunity to investigate the implications of pandemic policies for primary care and to tackle the potential problems that these policies may impose on the ability of GPs to participate effectively in the pandemic response. Method The research design consisted of three complementary studies: a systematic review of the literature, a document study, and qualitative semi-structured interviews with GPs. The systematic literature review (Study 1) was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and applied systematic approach to the literature search, study selection and data extraction. The objective of the systematic review was to examine evidence of challenges that primary care physicians encountered responding to past pandemics or large-scale epidemics. The document study (Study 2) involved analysis of the documents published by the health authorities in Australia, Israel and England during the 2009/A/H1N1 influenza pandemic. Information pertinent for the research question was separated from non-pertinent applying qualitative content analysis approach. Subsequent thematic analysis involved more focused reviewing of the retrieved data, which involved coding and category construction. The objective of the document study was to compare the approaches for management of the 2009/A/H1N1 influenza pandemic in primary care in these three countries. Qualitative semi-structured interviews with 65 GPs in Australia, Israel and England (Study 3) were conducted during June-September 2010. Thematic analysis of the qualitative data was applied. The objective was to explore the views of GPs on challenges they encountered managing the 2009/A/H1N1 influenza pandemic in these three countries. Findings The systematic review of the literature (Study 1) revealed that GPs from different countries experienced similar challenges during past epidemic or pandemic responses. These included: difficulties of communication with the health authorities; limited supply of Personal Protective Equipment (PPE) and difficulties with its use; challenges in performing public health responsibilities; limited support from the authorities; lack of appropriate training. However, the review did not allow a full-scale list of possible challenges of the pandemic response in primary care and yielded little systematic information concerning the nature of the identified challenges. The reasons for these were that only 10 studies met the inclusion criteria of the systematic review; the included studies had different objectives and designs; the studies provided little relevant information needed to consider the differences in patterns of the disease spread and GP involvement in the response in different countries. Study 2 and Study 3 of this thesis were designed to address the identified gap and to investigate the challenges of GP involvement in the 2009/A/H1N1 pandemic response in the selected examples of Australia, Israel and England. Study 2, document analysis, provided systematic evidence concerning the different approaches for involvement of GPs in the pandemic response in Australia, Israel and England. It showed that the involvement of GPs in the three countries differed in timing and allocated responsibilities. Study 3 of the thesis, qualitative interviews with GPs in Australia, Israel and England, elicited challenges in providing the pandemic response in primary care from the respective of GPs. The identified challenges were consistent with the findings of the systematic review of the literature. Systematic collection and analysis of the qualitative data from the three countries allowed identification of a full-scale list of challenges in three fields of the pandemic response: treatment of patients, performance of public health responsibilities and communication with the health authorities. Contribution of the Research to Knowledge This thesis adds to the existing knowledge concerning challenges of the pandemic response in primary care by differentiating between two types of challenges: (i) country specific challenges and (ii) cross country challenges intrinsic to the pandemic response in primary care in general. This was done by collating the data from the document study (Study 2) and qualitative interviews with GPs (Study 3). (i) Country specific challenges. These challenges were found to be influenced by the timing and severity of the disease spread, level of GP involvement in the response, support provided to GPs by the health authorities, and organization of primary care services in a country. (ii) Cross country challenges intrinsic to the pandemic response in primary care in general. These same difficulties were evident in each of the three countries and included difficulties in following pandemic guidelines (barriers affecting knowledge, attitudes and behaviour of GPs) and challenges related to the role delineation during the pandemic response that resulted in role ambiguity and role conflict. Conclusion and Recommendations for Future Pandemic Planning The experience of the 2009/A/H1N1 influenza pandemic management highlighted the centrality of primary care in the pandemic response. The findings of this thesis showed that GPs were intensively involved in the pandemic response in the three investigated countries, despite the differences in the responsibilities that were allocated to them. The connection of GPs to the populations they routinely serve and trust that these populations have in GPs, positioned them as the pivotal figures when people were concerned about their health or the possibility of getting sick. This situation is not likely to change in the future. In order to overcome challenges identified in this research, improvements in planning for involvement of GPs in the pandemic response should be introduced. Based on the thesis findings, the following recommendations were made: First, broader involvement of GPs in the process of planning should be targeted. This includes engagement of GPs and public health representatives in pre-pandemic drills, collaborative meetings and knowledge transfer; engagement of GP representatives and health authorities in pandemic policy evaluation; inclusion of GP representatives in decision making and planning committees. Second, improvement in clarity and strategy of the pandemic policies and guidelines communication to GPs should be introduced. This includes the establishment of one body that is responsible for communicating pandemic policy updates to GPs; making policy updates oriented to primary care by engaging GPs in pre-pandemic policy planning committees; engagement with GP professional bodies that develop and distribute guidelines for primary care; and establishment of mechanisms for GP feedback provision during the pandemic response. Third, planning the support to be provided to GPs during the pandemic response is imperative. This should include planning for rapid distribution of PPE and antiviral drugs in primary care; reimbursement for the pandemic vaccine administration; coordination during the mass vaccination campaign in primary care; and detailed guidelines to treat complicated pandemic cases.

