City Primary Care Trust Research Articles

Does general practice deliver safe primary care to people living with HIV? A case-notes review.

Safe care in general practice for people living with HIV requires early diagnosis of undetected infection and safe co-prescribing with antiretroviral therapy (ART). To evaluate safe co-prescribing in general practice patients who are taking ART, and to describe missed diagnostic opportunities for undiagnosed HIV infection in primary care. Retrospective case-notes review in general practices within NHS City and Hackney Primary Care Trust (PCT), London, UK. All general practices in NHS City and Hackney PCT were invited to participate. Patients known to be HIV positive were identified using Read Codes. Each practice undertook retrospective case-notes reviews on specialist correspondence, coding of ART, prescribing of common contraindicated drug pairings, and missed opportunities for HIV diagnosis. In total, 31/44 (70.5%) practices participated, and 1022 people living with HIV were identified. Practices had received HIV clinic letters for 698 of those 1022 (68.3%) patients in the previous 12 months. Of the 787 patients known to be prescribed ART, only 413 (52.5%) had correct drug codes recorded; 32/787 (4.1%) were receiving specified contraindicated drug pairings. In total, 89 patients were eligible for their case-notes to undergo a retrospective review of occurrences that took place pre-diagnosis. In the 2 years preceding diagnosis, these 89 had attended 716 face-to-face GP consultations, of which 123 (17.2%) were for indicator conditions. Fifty-one of these patients (57.3%) presented at least once with an indicator condition (interquartile range 1-3; median 2). In a large-scale evaluation of GP records of people living with HIV, gaps in ART recording and co-prescribing were identified, and evidence demonstrated missed opportunities for diagnosis within general practice. Specialists and generalists must communicate better to enhance safe prescribing and reduce delayed diagnosis.

PTU-318 The impact of an inflammatory bowel disease nurse-led biologics service

Introduction Southampton General Hospital is a busy teaching hospital providing specialist IBD services for a population of 650,000. Biologics have impacted hugely on the management of IBD but are high cost drugs requiring careful supervision. The absence of a clear biologics pathway made it challenging to provide the support required so we developed a specialist nurse-led biologics service to improve our IBD service. Method In 2010, an audit of biological therapies in 85 patients highlighted areas for improvement in monitoring and follow-up. A business case was developed to establish a nurse specialist to identify patients on biologics and ensure all received appropriate screening, education, and review. A 50/50 gain share was agreed with Southampton City and West Hampshire Primary Care Trust for 2013/14 onwards. The trust invested £60,000 to deliver service improvements. Outcomes were re-audited in 2014. Results In 2010, 17% of patients had a clear management plan documented. An infection screen was documented in 79% and chest x-ray in 56% of patients. 80% were reviewed ≤12 weeks post-induction to assess primary response, 1/3 were reviewed in clinic in ≤6 months, with 20% seen less than once a year. Treatment continuation decisions were documented in 73%. Biologic use has grown rapidly from 90 patients in 2011, to 328 in 2013. All prescription records are now kept in a centralised database. In the 2014 audit, infection screening and chest x-ray were documented in 100% of patients. 96% of patients had follow up ≤4 months post-induction to assess primary response, but 2 patients were seen 7 months post-induction. 80% were followed up again at 9–12 months (100% at 9–14 months) to assess appropriateness of treatment continuation, all with documentation of decision regarding ongoing treatment. The service has proved cost-effective: 109 biologics were discontinued from 2012–2014 and the £60,000 investment was recouped by March 2014 through 350 outpatient appointments and 35 colonoscopies. Research recruitment resulted in 77 patients participating in biologics trials since 2012, providing further income to the trust. Conclusion The specialist IBD biologics nurse-led service has resulted in significant gains in care quality and cost savings, fulfilling the IBD standards 1 by delivering high quality clinical care and a patient-centred service. The need for improved follow up of patients on biologics reflects increased pressures on clinic resources across the country. The introduction of a biologics nurse has provided invaluable support to our patients and facilitated the development of the IBD team at Southampton General Hospital. Disclosure of interest None Declared. Reference The IBD Standards Group, 2009 http://www.bsg.org.uk/attachments/160_IBDstandards.pdf. – Accessed 10th September 2014

PWE-108 Factors Influencing The Management Of Inflammatory Bowel Disease In Primary Care

IntroductionBetween 30–70% of United Kingdom (UK) adults with Inflammatory Bowel Disease (IBD) are managed solely by their General Practitioner (GP).1,2 There is, however, limited knowledge as to how UK GPs...

