Community-based Service Model Research Articles

Strengthening primary care for diabetes and hypertension in Eswatini: study protocol for a nationwide cluster-randomized controlled trial

BackgroundDiabetes and hypertension are increasingly important population health challenges in Eswatini. Prior to this project, healthcare for these conditions was primarily provided through physician-led teams at tertiary care facilities and accessed by only a small fraction of people living with diabetes or hypertension. This trial tests and evaluates two community-based healthcare service models implemented at the national level, which involve health care personnel at primary care facilities and utilize the country’s public sector community health worker cadre (the rural health motivators [RHMs]) to help generate demand for care.MethodsThis study is a cluster-randomized controlled trial with two treatment arms and one control arm. The unit of randomization is a primary healthcare facility along with all RHMs (and their corresponding service areas) assigned to the facility. A total of 84 primary healthcare facilities were randomized in a 1:1:1 ratio to the three study arms. The first treatment arm implements differentiated service delivery (DSD) models at the clinic and community levels with the objective of improving treatment uptake and adherence among clients with diabetes or hypertension. In the second treatment arm, community distribution points (CDPs), which previously targeted clients living with human immunodeficiency virus, extend their services to clients with diabetes or hypertension by allowing them to pick up medications and obtain routine nurse-led follow-up visits in their community rather than at the healthcare facility. In both treatment arms, RHMs visit households regularly, screen clients at risk, provide personalized counseling, and refer clients to either primary care clinics or the nearest CDP. In the control arm, primary care clinics provide diabetes and hypertension care services but without the involvement of RHMs and the implementation of DSD models or CDPs. The primary endpoints are mean glycated hemoglobin (HbA1c) and systolic blood pressure among adults aged 40 years and older living with diabetes or hypertension, respectively. These endpoints will be assessed through a household survey in the RHM service areas. In addition to the health impact evaluation, we will conduct studies on cost-effectiveness, syndemics, and the intervention’s implementation processes.DiscussionThis study has the ambition to assist the Eswatini government in selecting the most effective delivery model for diabetes and hypertension care. The evidence generated with this national-level cluster-randomized controlled trial may also prove useful to policy makers in the wider Sub-Saharan African region.Trial registrationNCT04183413. Trial registration date: December 3, 2019

Towards Circular Fashion: Design for Community-Based Clothing Reuse and Upcycling Services under a Social Innovation Perspective

With the rise of the circular economy, recycling, and upcycling is an emerging sustainable system in the fashion industry, emphasising a closed loop of “design, produce, use, and recycle”. In this context, this paper will explore community-based approaches to scale up clothing reuse and upcycling under a social innovation perspective. This study aims to establish community-based practice models, which contribute toward promoting a greater understanding of sustainable fashion and achieving collaborative cocreation frameworks for community stakeholders. This paper, therefore, takes a social innovation perspective to conduct design studies helping with the technical (problem-solving) and cultural (sense-making) barriers that clothing reuse and upcycling face. The research was conducted in the context of the Shanghai community, and a large amount of first-hand research data were obtained through field research, expert and user interviews, and participatory workshops. Finally, this research establishes a platform proposal which combines strategic service design and practical toolkit design. It is a new community-based service model highlighting a significant advancement in the degree of collaboration and cocreation in traditional community service models. Additionally, it dramatically demonstrates the potential of socially innovative design thinking in promoting circular fashion and the closed-loop fashion system.

Development of a framework for the collaborative adaptation of service models for child and family health in diverse settings (CASCADES).

The impact of health service access disparities has significant implications for society. The importance of addressing health and social inequities is never more critical than in the early years of a child's life. Despite advances in healthcare implementation, there is a lack of an evidence-based framework to specifically guide the adaptation of child and family health (CFH) service models for different community contexts. This paper describes the development of a framework for the adaptation of community-based CFH service models. Drawing on the findings of an integrative review and Delphi study, Participatory Action Research was used to test the framework, resulting in the Framework for Collaborative Adaptation of Service Models for Child and Family Health in Diverse Settings (CASCADES). The Framework uses the analogy of a waterfall to represent the iterative process of collecting information to inform each step. The framework supports a collaborative co-design approach to build a comprehensive understanding of the target community to inform the adaptation and evaluation of evidence-based interventions appropriate to the local context. The ultimate aim is to enable the delivery of services that are contextually relevant for local communities and provide greater access to effective, accessible services to support children and their families.