BackgroundThe recent UK Government paper ‘Five year forward view’ describes the need to move much patient management from secondary to primary care, and this will require a significant increase in the numbers of General Practice Nurses (GPNs). Until recently, there has been no clear recruitment strategy to address this. There have however been a number of proposed solutions to address the impending GPN recruitment crisis and to increase the numbers of new GPNs in post. General Practitioners (GPs) working in the Advanced Training Practice Scheme (ATPS) have been commissioned by Health Education England to provide placements for student nurses. This paper reports upon the findings of a study evaluating the South Yorkshire ATPS network in relation to nursing students’ perceptions of general practice as a placement and a potential career option post-graduation.MethodsData were collected using semi-structured interviews with 18 nursing students. Qualitative data analysis used a framework approach and themes were cross-checked within the team. The research had ethical approval and anonymity and confidentiality were maintained throughout.ResultsUsing the Communities of Practice (CoP) framework as a theoretical lens, two main themes emerged from the data: ‘Myths and misunderstandings’ outlined some of the misconceptions that abounded in the absence of an established CoP in general practice. These included perceptions of what constitutes a ‘good’ placement, an apparent lack of relevant content in the curriculum, and the widespread use of social media by students as a means of information gathering. ‘Changing hearts and minds’ referred to the need to positively influence the culture within general practice by addressing some of the longstanding myths. Through the fledgling CoP, the students’ perceptions of the GPN role in particular were positively revised, as was the prospect of a career in general practice upon graduation.ConclusionsThe CoP that is emerging through the ATPS placements appear to be gradually changing the socio-cultural landscape within general practice by enabling student nurses to experience the reality of life in general practice nursing, and to view the GPN role as a viable career option upon graduation.