Cervical screening and the aftermath of childhood sexual abuse: are clinical staff trained to recognise and manage the effect this has on their patients?

To evaluate the training needs and awareness of childhood sexual abuse amongst clinical staff taking cervical screening samples in one inner city primary care trust. Studies exploring sexual abuse and nonparticipation in cervical screening have demonstrated that women can experience re-traumatisation if care during examinations is insensitive to their particular needs. This was a mixed methods, service evaluation in three phases. A literature review, a questionnaire to cervical screening staff in an inner city primary care trust and a focus group of four staff drawn from questionnaire respondents to explore themes raised in the questionnaire data. Data analysis of both quantitative and qualitative data showed that clinical staff underestimated the frequency of childhood sexual abuse although they were aware of the difficulties and reluctance some women experience undergoing gynaecological examinations. When women did disclose childhood sexual abuse or when staff suspected a history of childhood sexual abuse, staff reported feeling unsure of how they should proceed. There was no support or clinical supervision, and unmet training needs were identified. Nurses expressed anxiety around the potential of the screening test to cause more harm than good and at their inability to provide more help than listening. Staff wanted support and further training after completing their cervical screening training course to assist in their provision of sensitive care to patients who have experienced childhood sexual abuse. Whilst our results cannot be generalised to a wider population, they may be meaningful for the community of cervical screening takers. We argue that screening staff require further training and professional support (clinical supervision) to increase their confidence when providing safe and sensitive practice for childhood sexual abuse survivors. If staff feel more confident and competent when responding to disclosure of childhood sexual abuse in screening situations, women who have experienced childhood sexual abuse might participate in the screening programme more readily.

A combined laboratory and field evaluation of the Cholestech LDX and CardioChek PA point-of-care testing lipid and glucose analysers

Combined lipid and glucose point-of-care testing (POCT) devices could facilitate widespread population screening for cardiovascular disease (CVD) and diabetes as part of the NHS Vascular Risk Assessment and Management Program (NHS Health Checks). An evaluation of the Cholestech LDX and CardioChek PA POCT analysers was performed in collaboration with the Wolverhampton City Primary Care Trust (PCT). Intra-/inter-batch imprecision, between-analyser variation and the effect of haematocrit and ascorbic acid assay interference were investigated. Accuracy of the POCT capillary whole blood total cholesterol (TC), high-density-lipoprotein cholesterol (HDL-C) and glucose measurements was estimated by comparison with those from the laboratory analysis of paired venous samples. POCT usability and clinical governance were also assessed. The LDX exhibited lower intra- and inter-batch imprecision and external quality assessment (EQA) scheme between-analyser variation for the measurement of TC, HDL-C and glucose when compared to the CardioChek. Ascorbic acid negatively interfered in all three assays on both POCT analysers and results reported by the CardioChek were influenced by the specimen haematocrit. The LDX displayed closer agreement with the laboratory methods for the measurement of TC and HDL-C but both the LDX and the CardioChek displayed positive bias for the measurement of glucose. POCT has clear advantages for delivering NHS Health Checks over the laboratory-based approach although device performance does differ. Users should also be aware of the potential clinical governance and interference issues associated with these devices.

Innovative hypoglycaemia care pathway for admission avoidance: a partnership approach with a local ambulance trust

AbstractIn 2010, Leicester City Primary Care Trust commissioned an Intermediate Care Diabetes Service. One aspect of the service plan was to work with the local ambulance trust to gather data around patients using ambulance services for hypoglycaemia, and to provide an advisory service for individuals post ambulance call‐out.This audit identified 388 diabetic emergency ambulance call‐outs locally (for the period 1 September 2010 to 31 March 2011) including those for hypoglycaemia in the Leicester City area.The new service commissioned by Leicester City included diabetes specialist nurse assessment within two working days for all hypoglycaemic individuals accessing ambulance services. A care pathway was drawn up and agreed over a series of meetings between the Intermediate Care Diabetes Service and ambulance service leads. Copyright © 2013 John Wiley & Sons. Practical Diabetes 2013; 30(4): 151–153

More time for patients: digital pens for clinicians

In a move to improve the timeliness and accuracy of recording patient data, Wolverhampton City primary care trust (PCT) explored a range of mobile technologies within its community services departments. The goal was to eliminate the need to re-enter handwritten patient notes into its i.Patient Manager (iPM) patient record system—a process which tied up both clinical time and increased the risk of mistakes, as information had to be recorded twice.

