Complex Long-term Conditions Research Articles

Understanding integrated care

ABSTRACT In this first of three papers, we seek to understand how the new “integrated care” global policy directive, pursuing greater alignment for health and social care systems, will be translated into preparation for practice concerning interprofessional education (IPE) from pre-to-post registration level and for continuing professional development. We ask questions about the implications for leaders and practitioners in the field of IPE and collaborative practice (CP). In seeking to understand this new global policy directive, we explore the plethora of definitions, concepts and perspectives, continuously evolving and at times counterproductive as they try to synthesize complexity, to describe how health and social care systems and practitioners work together. We trace research on how integrated care is understood drawing upon transnational current understandings of integrated working in North America, Europe and the UK. We ask questions of the ambitions of integrated care aligned to forging closer working relationships between health and social care practitioners to tackle modern complex healthcare challenges. In reading the literature we have sought to identify the themes which emerge to direct the field of IPE and CP so that the workforce is prepared to deliver care, as policy makers intended, within locally designed new innovative care systems. We conclude that it remains unclear as to whether these new policy aspirations will achieve the connectivity required, for a supported workforce, committed to working together to deliver care envisaged to help people experiencing complex long-term conditions, disadvantage and health inequalities. In our second paper, we review the developmental pathway for IPE, taking a closer look at preparation for integrated care pathways and collaborative practice, seeking evidence to guide us. Finally, in our third paper, we turn our attention to the implications for the workforce composition, dynamics, and relationships, exploring heightened progressive ever-changing roles and responsibilities, focusing on social work.

Patient experiences of remote consulting with chronic fatigue syndrome/myalgic encephalomyelitis and fibromyalgia: a qualitative study.

Remote and digital consulting in primary care has rapidly expanded since March 2020. It is important to understand patient experiences, particularly for those living with complex long-term conditions, to identify how care can best be delivered, including within the remote space. To explore the experiences of people living with Chronic Fatigue Syndrome/Myalgic Encephalomyelitis [CFS/ME] and Fibromyalgia when consulting remotely in primary care. Semi-structured interviews with patients living with CFS/ME and fibromyalgia in general practice in England METHOD: Semi-structured interviews were carried out with 13 participants. The interviews were transcribed and analysed thematically according to a Foucauldian theoretical framework. All participants highlighted needing to feel believed by clinicians. Many reported difficulties with telephone and online consulting due to the lack of physical communication. Positive outcomes were reported when there was a good relationship with a clinician. Continuity in care and recognising the complexity of these conditions were also considered important. This study allowed people living with CFS/ME and Fibromyalgia to describe their experiences when consulting remotely. Participants highlighted needing to feel listened to and felt they benefited from an ongoing relationship with a clinician although this was difficult to achieve when consulting remotely. Some advantages of remoted consulting were reported, particularly when symptoms were troublesome. Flexible access systems with a range of consultation modalities or preferred clinician(s) availability could improve healthcare encounters, particularly given the increased use of remote consulting, in primary care.

Sustaining work ability amongst female professional workers with long COVID.

Long COVID (LC) compromises work ability (WA). Female worker WA has been more adversely impacted than WA in men. Exploration of lived experiences could elucidate the WA support required. To explore the working conditions and circumstances experienced as affecting sustained WA amongst female workers with LC, to help mitigate worklessness risks. Online semi-structured qualitative interviews were conducted with 10 female workers self-reporting or formally diagnosed with LC who had made some attempt to return to work (RTW). Interviews were analysed using template analysis to map themes informing WA enablers and obstacles onto a biopsychosocial model of rehabilitation. All participants were professionals working in an employed or self-employed capacity. Key themes reflecting circumstances that afforded sustained WA included the autonomy over where, when and how to work indicated as facilitated by a professional role, rapid health care access, predominantly sedentary work, competent colleagues able to cover for transient reduced WA, a strong interface between specialist health and management support, and accessible organizational policies that steer health management according to equity rather than equality. Highly flexible, iterative, co-produced RTW planning, tolerant of fluctuating symptom expression appears vital. In return for providing such flexibility, participants felt that employers' workforce diversity and competence would be protected and that workers would need to reciprocate flexibility. These qualitatively derived findings of workers' lived experiences add to existing guidance on supporting WA for people struggling with LC. Moreover, the same principles seem appropriate for tackling worklessness amongst working-age adults with complex long-term health conditions.