Background: The gap between current and evidence-based management of type 2 diabetes is widely acknowledged in Australia. Therefore, there is a need to find effective strategies to encourage GP awareness and uptake of evidence-based diabetes guidelines. A well-developed and evaluated web-based education strategy is considered to be an appropriate method for practising GPs in rural and remote areas to undertake continuing medical education. This PhD research forms one part of an NHMRC project entitled “The effectiveness of continuing medical education and feedback in altering diabetes outcomes at a population level-A RCT”. Aims: 1) to examine the current knowledge, attitudes and practices of Australian rural and remote GPs regarding type 2 diabetes management, 2) to test the impact of an online education intervention on GPs’ learning outcomes, and 3) to identify barriers to GPs undertaking and completing the online educational intervention and online learning in general. Methods: The research design consisted of seven complementary studies: three systematic reviews of the literature; a cross-sectional national survey; a quasi-experimental study; and a mixed methods study comprising a short cross-sectional survey and semi-structured telephone interviews. The systematic literature reviews were conducted applying systematic approaches to the literature search, study selection and data extraction. The first systematic review (Study 1) aimed to assess evidence in the literature for the effectiveness of type 2 diabetes educational interventions specifically targeting practising GPs, and where possible, those practising in rural and remote locations. The second systematic review (Study 2) aimed to assess evidence in the literature for the effectiveness of online continuing medical education (CME) specifically targeting GPs. The third systematic review (Study 3) aimed to examine barriers to GPs undertaking and completing online CME. A national cross-sectional survey (Study 4) was conducted with 854 general practitioners (GPs) currently practising in rural and remote Australian communities with populations of between 10,000 and 30,000. A quasi-experimental design (Study 5) was used to compare the knowledge, attitudes and reported changes in practice of GPs who completed an online diabetes active learning module (ALM). The module has been offered by the main NHMRC project to 146 rural and remote GPs in the 11 intervention towns of NSW and QLD which have populations of 10,000 to 30,000. A mixed methods study, involving a short cross-sectional survey (Study 6) and semi-structured interviews (Study 7), were then used to identify enabling and inhibiting factors in undertaking and completing the online ALM. Findings: The national cross-sectional survey (Study 4) revealed that 209 completed surveys were returned, yielding an overall response rate of 24.5 %. GPs reported on their education preferences, knowledge, attitudes and practices relating to type 2 diabetes. GPs indicated a strong preference for face-to-face education options such as conferences and seminars (75.2 %). Whilst structured online education activities were less utilised than face-to-face options, GPs reported a desire to undertake more of their education online in the future. Survey findings revealed gaps in GP knowledge of the medical management of diabetes. The most prevalent self-reported learning needs related to pharmacological management (N = 87, (45.5 %)). Correspondingly, in the GP knowledge test, GPs received the lowest mean score for the section on medication management. GPs also reported having the least confidence in providing effective insulin treatment, compared with other aspects of diabetes management. GPs identified an array of difficulties encountered in providing best practice diabetes care, which were classified into three main categories: GP clinical management problems, patient-related challenges and health system-related difficulties. The quasi-experimental study (Study 5) failed to demonstrate the effect of the online ALM on learning outcomes due to inadequate responses to generate statistical inferences. Findings from the systematic review (Study 2) indicated that online CME has the capacity to improve GP satisfaction, knowledge and practice. However, there are very few well-designed studies that focus on this delivery method for GP education. A systematic review (Study 1) also showed that few studies have examined the effectiveness of GP type 2 diabetes education. Evidence to support their effectiveness in improving GP satisfaction, knowledge, practices and/or patient outcomes is partial and weak. GPs reported reasons for non-participation in the online diabetes CME (Study 6) that correspond with the findings from the systematic reviews (Study 3). Barriers to GP online learning were grouped into four main domains: 1) structure, 2) learners, 3) facilitator and 4) the online program itself. However, GPs rarely reported difficulties inhibiting their completion of the online ALM (Study 6 and Study 7). Contribution of the research: This research adds new knowledge to the field of general practice education in Australia and internationally. The research addresses some of the widespread challenges of CME evaluation: there are currently few well-designed studies focusing on (1) GP CME in general; (2) GP diabetes CME (Study 1); (3) GP online CME (Study 2). The research also provides new insights into the current knowledge, attitudes and practices of Australian rural and remote GPs regarding their type 2 diabetes management. This may further assist CME providers and policy-makers in developing and providing education that addresses GPs’ needs. Conclusions and Recommendations: The national cross-sectional survey highlights a number of barriers to GP provision of best practice diabetes care in rural and remote Australia. Despite the availability of education programs and clinical practice guidelines, the GP respondents revealed deficits in knowledge and confidence in type 2 diabetes management. GPs identified numerous challenges to effective patient care, some but not all of which can be addressed through CME. Online CME has the capacity to improve GP satisfaction, knowledge and practices, but there are very few well-designed studies that focus on this delivery method for GP education. In order to overcome challenges identified in this research, improvements are needed in planning, developing and selecting the topics of education that are needed for GPs. Based on the doctoral research findings, the following recommendations are made: First, in order to provide CME programs for GPs or health care professionals, the learning needs should be clearly identified prior to program implementation. CME providers need to tailor education programs that specifically focus on and address current GP needs. Second, there is a noticeable absence of research focussing on diabetes CME, specifically for GPs practising in rural and remote areas. The use of multiple combined education techniques showed mixed effects. Future studies may need to examine specific combinations of educational techniques and delivery methods tailored to specific desired outcomes for rural and remote GPs. Third, in order to provide online learning activities for GPs, providers who develop the learning programs need to take into account barriers to undertaking and completing online CME. The number of studies examining GP online education is very limited. Therefore, further research is warranted specifically targeting GPs. In addition, future research should focus on clarifying when to use online CME for GP education and how online teaching technologies can be used most effectively. Fourth, future studies need to examine strategies to improve GPs’ participation in CME programs, and in research evaluating these programs.