Improved Rehabilitation Outcomes for Persons With and Without Problematic Substance Use After 2 Years With Assertive Community Treatment-A Prospective Study of Patients With Severe Mental Illness in 12 Norwegian ACT Teams.

Background: Persons with severe mental illness often face difficulties in accessing and receiving adequate services enabling them to live independently. Many have co-occurring substance use problems that increase the risk of adverse outcomes. Community-based service models have been implemented around the world, including assertive community treatment (ACT), but the knowledge of rehabilitation outcomes in different subgroups is limited. We aimed to explore rehabilitation outcomes among patients suffering severe mental illness with and without substance use problems who had received ACT services for at least 2 years. Additionally, we compared differences in changes between the two groups.Methods: A total of 142 patients who received services for 2 years from the first 12 Norwegian ACT teams were included. Eighty-four (59%) had problematic substance use, while 58 (41%) did not. Data regarding housing, activity, symptoms, functioning, and subjective quality of life were collected upon enrollment into ACT and at 2 years of follow-up. Clinician-rated scales and self-report questionnaires were used. Changes within the two groups and differences in change between the groups were assessed using generalized linear mixed models.Results: Both groups were more likely to have good housing, higher level of functioning, and less anxiety and depressive symptoms after 2 years. The odds of good housing among participants with problematic substance use increased only after adjusting for age and gender. Participants with problematic substance use had less severe symptoms, particularly negative and manic symptoms, while participants without problematic substance use reported improved satisfaction with life in general. Neither group experienced a change in having a meaningful daily activity, positive symptoms, practical and social functioning, or subjective quality of life. The reduction of manic symptoms in the substance use group was the only difference between the groups.Conclusion: After 2 years, patients with and without problematic substance use experienced improvements in several important domains. Furthermore, the improvements were similar in both groups for most outcomes. This may suggest that ACT has a place in the continued effort toward integrated and comprehensive community services empowering patients with severe mental illness to achieve and sustain an independent life, including marginalized groups with severe substance use.

A community-based co-designed genetic health service model for Aboriginal Australians.

BackgroundAboriginal and Torres Strait Islander people experience a greater burden of disease and die younger than non-Indigenous Australians, with Aboriginal people living in remote areas of the Northern Territory of Australia having the lowest life expectancy estimates. Despite a high burden of chronic disease among Aboriginal and Torres Strait Islander people, access to specialist health services remains low and models of care that increase engagement, may improve health outcomes.MethodsWe describe client and staff perspectives of a model of clinical genetics services provided by the MJD Foundation (MJDF) in geographically and culturally complex contexts within the Northern Territory of Australia. We seek to understand the MJDF model’s success in supporting Aboriginal families with the familial, neurodegenerative condition Machado-Joseph disease and how it could be applied in the provision of other specialist services. Thematic analysis was undertaken on semi-structured interviews with primary health care staff (n = 2), Non-Aboriginal MJDF Staff (n = 7) and Aboriginal MJDF Clients / Community workers (n = 13).ResultsFour key themes regarding the MJDF model of service delivery were identified with the service being; 1) client led 2) accepting of various understandings of genetic disease causation 3) focused on relationships, continuity and trust between the service provider and the clients, and 4) committed to incorporating an inclusive whole-of-family practice. The MJDF model takes a community-based, person-and family-centred approach to successfully deliver effective specialist genetic health services in remote community settings. We propose that these approaches have broad application in the future design and delivery of specialist health services particularly in culturally complex settings.

Sustainability of Community-Based Specialized Mental Health Services in Five European Countries: Protocol for Five Randomized Controlled Trial-Based Health-Economic Evaluations Embedded in the RECOVER-E Program.