General practitioners' views on the use of the levonorgestrel-releasing intrauterine system in young, nulligravid women, in London, UK

ABSTRACTBackground and objectives The levonorgestrel-releasing intrauterine system (LNG-IUS, Mirena®) is one of the most reliable and cost-effective methods of contraception. In the UK, uptake of this method among nulligravid women under 25 years of age is very low. This study surveyed the knowledge and attitudes of general practitioners (GPs) towards the use of the LNG-IUS by young nulligravidae.Method A questionnaire containing 15 multiple choice questions was sent to GPs in City and Hackney Primary Care Trust, in London, in 2008.Results Seventy-one GPs responded (38%). None would opt for the LNG-IUS as their first choice contraceptive method for nulligravid women under 25 years of age. Ninety-two percent stated that an oral contraceptive was their first choice, whilst only 8% chose a long-acting reversible contraceptive (LARC). Seventeen percent considered that the LNG-IUS was associated with an increased risk of pelvic inflammatory disease (PID), and 23% stated it was associated with an increased risk of ectopic pregnancy.Conclusions The LNG-IUS was not widely promoted or provided to young nulligravid women by GPs participating in this survey. Misconceptions relating to PID and risk of ectopic pregnancy and perceived difficulty of insertion in nulligravidae may contribute to the low use of this contraceptive.

A multi-method evaluation of the Pharmacy First Minor Ailments scheme

To evaluate whether the Pharmacy First Minor Ailments scheme achieved its objectives in terms of improving access to medicines and reducing doctor workload for minor ailments by enhancing the role of community pharmacists in the management of minor ailments. Nottingham, the United Kingdom. A mixed-methods study was conducted, including semi-structured interviews with key stakeholders, a patient survey, and an analysis of the Nottingham City Primary Care Trust data. Stakeholders' acceptability of the scheme and scheme users' satisfaction with the scheme. Most health care professionals were positive about the implementation of the scheme, although they reported some problems, such as the restricted formulary. The majority of stakeholders perceived benefits of the scheme for both patients and health care professionals. The level of patient satisfaction with the scheme was high, particularly in terms of ease of access and convenience. The current structure of the scheme appears to be an acceptable way to run the scheme. Since its commencement the scheme has enabled the transfer of a substantial number of minor ailments consultations from general practices to community pharmacies. It appears that the Nottingham City Primary Care Trust is successful using community pharmacies to improve access to medicines and provide a greater choice in primary care for patients with minor ailments. Thus, the Primary Care Trust should continue the scheme, although there are some important issues (e.g. the restricted formulary, the lack of privacy in some pharmacies) that need to be addressed to improve and develop the service further. The Nottingham City Primary Care Trust should build on this success to further utilise the pharmacy in their primary care service development.

Lights … camera … infection prevention in action

Infection prevention and control (IPC) education of independent contractors is a challenge for Infection Prevention and Control Practitioners (IPCP) working in community, due to the diversity of disciplines working across many services and their geographical locations. This article focuses on two differing and innovative teaching methods of play presentation and educational DVD used by the IPCP in a large city primary care trust—commissioning organisation aimed at general dental practice staff (GDPs). The experience suggests that innovative learning activities such as drama and scenario-based DVDs in teaching IPC principles may be applicable in other areas of primary care areas such as general practice, in the wider healthcare community within care homes and are transferable to acute care settings.