Digital-driven service improvement during the COVID-19 pandemic.

COVID-19 brought a lot of children's routine clinical services in the UK to a complete halt in March 2020. The NHS had to radically change the way clinical services are provided with the rapid introduction of telemedicine, virtual consultations, and video conferencing facilities to support team working. This paper describes how Peterborough Child Development Centre rapidly redesigned the services with digital tools to continue offering neurodevelopmental and neurodisability services more virtually. We demonstrate how we adapted our approaches to assess and manage complex long-term conditions with improved quality and outcomes by using digital tools. The changes to the clinical processes and systems are here to stay beyond the COVID-19 pandemic and have the potential to revolutionise the services.

Development of a genomics module within an epilepsy-specific electronic health record: Toward genomic medicine in epilepsy care.

Both clinical genomics and e-Health technology are changing the way medicine is being practiced. Although the basic clinical methodology of good medical care will remain unchanged, the combined power of genomics and electronic health records has the capability of enhancing, and in some cases transforming, the practice of medicine. This is particularly true in the care of patients with complex long-term medical conditions such as chronic refractory epilepsy, especially in those with related complex comorbidities including intellectual disability and psychiatric disease. Herein we outline the development and integration of an epilepsy genomics module into a preexisting epilepsy electronic patient record (EPR) system. We describe how this EPR infrastructure is used to facilitate discussion at multidisciplinary clinical meetings around molecular diagnosis and resulting changes in management. This work illustrates the role of eHealth technology in embedding genomics into the clinical pathway.

The feasibilities and practicalities of the integrated working journey: exploring the development and implementation of a whole population approach to delivering person-centred care within the United Kingdom

Introduction: The demographic shift of an ageing population increases demand on health and social care services, in a time of limited resources. Services are currently faced with the challenge of providing high quality, patient-centred care to a population who are increasingly living with multiple complex long-term conditions. This often results in care from multiple providers, subsequently increasing the risk of duplication, inefficiency, poor coordination and experience. Services therefore urgently need to work in partnership in order to deliver person-centred care. Methods: A qualitative study utilising in-depth semi-structured interviews with representatives from strategic roles was undertaken to explore perspectives of developing and implementing integrated services across organisations. The strategy includes a shift from working in organisational silos to delivering integrated care to the whole population. Primary data were collected in a rural setting within the United Kingdom. Data were transcribed and analysed using a thematic analysis approach. Results: Data were grouped into six themes including: focus and purpose of the integrated concept, multidisciplinary team working and engagement, professional roles and responsibilities, contextual factors and challenges of integration, expectations and the reality of integration, and aspirations and future goals for care delivery. Transferable key enablers for progression included a clear shared vision, organisational commitment, cultural change, individual behaviours and personalities, and period of stability in workforce and leadership. The systemic, organisational, and professional challenges experienced are likely to be represented across initiatives aiming to integrate care. Discussions: Despite extensive research and policy changes, initiatives continue to experience similar barriers in progression with integration and population health management. Robust case study designs and in-depth qualitative explorations into the experiences of those developing approaches to improve care delivery, add essential value to understanding associated barriers and facilitators. These findings are therefore highly relevant to those developing integrated care initiatives across international contexts. Conclusions: While a combination of relational and technical aspects are necessary for progression, the success of the initiative was largely perceived to be dependent upon the workforce, and individual behaviours and personalities rather than processes and structures. In light of the often underestimated lengthy process of large-scale system transformation and organisational change, it was apparent that the initiative remained in its infancy. As health services run on people and not processes, relational aspects and increased workforce investment may therefore hold the potential for success and sustainability of integrated approaches to care delivery. Lessons learned: The need to start small and scale up, invest time in building relationships and peer support, and focus on proactively supporting people, before expanding models, were highlighted. Limitations: Whilst the appreciation of the contribution of contextual factors to the challenges of integration are transferable, the case study nature may limit the applicability of some aspects. A further potential limitation includes the inferred organisationally representative nature of the participants in their perspectives of strategy development. Suggestions for future research: There is the need to develop approaches to measuring outcomes which account for impacts at the individual patient and professional level. Explorations into integrated workforce development is also advocated.