BackgroundCommunity-based recovery-oriented mental health services for people with severe mental disorders have not been fully implemented in Bulgaria, Croatia, Macedonia, Montenegro, and Romania. The RECOVER-E project facilitates the implementation of specialized mental health care delivered by setting up services, implementing the services, and evaluating multidisciplinary community mental health teams. The outcomes of the RECOVER-E project are assessed in a trial-based outcome evaluation in each of the participating countries with a health-economic evaluation linked to these trials.ObjectiveThe aim of this protocol paper is to describe the methodology that will be used for the health-economic evaluation alongside the trials.MethodsImplementation sites have been selected in each of the five countries where hospital-based mental health services are available (care as usual [CAU]) for patients with severe mental disorders (severe depression, bipolar disorder, schizophrenia, and other psychotic disorders). The newly implemented health care system will involve community-based recovery-oriented mental health care (CMHC). At each site, 180 consenting patients will be randomized to either CAU or CMHC. Patient-level outcomes are personal and social functioning and quality-adjusted life years (QALYs). Data on participants’ health care use will be collected and corresponding health care costs will be computed. This enables evaluation of health care costs of CMHC as compared with CAU, and these costs can be related to patient-level outcomes (functioning and QALY gains) in health-economic evaluation.ResultsData collection was started in December 2018 (Croatia), February 2019 (Montenegro), April 2019 (Romania), June 2019 (North Macedonia), and October 2019 (Bulgaria). The findings of the outcome evaluations will be reported for each of the five countries separately, and the five trials will be pooled for multilevel analysis on a combined dataset.ConclusionsThe results of the health-economic evaluation of the RECOVER-E project will contribute to the growing evidence base on the health and economic benefits of recovery-oriented and community-based service models for health systems in transition.Trial Registration(1) ClinicalTrials.gov NCT03922425 (Bulgaria); https://clinicaltrials.gov/ct2/show/NCT03922425 (2) ClinicalTrials.gov NCT03862209 (Croatia); https://clinicaltrials.gov/ct2/show/NCT03862209 (3) ClinicalTrials.gov NCT03892473 (Macedonia); https://clinicaltrials.gov/ct2/show/NCT03892473 (4) ClinicalTrials.gov NCT03837340 (Montenegro); https://clinicaltrials.gov/ct2/show/NCT03837340 (5) ClinicalTrials.gov NCT03884933 (Romania); https://clinicaltrials.gov/ct2/show/NCT03884933International Registered Report Identifier (IRRID)DERR1-10.2196/17454

Uptake and acceptability of human papillomavirus self-sampling in rural and remote aboriginal communities: evaluation of a nurse-led community engagement model

BackgroundAboriginal women experience disproportionately higher rates of cervical cancer mortality yet are less likely to participate in screening for early detection. This study sought to determine whether a community-based HPV self-sampling service model can effectively recruit never-screened and under-screened Aboriginal women to participate in cervical cancer screening; assess the clinical outcomes; and explore the acceptability of the model from the perspective of the participants.MethodsAboriginal women aged 25–69 years of age were recruited from eight rural and remote communities in New South Wales, Australia to participate in HPV self-sampling via a community-based service model. Outcome measures were: number of women screened by HPV self-sampling, their prior cervical screening status (under-screened or never-screened), clinical outcomes and participation in follow-up pathways of care, and satisfaction with the service model.ResultsIn total, 215 women conducted a HPV self-sampling test and 200 evaluation surveys were completed. One-fifth of participants (n = 46) were never-screened and one-third (n = 69) were under-screened. Many were unsure of their screening status. Nine women were HPV 16/18 positive and eight had completed all follow up by the conclusion of the study. A further 30 women tested positive for a high risk type other than HPV 16/18 (HPV other), of which 14 had completed follow up at the conclusion of the study. Satisfaction with the HPV self-sampling kit, the process of self-sampling and the service model was high (> 92% satisfied on all items). Many women had difficulty understanding their official HPV results and placed high importance on the nurse explaining it to them.ConclusionsA community-based service model that respects Aboriginal Women’s Business can effectively recruit under-screened and never-screened Aboriginal women to complete cervical cancer screening. Furthermore, this service model supports them to complete recommended follow-up care and engage with their local existing health services.