Medication errors in community pharmacy: an investigation into the types and potential causes

Abstract Objectives To establish the nature of medication errors occurring within community pharmacy and analyse common error patterns. To identify factors which influence the occurrence of medication errors and near misses, with the intention of designing systems or strategies to reduce the occurrence of these events. Setting Fifteen community pharmacies situated within Brighton and Hove City Primary Care Trust, East Sussex, between January and March 2004. Method A self-reporting form was designed, piloted and administered to pharmacists, which gathered information on the detection of an error or near miss in the dispensing process. Key findings One-hundred and thirteen near misses and thirty-two medication errors were reported. The majority of near misses were detected by the pharmacist at the final check, and the majority of medication errors were detected by the patient or patient's representative. Selection errors were most common, with similar drug names and packaging cited as the main contributory factors. ‘Business’ was frequently cited as the circumstance surrounding the error. Conclusion This study demonstrates that pharmacists do have an important part to play and the positive impact of community pharmacists in preventing, detecting and correcting errors and thus preventing harm to patients in the primary care setting. However, medication errors do occur, and therefore a multifactorial approach by manufacturers, marketing and packaging personnel, in addition to input from pharmacists, may be an effective permanent solution in reducing the errors made.

Pharmacists' perspectives on the Pharmacy First Minor Ailments Scheme

Abstract Objective To investigate pharmacists' perspectives about the acceptability of the Pharmacy First Minor Ailments Scheme and barriers to the use of the scheme as well as to determine potential improvements to the scheme. Method Semi-structured interviews were conducted with 26 pharmacists between November 2004 and March 2005. Setting Community pharmacies within Nottingham City Primary Care Trust (PCT). Key findings The study has demonstrated that the Pharmacy First Minor Ailments Scheme was well received by the majority of pharmacists and they were positive about the benefits of the scheme to both patients and healthcare professionals, despite raising some problems. Our findings highlighted a number of important issues that might be barriers to running the minor ailments scheme, including the quantity of paperwork involved, the lack of privacy in a pharmacy, and the restrictive nature of the formulary and protocols of the scheme. Conclusion The Pharmacy First Minor Ailments Scheme has been developed and implemented as part of Nottingham City PCT's strategy to improve access to primary care. Findings show that the majority of the pharmacists were positive about the scheme. It can be seen as a way of improving patient access to medicines and advice as well as choice in primary care. In other countries, health policy makers may consider such a scheme if it would fit their healthcare system.

Delivering the WISE (Whole Systems Informing Self-Management Engagement) training package in primary care: learning from formative evaluation

BackgroundThe WISE (Whole System Informing Self-management Engagement) approach encompasses creating, finding, and implementing appropriate self-care support for people with long-term conditions. A training package for primary care to introduce the approach was developed and underwent formative evaluation. This entailed exploring the acceptability of the WISE approach and its effectiveness in changing communication within consultations. The study aimed to refine the patient, practitioner, and patient level components of the WISE approach and translate the principles of WISE into an operational intervention deliverable through National Health Service training methods.MethodsNormalisation Process Theory provided a framework for development of the intervention. Practices were recruited from an inner city Primary Care Trust in NW England. All practice staff were expected to attend two afternoon training sessions. The training sessions were observed by members of the training team. Post-training audio recordings of consultations from each general practitioner and nurse in the practices were transcribed and read to provide a narrative overview of the incorporation of WISE skills and tools into consultations. Face-to-face semi-structured interviews were conducted with staff post-training.ResultsTwo practices out of 14 deemed eligible agreed to take part. Each practice attended two sessions, although a third session on consultation skills training was needed for one practice. Fifty-four post-training consultations were recorded from 15 clinicians. Two members of staff were interviewed at each practice. Significant elements of the training form and methods of delivery fitted contemporary practice. There were logistical problems in getting a whole practice to attend both sessions, and administrative staff founds some sections irrelevant. Clinicians reported problems incorporating some of the tools developed for WISE, and this was confirmed in the overview of consultations, with limited overt use of WISE tools and missed opportunities to address patients' self-management needs.ConclusionsThe formative evaluation approach and attention to normalisation process theory allowed the training team to make adjustments to content and delivery and ensure appropriate staff attended each session. The content of the course was simplified and focussed more clearly on operationalising the WISE approach. The patient arm of the approach was strengthened by raising expectations of a change in approach to self-care support by their practice.