Primary care improvement for patients with complex long-term conditions

BackgroundPatients with five or more long-term conditions have been shown in Barking, Havering and Redbridge Clinical Commissioning Groups to be the heaviest users of health and social care. An innovative new model of primary care, ‘Health 1000’ was thus established. Comprising a fully integrated multidisciplinary team (including third sector, a social worker and dual skilled ‘keyworkers’) this practice aligned the care of complex patients and endeavoured to avoid unnecessary hospital admissions.AimTo test the hypothesis that Health 1000 (a multidisciplinary GP practice with consultant geriatrician support) would align and improve quality of care and health/social outcomes for complex patients with five-plus long-term conditions.MethodUsing anonymised disease registers, an eligible cohort was identified and invited by their existing practices to re-register with Health 1000. Each patient received comprehensive initial consultation at registration, encompassing reviews of pill burden and social need. Biweekly multidisciplinary discussion ensured their care was aligned and met to a high quality. Independent qualitative evaluation was undertaken by the Nuffield Trust using face to face/telephone interviews with staff/patients.Results408 patients (from an eligible cohort of approximately 2000) were registered. Most patients were extremely satisfied with the new service highlighting friendly welcoming atmosphere, speed of service, key workers’ responsiveness, availability of phone consultations with GPs, longer appointment slots and home visits.ConclusionQualitative outcomes were very positive and suggest that there is benefit for patients with multiple long-term conditions from embedding a multidisciplinary team in primary care with specialist expertise.

Invest in district nurses if you want to cope with winter pressures

NHS England chief executive Simon Stevens announced that 2,000-3,000 extra hospital beds will be freed up to help the NHS cope with winter pressures. This is understandable given the growing number of frail, older people with complex long-term conditions who have an increased risk of falls during winter, are vulnerable to exacerbations of their illnesses or may require additional care at the end of life.

Multi-Disciplinary Decision Making In General Practice- A Case Study Of Switching Between Oral Anticoagulants

As the prevalence of chronic conditions and co-morbidities increase complex long-term conditions, management responses are required. Such responses require an integrated approach to care. This necessitates a multi-disciplinary approach to decision making when treating patients with Atrial Fibrillation (AF). While the European Society of Cardiology guidelines (Kirchhof, 2017) advocate a structured integrated approach to care, that is patient-centred with multidisciplinary teams, the collaboration needs to be meaningful and appropriate. It is important to determine if General Practitioners (GPs) are collaborating in the multidisciplinary decision making when switching between oral anticoagulants (OACs) for AF patients. This paper explores Irish GPs’ experience of switching between OACs, the prevalence of multi-disciplinary decision making and determines what GP characteristics influence the likelihood of multi-disciplinary decision making in the community. Primary data was used and a probit and multinomial logit applied to determine the factors influencing the likelihood of multi-disciplinary decision-making for OAC switching decisions. While 88% of GPs in the survey indicated they had AF patients whose OAC was switched, only 64% of GPs indicated the decisions involved more than one decision maker, i.e. were multidisciplinary. Female GPs and GPs who initially prescribed OACs were more likely to engage in multidisciplinary decision-making surrounding switching OACs amongst AF patients. The latter characteristic suggests a greater sense of appreciation of the complexities and pharmacokinetic/pharmacodynamic characteristics of OACs, which is unsurprising. This case study reveals that some multidisciplinary decision-making is occurring, but it is not standard practice. Moreover there is a lack of patient participation in the decision making process. As indicated by Kirchhof (2017) integrated care, with coordinated multidisciplinary decision-making, has the potential to provide continued care in the community. Knowledge of these prescribing decisions is necessary to promote optimal use of OACs and in particular costly NOACs and to ensuring patient-centred care.