Towards community-based and recovery-oriented care for severe mental disorders in Southern and Eastern Europe: aims and design of a multi-country implementation and evaluation study (RECOVER-E)

BackgroundSubstantial strides have been made around the world in reforming mental health systems by shifting away from institutional care towards community-based services. Despite an extensive evidence base on what constitutes effective care for people with severe mental ill-health, many people in Europe do not have access to optimal mental health care. In an effort to consolidate previous efforts to improve community mental health care and support the complex transition from hospital-based to community-based care delivery, the RECOVER-E (LaRge-scalE implementation of COmmunity based mental health care for people with seVere and Enduring mental ill health in EuRopE) project aims to implement and evaluate multidisciplinary community mental health teams in five countries in Central and Eastern Europe. This paper provides a brief overview of the RECOVER-E project and its methods.MethodsFive implementation sites were selected (Sofia, Bulgaria; Zagreb, Croatia; Skopje, North Macedonia; Kotor, Montenegro; Siret-Suceava, Romania) where hospital-based mental health services are available (care as usual, CAU) for patients with severe mental disorders (severe depression, bipolar disorder, schizophrenia). The intervention consists of the introduction of a new service delivery model in each site, consisting of community-based recovery-oriented care delivered by trained multidisciplinary community mental health teams (including a peer worker with lived experience of a severe mental disorder). The implementation outcomes of the teams and the effect of the team’s approach on patient and service utilisation outcomes will be evaluated using a mix of research methods. The study includes five planned hybrid implementation-effectiveness trials (1 per site) with patient-level randomization (n = 180, with patients randomised to either care as usual or intervention condition). Effectiveness is evaluated using a pragmatic non-blinded design with patients randomised into two parallel groups: receiving new community-based care or receiving usual care in the form of institutional, hospital-based mental health care. Trial-based health economic evaluation will be conducted; implementation outcomes will be evaluated, with data aligned with dimensions from the RE-AIM framework. Pathways to sustaining project results will be developed through policy dialogue sessions, which will be carried out in each country and through ongoing policy engagement activities at the European level.DiscussionThe RECOVER-E project has been developed and conducted to demonstrate the impact of implementing an evidence-based service delivery model for people with severe mental illness in different contexts in middle-income countries in Central and Eastern Europe. It is expected that the results will contribute to the growing evidence-base on the health and economic benefits of recovery-oriented and community-based service models for health systems in transition.Trial registration Each trial was registered before participant enrolment in the clinicaltrials.gov database: Site—Croatia, Zagreb (Trial Reg. No. NCT03862209); Montenegro, Kotor (Trial Reg. No. NCT03837340); Romania, Suceava (Trial Reg. No. NCT03884933); Macedonia, Skopje (Trial Reg. No. NCT03892473); Bulgaria, Sofia (Trial Reg. No. NCT03922425)

Development of a community-based hearing loss prevention and control service model in Guangdong, China

BackgroundHearing loss is a prevalent sensorineural disorder and a major public health issue in China. It is suggested that half of all cases of hearing loss can be prevented through public health measures. However, national strategies for hearing healthcare are not implemented well in Guangdong and some other regions in China.MethodsTo develop a community-based service model for the prevention and control of hearing loss in Guangdong, we integrated the model with multiple maternal and child healthcare models, and set up a series of clinical programs along with an optimum timeline for the preventive measures and intervention treatments to take place. A total of 36,090 families were enrolled in the study, including 358 high-risk families and 35,732 general-risk families.ResultsThe study lasted for 6.5 years, and 30,769 children were born during that period. A total of 42 children were born with congenital deafness; 17 of them were born into families with advanced genetic risks for hearing loss, 9 were born with specific medical conditions, and 16 were born into general-risk families. About one third of them were diagnosed prenatally, others were diagnosed within 3 months of age, and 72% of them received interventions initiated before 6 months of age. 13 children presented with delayed hearing loss; 9 of them were diagnosed with delayed hereditary sensorineural deafness in neonatal period, and 4 were diagnosed within 3 months after onset. Timely interventions were provided to them, with appropriate referrals and follow-ups. Beside these, 80 families were identified with genetic susceptibility to aminoglycoside ototoxicity. Detailed medication guides were provided to prevent aminoglycoside-induced hearing loss. Moreover, through health education and risk reduction strategies, the prevalence of TORCH syndrome decreased from 10.7 to 5.2 per 10,000. Additionaly, the awareness rates of health knowledge about hearing healthcare significantly increased in the cohort.ConclusionsAdapting national strategies for local or district projects could be an important step in implementing hearing loss prevention measures, and developing community-based service models could be of importance in carrying them out.