Background Undergraduate medical education and foundation training are still largely hospital based. General practice trainees also spend nearly half of their speciality training in hospitals. Aims: To explore adaptation experiences of general practice speciality trainees throughout the training. Method: Semi-structured participant-observer interviews with 18 purposively selected trainees on the East Staffordshire vocational training scheme, observation, stakeholder discussions and concurrent inductive thematic analysis. Results: Undergraduate and early general practice experience during speciality training, general practice trainer role modelling and mastering core general practice skills, facilitated transition. An inclusive and supportive general practice environment, facilitating engagement with a community of practice involving peers, general practice trainers and vocational training programme fostered belongingness. A reduced sense of belongingness during hospital rotations impacted on training and work. Building bridging social connections, personal agency initiatives to bring general practice relevance into hospital training, signposting to general practice relevant duties and mastery of secondary care relevant competencies helped gain belongingness in hospital. While some international graduates required assistance in specific areas; overall, general practice trainees had optimistic views of their future. Conclusion: The main contribution of this study was to relate the adaptation experiences of trainees to learning and practice based on Wenger’s communities of practice to enable a better understanding of how they can be influenced to enhance training. Abbreviations: CoP: Community of practice; GP: General practice; GPST: General practice speciality trainee; M: Male; F: Female; ST1: First-year GPST; ST2: Second-year GPST; ST3: Third-year GPST; UKG: UK-based primary medical qualification; IMG: Non-UK primary medical qualification.

BackgroundThe UK Government document 5 year forward view describes the need to move chronic disease management from secondary to primary care, which will require a significant increase in the numbers of General Practice Nurses (GPNs). Until recently, there has been no specific recruitment strategy to address this increased need. In recent times, a number of solutions have been suggested to address this impending GPN recruitment crisis. For example, Health Education England (HEE) commission General Practitioners (GPs), who are members of the Advanced Training Practice Scheme (ATPS), to provide placements for student nurses within general practice.MethodsA descriptive qualitative study was undertaken, in which data were collected using semi-structured interviews with 16 GPs and 2 GPN partners*. Qualitative analysis used a framework approach and themes were cross-checked within the team and member checking was undertaken with a convenience sample of GPs. The research had ethical approval and anonymity and confidentiality were maintained.ResultsFrom the GP perspective, there were two key themes that emerged from the data. The first theme of ‘fishing in the same small pond’ included succession planning for the general practice workforce, the ‘merry go round’ of poaching staff from other practices, and the myths and misunderstandings that have grown up around general practice nursing. The second theme, ‘growing your own’, looked at the impact of the student nurse placements as a means to address the crisis in GPN recruitment. There was recognition of the need for cultural change in the way that GPNs are recruited, and that the ATPS was one way of helping to achieve that change. There were however a number of challenges to sustaining this cultural shift, such as the financial constrains placed upon the GP practice, and the need to function as a ‘small business’.ConclusionsDespite all the challenges, the evidence is that, through the Community of Practice (CoP), the ATPS scheme is beginning to ‘bear fruit’, and there is a subtle but discernible move by GPs from a ‘why would we?’ to ‘why wouldn’t we?’ invest in education and training for nurses in general practice.N.B. The term GPN partner* denotes a GPN who is a ‘full partner’ in the practice business, holding the same NHS contracts and the same status as a GP. For the purposes of the paper itself, the term GP will be used to denote both types of partner.