The effects of intervention on frequent attenders' adherence to health regimens, depression, somatization and hypochondriasis

Background and objective: Frequent attender is the largest group to whom health care resources are allocated. Therefore potential interventions should be targeted at this group. Nurse-based case management considers frequent attenders’ (FAs’) needs for care as a whole and thus may reduce the use of other health services operators’ resources. The objective of this study is to evaluate the effects of nurse-led case management on adherence to health regimens, depression, somatization and hypochondriasis in FAs.Methods: The study is a quasi-experimental intervention trial, carried out as a prospective 2-year follow-up design with an intervention group (n = 285) and a control group (n = 435). The hypothesis was that nurse-led case management based intervention would have a positive impact on FAs’ adherence to health regimens, somatization, hypochondriasis, and depression. The intervention patients received nurse-led case management which included an evaluation of patient needs and resources, an individualized care plan, the coordination of multidisciplinary services, and support for self-management. The control patients received the usual care, which means patient support and education during visits to the health center. The data were collected from at least 18 years of age frequent attenders by self-reported instruments: the Adherence of Chronic Disease Inventory, the Whiteley Index, the Symptom Checklist-90-R and Beck Depression Inventory, and one- and two-year follow-ups between October 2008 and May 2011.Results: The intervention had an uplifting effect on the FAs’ mood, and there was a statistically significant difference between the intervention patients and the control patients (p = .03). Intervention reduced somatization with FAs, and it improved FAs’ adherence to health regimens, but there was not a statistically significant difference between groups. Hypochondriasis increased in the intervention group compared to the control group after intervention (p = .01).Conclusions: Nurse-led case management has a positive effect on FAs’ depression symptoms, somatization, and adherence to health regimens. The results will be useful in developing effective nurse-led interventions and support methods for FAs with complex long-term health conditions. Hypochondriasis increased in the intervention group although the purpose was for the community matron to discuss with FAs and reduce their concerns.

Quality of life related to the health and socio-economic resources of the elderly

IntroductionAging is a very heterogeneous and dissimilar process, full of asymmetries. There is evidence that socio-economic differences determine disadvantages and inequalities in old ages. Older people face particular inequalities in healthiness especially with more complex and vulnerable long-term conditions, being more likely to need support from social care services.AimTo evaluate the quality of life (well-being) related to the health of the elderly according to socio-economic indicators.MethodCross-sectional quantitative study was performed. A total of 316 elderly people (M = 74.78; SD = 9.78 years of age) was interviewed with the Portuguese version of the EQ-5D-3L scale for health-related quality of life.ResultsThe interaction between income and the type of residential follow-up (alone vs. accompanied) was not statistically significant [F (2.310) = .910, P < .407; Ƞp2 = .006]. Differences in health status index were statistically significant for income [F (2.310) = 5.518, P < .004; Ƞp2 = .034]. Post-hoc comparisons indicated that the mean score for those with insufficient income for their expenses (M = .39, SD = .27) was significantly different from those with income reaching their expenses (M = .50, SD = .25) as well as those with income covering their expenses sufficiently (M = .60, SD = .21). The main effect for the type of follow-up (alone vs. accompanied) did not reach statistical significance [F (2.310) = .224, P < .636, Ƞp2 = .672].ConclusionsIncome has an impact on health-related quality of life. Health in aging as a social phenomenon is not neutral to economic differences and is exposed to these structural disadvantages.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Managing complex long-term conditions and multimorbidity

Healthcare systems, medical education and research worldwide are designed to deliver care for individual diseases. However, complex long-term conditions (LTCs) and multimorbidity are on the rise. The existing systems are proving to be inefficient in caring for people with multimorbidity and a wider approach is necessary.1 The Royal College of Physicians (RCP) in conjunction with Association of British Clinical Diabetologists (ABCD) organised a conference with the aim to improve understanding of LTCs. Common LTCs like chronic obstructive pulmonary disease (COPD), heart failure, dementia, chronic kidney disease (CKD), diabetes, chronic steroid use, serious mental illness and physical disease, and Parkinson’s disease were discussed. The interactive sessions focused on views and experiences of various medical experts in the UK on care pathways, care networks and care models that can help to manage LTCs.