The Prevalence of Suicide Attempts and Independent Demographic and Clinical Correlates among Chronic Schizophrenia Patients in Agricultural Areas of China.

This study investigated the lifetime prevalence of suicide attempts (SA) and independent demographic and clinical correlates in stabilized schizophrenia inpatients. A cross-sectional study was conducted in three psychiatric hospitals in Anhui province, an agricultural province located in east China. Psychopathology and depressive symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS) and Hamilton Depression Rating Scale (HAMD), respectively. A total of 315 stable schizophrenia inpatients were interviewed prior to discharge. The lifetime prevalence of SA was 22.2%. Multiple logistic regression analysis revealed that female gender (P < 0.001, OR = 3.4, 95%CI: 1.9-6.0), being married (P = 0.02, OR = 2.2, 95%CI: 1.1-4.4) and having more severe depressive symptoms (P = 0.014, OR = 1.2, 95%CI: 1.01-1.3) were independently and significantly associated with higher risk of SA. Lifetime SA is common among hospitalized schizophrenia patients living in agricultural areas of China. For suicide prevention, regular assessments, appropriate interventions and clinical management should be integrated into a community-based psychiatric service model for this population.

Emerging community-based service models for older adults in urban China: A case study in Zhongshan City, Guangdong Province, China

ABSTRACTThis article examines community service provision for older adults under the context of contracting in Zhongshan City, Guangdong Province, China. Two street communities, which adopt different models of non-competitive contracting and competitive contracting, are used to show how community services are provided for older adults. Implications for the further development of community service contracting for older adults are discussed.

It Takes a Community to Create a Library

ABSTRACT Over the course of four years, Working Together Community Development Librarians in Vancouver, Regina, Toronto and Halifax worked in diverse urban neighborhoods and with diverse communities, traditionally considered marginalized or socially excluded. This practitioner-community-based project allowed community voice to drive the projects process, not librarian generated beliefs, literature or other professional discourse. The Working Together Project conceptualized and reviewed the traditional library service planning model and developed a new community-based service model: the Community-Led Service Planning Model. Community-led service planning builds upon the traditional library service planning model and provides a new method that brings library staff together with community members in an effort to identify and meet community needs. Socially excluded community members are involved in each step of the community-led service development process, from needs assessment to evaluation. This non-prescriptive model is flexible and can be applied in all library settings, by all librarians, and to all program and service development.

An Efficient Nurse Practitioner–Led Community-Based Service Model for Delivering Coordinated Care to Persons With Serious Mental Illness at Risk for Homelessness

Access to mental health care is a struggle for those with serious mental illness (SMI). About 25% of homeless suffer from SMI, compared with 4.2% of the general population. From 2003 to 2012, St. Paul's Center (SPC) operated a unique model to provide quality care to the homeless and those at risk for homelessness, incarceration, and unnecessary hospitalization because of SMI. Data were available for analysis for the years 2008 to 2010. The SPC was developed, managed, and staffed by board-certified psychiatric/mental health nurse practitioners, offering comprehensive mental health services and coordinated interventions. All clients were housed and none incarcerated. From 2008 to 2010, only 3% of clients were hospitalized, compared with 7.5% of adults with SMI. Clinical, academic, and community partnerships increased value, but Medicaid reimbursement was not available. Mental health provisions in the recently passed 21st Century Cures Act support community mental health specialty treatment. The SPC provides a template for similar nurse practitioner-led models.