Introduction The number of pharmacists and pharmacy technicians working within general practice has significantly increased with the NHS Long Term Plan and the introduction of the ‘Additional Roles Reimbursement Scheme’ (ARRS)1,2. Whilst there is an approved learning pathway for those employed under ARRS3, it is not clear what additional development the whole local workforce needed both immediately and into the future. Aim To establish what learning & development was being completed by the pharmacy professionals in general practice and what was required to support the roles into the future. Methods An online, anonymous survey was sent to all members of the pharmacy workforce working in GP practices or Primary Care Networks across Bristol, North Somerset & South Gloucestershire (119 pharmacists and 36 pharmacy technicians). The tool used a mixture of qualitative and quantitative questions to investigate existing learning needs, current programmes of study and the use of competency frameworks to support learning. In addition, it investigated whether respondents used ‘communities of practice’ to support their learning and what future networks may be required. Qualitative data were grouped by themes and actions taken on the key themes. Descriptive statistical analysis was undertaken on the quantitative data. The survey was not considered to be research; therefore ethics approval was not required. Results There was a 25% response rate (n=39) which included 29 pharmacists (24%) and 10 pharmacy technicians (28%). 15 respondents were either on the accredited pathway or had completed it (38%) and of the pharmacists, 20 were registered prescribers (69%). 21% (n=8) of respondents were using a framework to evidence competencies. Career aspirations included becoming Advanced Clinical Practitioners, Consultant Pharmacists or Partners in their practice. 44% (n=17) of respondents reported no protected development time. 30 respondents belong to one or more network groups (81%). 73% (n=28) of the respondents supported the development of more communities of practice although some suggested the purpose should be clear and the impact on work-life balance considered. Discussion/Conclusion This study provided a broad overview of the current need for learning and development in the local area although a limitation was the small proportion of the workforce that responded. It was clear that the pharmacy workforce in general practice in BNSSG required more support for career development. The information gathered through this survey has shaped the support provided by the Pharmacy Lead at the BNSSG Training Hub. Guidance has been produced to support practices with understanding roles of pharmacy professionals and their development needs including protected time. A business case has been submitted to explore funding for advanced clinical skills as this was seen as a priority by respondents. In addition, an additional community of practice has been developed to enable peer discussions and support amongst pharmacy professionals. There is further work to be done to support the learning and development of the workforce in general practice. The Royal Pharmaceutical Society Core Advanced Curriculum and the use of already established frameworks will enable pharmacy professionals to demonstrate their skills and competence and will be used to identify their learning needs.