Managing complex long-term conditions (LTC) and multi-morbidity

Managing complex long-term conditions (LTC) and multi-morbidity

Alternative perspectives of safety in home delivered health care: a sequential exploratory mixed method study.

The aim of this study was to discover and describe how patients, carers and case management nurses define safety and compare it to the traditional risk reduction and harm avoidance definition of safety. Care services are increasingly being delivered in the home for patients with complex long-term conditions. However, the concept of safety remains largely unexplored. A sequential, exploratory mixed method design. A qualitative case study of the UK National Health Service case management programme in the English UK National Health Service was deployed during 2012. Thirteen interviews were conducted with patients (n=9) and carers (n=6) and three focus groups with nurses (n=17) from three community care providers. The qualitative element explored the definition of safety. Data were subjected to framework analysis and themes were identified by participant group. Sequentially, a cross-sectional survey was conducted during 2013 in a fourth community care provider (patient n=35, carer n=19, nurse n=26) as a form of triangulation. Patients and carers describe safety differently to case management nurses, choosing to focus on meeting needs. They use more positive language and recognize the role they have in safety in home-delivered health care. In comparison, case management nurses described safety similarly to the definitions found in the literature. However, when offered the patient and carer definition of safety, they preferentially selected this definition to their own or the literature definition. Patients and carers offer an alternative perspective on patient safety in home-delivered health care that identifies their role in ensuring safety and is more closely aligned with the empowerment philosophy of case management.

COPD and emotional distress: not always noticed and therefore untreated.

There are more than three million people in the UK living with chronic obstructive pulmonary disease (COPD). Focus tends to be on the physical effects of the condition; however, many patients living with COPD develop mental health symptoms that could go unnoticed and therefore untreated. The community nurse's role includes the management of patients with complex long-term conditions, which may include mental health issues. However, training to support patients whose condition includes a mental health component has long been considered inadequate and may lead to under diagnosis. Compared with other patients with long-term conditions, patients with COPD recount worse psychological functioning and greater psychological distress. Health-care workers' lack of mental health knowledge may be a contributory factor to why only a small proportion of patients are diagnosed and receive effective treatment.

The importance of education for a new primary care workforce.

© 2 01 5 M A H ea lth ca re L td It is well recognised that the NHS currently faces significant financial hardship, and the increasing demand for its services, without further annual efficiencies or an increase in funding, will produce an imbalance between available resources and patient need of almost £30 billion per year by 2020–21 (NHS England, 2014). Change is needed on all three aspects of demand, efficiency and funding to sustain the current high-quality service. Ever since the publication of the NHS Plan (Department of Health (DH), 2000), DH has promoted radical change with new ways of working, new models of care and to maximise the contribution of the wide range of health professionals by working more collaboratively to ensure care is efficient, effective and cost effective. The recent focus on transformation in the acute sector has paved the way for radical change in the delivery of primary care. With several attempts to reorganise primary care, —for example, the Wanless’ review (2002) recommending a radical improvement in prevention and public health, and in 2005 the introduction of 3000 new community matrons to integrate the health and social care services (DH, 2005)—the recent publication of The future of primary care (Primary Care Workforce Commission (PCWC), 2015) proposes a much more radical reform. Drawing on the Five Year Forward View (NHS England, 2014) that identified the changes required to address the current challenges facing the NHS, The future of primary care sets out a vision for the new primary care workforce and has significant implications for the education of health and social care professionals. There is clear evidence that people are living longer, often with complex long-term conditions (Ham et al, 2012), and the media are quick to portray the changing pattern in public health with one in five adults still smoking, a third drinking too much alcohol and just under two thirds overweight or obese (NHS England, 2014). Nevertheless, there is clear acknowledgement that investment in primary care has fallen well short of investment in the acute sector, in spite of increasing expectations (PWCW 2015). If we Elizabeth Rosser

What is Shared Care Planning?