Implementing the mental health action plan – experiences and challenges

The WHO European mental health action plan was adopted by all countries in the European region in Izmir in September 2013. Its 6 objectives cover promotion and prevention, human rights, services and partnerships. Since its adoption, the WHO mental health programme is working in some 25 countries, supporting policy development and implementation. Priorities are the introduction of health promotion programmes for vulnerable groups; the competence of primary care to identify, diagnose and treat people with mental disorders; and the implementation of community-based service models sensitive to the culture and resources of countries.Particularly successful have been countries where a consensus was established between policymakers and professional leaders, and where different levels of government worked together. Obstacles experiences have been funding cuts and lack of incentives. Some examples will be presented.Disclosure of interestThe author has not supplied his declaration of competing interest.

Providing high-quality care in North Carolina nursing homes.

Quality in North Carolina's nursing facilities is intertwined in multiple dimensions of person-centered care, evidence-based practice, innovation, pursuit of continued excellence, meaningful relationships, and recognition of choice and autonomy. By striving to excel in their role of providing skilled nursing care for medically related acuity, North Carolina's nursing facilities have been a contributor to the growth of the long-term care continuum, enabling North Carolina to have an extensive and well-developed system of skilled care and home- and community-based service models.

Pharmacological treatment of schizophrenia

Background: A lack of human and financial resources, as well as effective health systems, leads to a worldwide treatment gap for schizophrenia. The aim of this paper is to propose evidence-based antipsychotics interventions for people with schizophrenia with special focus in low and middle income countries (LAMIC) reality. Method: A comprehensive search was conducted to locate the main clinical trials, reviews and relevant meta-analyses, and a number of the main recent international clinical practice guidelines. Results: First- and second-generation antipsychotics are similarly effective in the acute treatment of psychotic symptoms. In LAMIC, the treatment of choice for medical treatment of psychotic conditions is the group of so-called ‘first generation antipsychotics’ (FGAs) preferentially delivered in a community-based service model. Conclusions: Although the symptomatic control is essential, it is not the ultimate goal of treatment. The main aim of treatment is to improve functional recovery and social reintegration of patients.

Teambasierte Gemeindepsychiatrie

The German Society for Psychiatry, Psychotherapy and Neurology (DGPPN) guidelines on psychosocial interventions for people with severe mental illness appraise the transferability of results of trials evaluating community-based mental health services to the German situation. This assessment has to draw on research results on factors determining effectiveness. This must be seen against the background of a lack of high-quality trials in Germany. The article discusses system, context and setting factors related to the transfer of evidence on community-based service models from other countries. These issues are discussed on the basis of evidence concerning the models of case management, assertive community treatment and community mental health teams. International differences in study findings are highlighted and the importance of treatment-as-usual in influencing study results is emphasized. The more control services including elements of community-based care there are and the less the pressure to reduce inpatient treatment (threshold to inpatient care admission), the smaller the relative effect sizes of innovative care models will be.In the absence of direct evidence, careful examination of transferability is required before introducing health care models. Research has revealed solid evidence for several factors influencing the effects of innovative community mental health care. Among key factors in the care of people with severe mental illness, home visits and joint team responsibility for both psychiatric and social care were identified. This evidence can facilitate the adaptation of successful mental health care models in Germany.