Aim: The aim of this study was to examine the health and health related quality of life of patients with one or a combination of the following stable chronic diseases: ischaemic heart disease, hypertension and type 2 diabetes. The patients were enrolled in a twelve month practice nurse-led model of care, trialled in three general practices in Australia. Background: Chronic disease is increasing at alarming rates within the Australian and global community. More than 36 million people die each year from chronic diseases and cardiovascular disease accounts for most of these deaths. Chronic diseases are often associated with older age groups, but there are indications that many deaths attributable to chronic disease occur before the age of 60. In Australia the majority of chronic disease management is carried out in general practice, with the general practitioner being the main caregiver. However, evidence suggests that the current models of care within general practice are not effective in meeting the needs of the community. It has been estimated that 60% of patients with diabetes are not reaching recommended glycaemic levels and only one in seven patients are reaching recommended targets for glycaemic, blood pressure and lipid targets combined. It is evident that a paradigm shift in the delivery of health care in Australia is required to attend to the complex needs of patients with chronic diseases. Practice nurses are now employed in approximately 60% of general practices in Australia, and their scope of practice is being advanced, particularly in relation to chronic disease management. However, minimal research has been conducted examining these expanded roles and there is little evidence of the effectiveness of the care they provide. Method: A mixed methods sequential explanatory design consisting of two discrete phases was used to conduct this study. The first phase was part of a larger study where patients with ischaemic heart disease, hypertension, and/or type 2 diabetes, were randomly allocated to a practice nurse-led model of care or usual general practitioner care. Clinical data and patients’ scores on the SF-12 health survey were collected at baseline, six and 12 months. The second phase consisted of semi-structured interviews with purposively selected patients who were enrolled in the practice nurse-led model of care. The interviews were conducted for a dual purpose which was to elicit further information about the patients perceptions of their health related quality of life and the impact of the practice nurse-led care. Data were analysed thematically using a framework approach. Results: Data obtained in the first phase of the study showed little difference between the general practitioner-led and practice nurse-led care groups. The SF-12 physical component summary scores and mental component summary scores of both the practice nurse-led and general practitioner-led groups deteriorated over the 12-month period; however, there was no statistical difference between the groups in the rate of deterioration. Further examination of the participants’ health related quality of life was explored using interviews which revealed the complex nature of how patients manage their lives. Three themes were conceptualised from the qualitative data – managing the chronic disease, active involvement in life, and state of mind. These themes consisted of eleven sub-themes. The impact of the practice nurse-led model of care was also explored, and a further three themes emerged from the data – time, ambiance and dimensions of the nurse role. The SF-12 and qualitative data were compared which provided further understandings of the patients perception of their quality of life. Conclusion: This is the first study in Australia where the care of patients with one or more of the following chronic diseases; ischaemic heart disease, hypertension or type 2 diabetes was transferred from usual general practitioner-led care to a practice nurse-led model of care. The results show that a practice nurse, when following specifically defined clinical protocols can provide care which achieves similar outcomes to those of a general practitioner. In phase two of the study further examination of the patients’ health and/or health related quality of life suggested that practice nurses had a positive impact of the patients’ ability to manage their chronic disease. This infers that there is scope for the PN to expand their role in chronic disease management by utilising clinical protocols in conjunction with chronic disease management plans to assist patients to better self-manage their chronic diseases. These findings are encouraging and highlight that practice nurse-led care can have a beneficial effect on the health and/or health related quality of life of patients by increasing their health literacy and enabling them to make decisions about their own health care.

BackgroundMany patients with back pain do not receive health care in accordance with best practice recommendations. Implementation trials to address this issue have had limited success. Despite the known effectiveness of clinical decision support systems (CDSS), none of these are available for back pain management.ObjectiveThe objective of our study was to develop a Web-based CDSS to support Australian general practitioners (GPs) to diagnose and manage back pain according to guidelines.MethodsAsking a panel of international experts to review recommendations for sixteen clinical vignettes validated the tool. It was then launched nationally as part of National Pain Week and promoted to GPs via a media release and clinic based visits. Following this, a mixed methods evaluation was conducted to determine tool feasibility, acceptability, and utility. The 12 month usage data were analyzed, and in-depth, semistructured interviews with 20 GPs were conducted to identify barriers and enablers to uptake.ResultsThe tool had acceptable face validity when reviewed by experts. Over a 12 month period there were 7125 website visits with 4503 (63.20%) unique users. Assuming most unique users are GPs, around one quarter of the country’s GPs may have used the tool at least once. Although usage was high, GP interviews highlighted the sometimes complex nature of management where the tool may not influence care. Conversely, several “touch-points”, whereby the tool may exert its influence, were identified, most notably patient engagement.ConclusionsA novel CDSS tool has the potential to assist with evidence-based management of back pain. A clinical trial is required to determine its impact on practitioner and patient outcomes.