Introduction: The concept of shared care, with synergy from integrated, collaborative and coordinated care as well as case management, has attracted interest internationally. A New Zealand (NZ) pilot (2011-2012) implemented a shared care planning model to enable patientcentred care as a key element of the NZ Ministry of Health’s strategy 1) to address some of the clinical and system issues involved in caring for people with complex long-term conditions and multi-morbidity and 2) to identify a sustainable and integrated health care model for the 21st century. The pilot approach featured Information technology (IT)-facilitated information sharing and communication among all involved in a person’s care, including patients, and IT-supported shared care planning activities [1, 2]. Methods: Inspired by this NZ pilot, we reviewed literature for relevant definition and evaluation of shared care, shared decision making and care planning to provide a perspective and clarification on what a shared care planning model is, where its value might lie and what evidence supports it. Results: Key terms for defining shared care planning include shared care [3], integrated care [4, 5], shared decision making [6] and care planning [7]. Our interpretation of these components is that the *shared care planning* concept includes sharing of skills, knowledge and planning by a wider healthcare team who together undertake responsibility for a patient’s care, balanced equally with the need to share decision making, goal setting and responsibility for day-to-day health decisions with the patient and family. This implies monitoring and exchanging of patient health 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 1 International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-117071– http://www.ijic.org/ data, sharing knowledge between disciplines, creating a proactive goal-centered care plan and involving patients within a care team. Systematic reviews that evaluate shared care planning outcomes have reported somewhat inconsistent findings including mixed results on cost benefit [811]. However, some projects reported potential benefits such as better care continuity and care quality. Discussion: We found no agreed definition consensus for ‘shared care planning’ or the essential elements, roles or responsibilities needed for its delivery. We believe the ideal of shared care is equally about sharing the care and responsibility with patients and their family as it is about sharing care within the interdisciplinary team. Conclusions: Combining the shared care philosophy with proven care planning processes, shared care planning is a comprehensive approach to integrated, culturally appropriate and patient-centred care through facilitating both care coordination and supported self-management. Lessons learned: The literature and NZ experience suggest that shared care planning approaches need to address various complex challenges such as shortage of workforce skills to deliver care planning, lack of time/personnel and funding models to implement shared care, IT interface challenges and mechanisms to involve patients and families. Limitations: A key limitation of this review is its lack of systematic rigour. However, we do not believe a meaningful systematic review is currently possible with few high-quality studies and the inconsistency in definitions and terminology of shared care planning interventions. Suggestions for future research: NZ research is needed, e.g., to explore barriers/ facilitators of funding models for shared care and patient role in shared decision making.

Shape of caring: a whole systems approach to integrated care.

This consultation was circulated 1 year after the publication of the Francis Report (2013). Against a background of the new NMC Standards (2010) and the move to an allgraduate intake in 2013, it is not surprising that we continue to question whether our education is fit for purpose. Unusually, this consultation seeks to recognise and build on existing good practice. In an attempt to find ways to improve the quality of care, the consultation has sought to find good examples involving patients and their carers in the recruitment, delivery and/or assessment of nurse education programmes, where care assistants are valued, prepared for their role and given the opportunity to progress in their career and, for some, to progress to undergraduate nursing preparation. Continuing education of nurses is also at the fore; seeking examples of good practice in relation to ongoing support and supervision, postgraduate career frameworks and creative approaches to funding to support ongoing development. With the increasing number of people with complex long-term conditions, moving from interprofessional working to integrated care should encourage both health and social care services to concentrate on patient needs. The move to integrated care has been advocated for some time and in this column last year, Professor Fiona Ross explored the skills required by nurses to achieve integrated care (Ross, 2013). Despite considerable investment, this has been slow to take off. With renewed financial investment through the pilot studies under the banner of Better Together (Goodwin et al, 2011), it is anticipated that the integration of health and social care services will become more viable. Previous attempts to integrate, such as the Elizabeth Rosser