A randomised controlled trial and cost-effectiveness evaluation of "booster" interventions to sustain increases in physical activity in middle-aged adults in deprived urban neighbourhoods

BackgroundSystematic reviews have identified a range of brief interventions which increase physical activity in previously sedentary people. There is an absence of evidence about whether follow up beyond three months can maintain long term physical activity. This study assesses whether it is worth providing motivational interviews, three months after giving initial advice, to those who have become more active.Methods/DesignStudy candidates (n = 1500) will initially be given an interactive DVD and receive two telephone follow ups at monthly intervals checking on receipt and use of the DVD. Only those that have increased their physical activity after three months (n = 600) will be randomised into the study. These participants will receive either a "mini booster" (n = 200), "full booster" (n = 200) or no booster (n = 200). The "mini booster" consists of two telephone calls one month apart to discuss physical activity and maintenance strategies. The "full booster" consists of a face-to-face meeting with the facilitator at the same intervals. The purpose of these booster sessions is to help the individual maintain their increase in physical activity. Differences in physical activity, quality of life and costs associated with the booster interventions, will be measured three and nine months from randomisation. The research will be conducted in 20 of the most deprived neighbourhoods in Sheffield, which have large, ethnically diverse populations, high levels of economic deprivation, low levels of physical activity, poorer health and shorter life expectancy. Participants will be recruited through general practices and community groups, as well as by postal invitation, to ensure the participation of minority ethnic groups and those with lower levels of literacy. Sheffield City Council and Primary Care Trust fund a range of facilities and activities to promote physical activity and variations in access to these between neighbourhoods will make it possible to examine whether the effectiveness of the intervention is modified by access to community facilities. A one-year integrated feasibility study will confirm that recruitment targets are achievable based on a 10% sample.DiscussionThe choice of study population, study interventions, brief intervention preceding the study, and outcome measure are discussed.Trial RegistrationCurrent Controlled Trials: ISRCTN56495859; ClinicalTrials.gov: NCT00836459.

An analysis of the East Kent Outcome System for use in intermediate care

Aims Intermediate care is a multiprofessional rehabilitation service aimed at helping people to remain in their own homes and to avoid hospital admission. Historically, however, each profession of the rehabilitation team has set their own goals with the client. This study aimed to identify and test the feasibility of using a goal attainment outcome measure that the whole intermediate care team could adopt; if successful, this would enable combined goals and thus a more efficient service. Methods A literature review was carried out to identify a suitable and appropriate goal attainment outcome measure. The East Kent Outcome System (EKOS) was chosen and adopted by four intermediate care teams in Nottingham City Primary Care Trust, UK. An audit of EKOS record forms was then conducted in 2008, which looked at EKOS goal summary records completed by all members of the multidisciplinary team. Findings EKOS goal summary records were completed for 334 service users who were receiving rehabilitation either at home or in a residential care setting over this 1-year period. The total number of goals set for this population was 1061, with an average of three goals per service user. Of these goals, 79% were fully achieved and 13% were not achieved. Of the goals not achieved, the most common reason was that people's health had deteriorated. Conclusions The EKOS can be used with success by intermediate care services to quantify the goal setting process and provide a consistent, systematic method of writing and recording goals.

Unequal Lives: Health and Socioeconomic Inequalities

With the compelling evidence that more redistributive universal welfare benefits and education provide the main escalator to reducing inequalities, this is a timely and thought-provoking book for all those concerned to reduce our societies' embedded structural inequalities, cumulative disadvantages and health Australian and New Zealand Journal of Public Health Unequal Lives is the book that we have all been waiting for. In this skilfully crafted volume, Hilary Graham makes the vital connection between health inequalities and social inequalities in a way that opens up new understandings of both concepts and consequences for policy. Scholarly yet accessible, this is a 'must read' book for researchers, policymakers and practitioners alike. Margaret Whitehead, WH Duncan Professor of Public Health, University of Liverpool, UK book has high educational value and is worthy of being considered as a resource for students in relevant courses. It will also be helpful for policymakers, clinicians and social workers, especially those settling and the changes in health outcomes are being observed. The author should be congratulated for bringing clarity to a complex, interlacing and intricate relationship of social and health sciences. Nilamadhab Kar, MD, DPM, DNBConsultant Psychiatrist, Wolverhampton City PrimaryCare Trust; Resource Person, Quality of Life Researchand Development Foundation, UK and Consultant Psychiatrist, Mental Health Directorate,Wolverhampton City Primary Care Trust, Steps toHealth, Showell Circus, Wolverhampton, UK. What is meant by health inequalities and socioeconomic inequalities? What evidence is there to support the link between socioeconomic status and health? Why do these links persist over time, between and within societies, and across people's lives? What part do policies play in the persistence of social and health inequalities?Unequal Lives provides an evidence-based introduction to social and health inequalities. It brings together research from social epidemiology, sociology and social policy to guide the reader to an understanding of why people's lives and people's health remain so unequal, even in rich societies where there is more than enough for all. The book introduces the non-specialist to key concepts like health inequalities and health inequities, social class and socioeconomic position, social determinants and life course, as well as to the key indicators of health and socioeconomic position. It provides a wealth of evidence on socioeconomic inequalities in health at both national and global level, and explores how these inequalities persist as countries industrialise, patterns of employment and family life change, and chronic diseases emerge as the big killers. Consideration is given to policy and its impact on inequalities within the UK, Europe and beyond and an assessment made of health inequalities throughout the life. This new book from best selling author Hilary Graham is of particular interest to students in sociology, social policy, health studies, health promotion and public health as well as to social work and community nursing students and those working in the health and welfare fields.