The paper uses the theory of communities of practice to explore the effects of professional and organisational boundaries on the implementation of a service improvement initiative within and across primary care settings. It shows that in spite of epistemic and status differences, multiprofessional communities of practice can develop and professional boundaries between general practitioners, practice nurses and practice managers co-located in the same organisation can be successfully bridged without major tensions or conflict. While knowledge circulates relatively easily within these multiprofessional communities of practice, barriers to knowledge sharing emerge at the boundary separating them from other groups existing in the same organisation. The strongest boundaries, however, lie between individual general practices, with inter-organisational knowledge sharing and collaboration between them remaining unequally developed across different areas due to historical factors, competition and strong organisational identification. Manipulated emergence of multi-organisational communities of practice in the context of primary care may thus be problematic. This is likely to affect the implementation of the primary care reform currently implemented in the English National Health Service, underscores the importance of facilitation in addressing organisational boundaries, and suggests that inter-organisational learning, collaboration and knowledge sharing in primary care landscape should get more attention from researchers.

General practice services are under pressure due increased demand. Alongside substantial national recruitment challenges, there exists a shortage of general practitioners to meet current need. Resultingly, allied healthcare professionals, including paramedics, are being utilised in general practice. To determine the models of paramedics in general practice settings; the mechanisms that underpin effective paramedics in general practice; and the impact of paramedics in general practice on safety, costs and clinical and patient-reported outcomes and experience. A mixed-methods realist evaluation comprised a rapid realist review followed by an evaluation of paramedics in general practice in general practice case study sites. Patient and public involvement and input was integral, ensuring validity from a patient and carer perspective. General practices in England. A total of 34 general practices participated as case study sites, of which 25 were 'paramedics in general practice' sites. Data from qualitative realist interviews (n = 69), quantitative questionnaires (n = 489) and electronic records (n = 22,509 consultations) were collected. Paramedics in general practice models were classified according to: (1) level of integration of the paramedic to the general practice team; and (2) complexity of patients seen by paramedics. Qualitative interviews investigated initial programme theories with staff and patient participants. Patient participant questionnaires utilised validated measures: the Patient-Reported Experiences and Outcomes of Safety in Primary Care (safety); EuroQol-5 Dimensions, five-level version (health-related quality of life); Primary Care Outcomes Questionnaire; the Modular Resource Use Measure (health and care resource utilisation). Electronic health records provided data on primary care use. A rapid realist review of the published and grey literature, supplemented with direct enquiry with system leaders and key stakeholders. The rapid realist review highlighted significant variation in paramedics' roles in general practice. Qualitative interviews identified domains related to access, safety, workforce reconfiguration, infrastructure, patient experience, and outcomes. Lower Patient-Reported Experiences and Outcomes of Safety in Primary Care practice activation scores were found at paramedics in general practice sites (perceived less engaged in promoting safety), in particular those with medium and low levels of paramedics in general practice integration and complexity. There was a small statistically significant difference in the Primary Care Outcomes Questionnaire 'Confidence in Health Plan' by paramedics in general practice complexity, such that confidence had deteriorated slightly more in the high-complexity group compared to non-paramedics in general practice. Paramedics in general practice sites had lower scores at initial visit and 30 days for the Primary Care Outcomes Questionnaire 'Confidence in Health Provision'. We found little evidence that paramedics in general practice care led to substantial spillover effects via increased reconsultations, prescriptions, secondary care referrals or unplanned hospital admission costs. The study faced challenges in recruitment. Self-selected participating sites may not be representative of all general practitioners in England, and categorising paramedics in general practice models for analysis was more complex than anticipated. The comparison of costs and outcomes between paramedics in general practice and non-paramedics in general practice sites was based on an observational study design. Paramedics in general practice care improves access to general practice. Safety and acceptability require resources for induction, supervision, training and education. Paramedics in general practice integration affects staff satisfaction and role longevity. Paramedics in general practice allows paramedics to develop and evolve. Larger studies utilising different study designs with longer follow-up are needed to fully understand the impact of paramedics in general practice on clinical outcomes and episode of care costs. This study is registered as ISRCTN56909665 https://doi.org/10.1186/ISRCTN56909665. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR132736) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 6. See the NIHR Funding and Awards website for further award information.