E-010 THE COMMUNITY-BASED TELEHEALTH CARE MODEL FOR HYPERTENSION IN TAIPEI

Background In this study, we developed a community-based service model for hypertension based on the Citizen Telemedical Care Service System (CTCS). This study tried to discover the acceptance of the community-based telehealth model on hypertension in Taipei. Methods This study was a cross-section telephone survey in May 2010. The participants who used the service over three times were selected since Mar. 2010. According to the records on the system, regular (≥3 times/week) and irregular BP measurement habits were divided in two subgroups. The questionnaires were based on the technology acceptance model. Results 186 (93.0%) were included for further statistical analyses. In the perceived easiness facet, the irregular measurement habit subgroup had the higher satisfaction (OR = 3.146, p < 0.05)in the construct of service convenience compared to regular measurement habit subgroup, and there was lower satisfaction (OR = 0.25, p < 0.05)in the construct of general device satisfaction. In the perceived usefulness facet, the irregular measurement habit subgroup had the higher satisfaction (OR = 8.692, p < 0.01)in the construct of increasing interaction between the users and physician or/ other medical personnel. In the service satisfactions facet, the irregular measurement habit subgroup had the higher satisfaction (OR = 7.623, p < 0.05)in the construct of the case manager paying attention to the BP reading tendency of participants. Conclusions The telehealth care service impacts on the patient and provider relationship and the design for special users are needed to be further explored. Establishing a decision support system for caregivers and users to provide further assistances to achieve local-based, community-based health care should be considered.

Evaluating the clinical efficacy of a primary care‐focused, nurse‐led, consultation liaison model for perinatal mental health

In Australia, perinatal mental illness is common, although poorly identified and treated. Improved perinatal mental health depends on service provision models that reflect a focus on promotion, prevention, and early intervention, while facilitating improved referral pathways between primary health and specialist mental health services. In 2008, a contemporary community-based model of mental health service provision was developed as an alternative to the pre-existing hospital-based service model. The model is delivered primarily by mental health nurses using a consultation liaison framework. It provides for specialist mental health assessment and brief intervention in collaboration with the general practitioner, who remains the primary health provider. It also aims to raise community awareness and build capacity for the management of perinatal disorders in the primary care sector. Evaluation of the clinical effectiveness of the model, and the improvement in access for primary health providers and women, was conducted at 2 years from its implementation. Clinical effectiveness was evaluated by using comparative data from the Edinburgh Depression Scale and Depression Anxiety and Stress Scale, and the results demonstrated clinical efficacy. Improved attendance rates indicated that women preferred this community-based service model as an alternative to the pre-existing service model.

Letter - Response to 'Future-proofing primary health care: GP recruitment and retention in the new NHS'

I am increasingly bemused by the narrowing and blinkered view of training to becoming a GP. Rosenthal and Chana1 comment 'many trainees still spend part of this time in posts that offer traditional hospital-based experience that may not reflect the context of new community based service models'. Cautiously I would like to add the comment 'so what?' We do want 'well rounded' GPs, people open to new ideas, and who are open to 'lifelong learning.' Many who qualified at a similar time to me will have done hospital jobs as 'part of the team.' Six months at the end of which we were hopefully competent but also confident. Confident. Now that's a word we haven't been using too much recently but, as long as not false, important.Doing 6 months and making a good job of a delivery or episiotomy repair, doing pleural taps or biopsies, covering the paediatric clinic when the consultant had to rush off. Not perhaps relevant to my job now but it did instill a confidence and satisfaction to my work. There is now much less 'hands on'.Interestingly a local gastroenterologist recently told me he used to teach his GP trainees to do endoscopies, no longer, as 4 months is 'not enough.' We now have tasters that might encourage some degree of competence ('please sign me up' ) but are we creating doctors with no confidence in their own abilities?I like the idea of First5, encouraging doctors as they start their careers as GPs, dealing with issues, and educating around the GP mantle. It is a long career and may become longer so we need to generically give new GPs the tools to handle the future. Are we narrowing so much and trying too hard with training that we're taking the enjoyment out of the process, when perhaps some of this could be done later? It is now rare to have colleagues, who had done several years as gynaecologists/surgeons, join our ranks and I think we have lost something here.In my GP career I have been very grateful for sabbaticals to try working in different places/environments. This also seems to becoming more difficult and not encouraged generally while trying to achieve CCT. That great idea of learner-led education, particularly for trainees, seems to have gone out of the window.I suppose I am saying, can we be a bit more generic in our training years, widen our horizons again, and use First5 to help settle doctors into the rewarding job we do?