Collagen: pregnancy and prolapse.

1Ashton, Leigh and Wigan Primary Care Trust, Wigan, UK 2Macclesfield District General Hospital, Macclesfield, UK 3Nottingham City Primary Care Trust, Nottingham, UK 4Wirral Hospital National Health Service Trust, Upton, Wirral, UK Journal of the Association of Chartered Physiotherapists in Women's Health, Autumn 2006, 99, 14–22

Introducing clinical supervision for community-based nurses

City and Hackney Teaching Primary Care Trust has introduced mandatory clinical supervision for all front-line nursing staff (district nurses, health visitors, school nurses, staff nurses, health care assistants). A group model is used, with sessions occurring monthly and lasting 90 minutes. Groups include a mixture of qualified and unqualified staff. The project was introduced in two phases. First, external facilitators were used to run sessions for 18 months. An evaluation toward the end of this period found very strong staff support for the innovation. Internal facilitators were then trained to implement the second phase. A second evaluation found continuing support for clinical supervision, and a preference for multidisciplinary groups. Clinical supervision is now firmly embedded in the organization. It is primarily 'restorative', offering staff relief from the stresses of working in a very deprived and ethnically diverse area where the recruitment and retention of staff is an enduring challenge.

Coping with diabetes project, Hackney Diabetes Centre

AbstractThe City and Hackney Primary Care Trust area has one of the most diverse populations in the UK. It has a very diverse ethnic mix and many community languages. ‘Coping with Diabetes’ is a Neighbourhood Renewal Fund (NRF) funded project based at the Hackney Diabetes Centre which aims to empower and educate people with diabetes and at risk of diabetes from ethnic minority and vulnerable groups.The project has implemented many group education sessions, has been present at health fairs, and has produced an audio CD, patient held records, educational leaflets and a website to enable not just the project workers, but the whole Primary Care Trust to reach out to communities who are at risk of diabetes and to people with diabetes who do not have English as a first language. The project has so far been running for six months and over 1000 people have been screened for diabetes, over 30 educational groups have been run, an audio CD in Turkish has been produced and 800 copies have been distributed to GPs and patients. Patient held records for 7500 patients are being printed, a website has been produced and a script for a DVD is currently being designed.Hackney Diabetes Centre is making real in‐roads into meeting targets 1, 2, 3 and 4 of the Diabetes National Service Framework, in a diverse and hard to reach population. Copyright © 2006 John Wiley & Sons, Ltd.

Developing career pathways for new nurses: lessons from inner London

Inner city primary care trusts (PCTs) often have difficulty in recruiting nursing staff, while newly qualified nurses are often unaware of what opportunities community settings offer. This article reports the development of a rotational scheme designed to reduce recruitment problems and to assist understanding by newly qualified nurses of the interface between hospital and primary care. The scheme was jointly run by a PCT, a hospital and an academic unit. Various difficulties were encountered, as revealed in an interim evaluation. For example, the impression was created among some participating staff nurses and their mentors and managers that they had student status, which limited their opportunities both to learn and to provide care. The scheme was re-designed in the light of the evaluation, and a further evaluation found that participating staff nurses appreciated the opportunities the scheme offered, and that their work was valued by placement mentors and managers.