Outcomes assessment for people with long-term neurological conditions: a qualitative approach to developing and testing a checklist in integrated care

BackgroundFailure to demonstrate the effect of integration on service users using conventional outcome measures suggests that research to date has failed to measure the outcomes that actually matter to people with complex long-term conditions and that might result from integrated health and social care. Developing outcome measures that capture the important issues for service users may also help to better reflect the particular ways integrated teams work and what such teams strive to achieve in addressing service user outcomes.ObjectivesThe objectives of this research were to (1) identify factors that affect integration between health and social care; (2) identify outcomes important to people with long-term neurological conditions (LTNCs) who are clients of an ‘integrated’ service; (3) develop these outcomes into a checklist and explore whether or not these outcomes can be assessed in practice; and (4) understand how different models of integration affect outcomes.Design, methods and participantsA case study approach, using in-depth, semistructured interviews, was adopted. The cases were four English primary care trusts (PCTs) and their associated local authorities. Case sites had a neurological-rehabilitation team (NRT), each with a different approach to health and social care integration. The research took place in three stages. In stage 1, interviews with 43 commissioners, managers, NRT staff and social care practitioners, and documentary analysis, helped to understand service contexts and approaches to assessment. Interviews, guided by earlier outcomes work, were held with 35 people with LTNCs to identify important outcomes. Interviews with 13 carers illustrated relationships between NRTs and carers. In stage 2, these outcomes were developed into a checklist in partnership with NRTs. NRTs used the outcomes checklist (OC) as part of their routine assessment, and we monitored its use. In stage 3, we conducted interviews and focus groups with 21 NRT staff and 12 clients to evaluate the use of the OC in practice.AnalysisQualitative data were managed and analysed thematically using the framework approach.ResultsPerson, service and structural-level factors influenced integration between health and social care. Relationships between practitioners and services often drove integration in practice. However, wider structural arrangements were important and could facilitate these relationships. We identified 20 outcomes important to people with LTNCs. These were grouped into three outcome domains: personal comfort, economic and social participation, and autonomy. Use of the OC in practice was viewed differently by the NRTs. One NRT felt that it duplicated existing assessments, one felt that it covered issues outside their remit and two felt that the OC worked for them. Some of the outcomes could be difficult for staff and clients to raise but clients felt that they should all be included in assessments. Use of the OC was sometimes challenging due to staffing and caseload pressures, changes to service structures and remit, and competing demands of other compulsory paperwork. All NRTs thought that the OC had potential value as a benchmarking or training tool. Larger, more interdisciplinary models of integrated NRTs appeared to give more scope for interpreting, assessing and potentially achieving outcomes.ConclusionsMany of the outcomes that are important to service users with LTNCs are not addressed in validated ‘outcome measures’. This has implications for commissioners and practitioners to ensure that service users’ needs are met in practice. Turning the OC into a measurement tool could go some way to addressing this. Many of the outcomes are interdependent; an impact on one particular outcome will have a ‘knock-on’ effect on other outcomes. These inter-relationships demonstrate the complexity of what is important in the lives of people with LTNCs. Service changes can affect integrated arrangements negatively. More research is needed to explore the longer-term effects of organisational change on integrated service provision.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Is UK general practice education and training now fit for purpose?

Recent major structural and policy developments in the UK health services have significantly impacted on the primary role of the GP as a generalist clinician; there is increasing emphasis on their capabilities as team leaders, care coordinators, educators, and commissioners.1 Sir Bruce Keogh, the NHS Medical Director in England, is exploring issues of demand for services and the need to ensure people with long-term conditions are better looked after outside the hospital system, thus reducing their need for emergency care services. The Health Secretary for England, Jeremy Hunt, is calling for better integration between the health and social care systems, which implies a significantly revised model for the delivery of primary care. NHS England launched ‘Call to Action’2 to stimulate debate in communities and enable GPs to play a stronger role in delivery of out-of-hospital integrated services for an improved patient experience, personalised care, with more effective and efficient use of the resources. In the devolved administrations there are similar policy directives reflecting the wish to increase care in the community in the future.3–5 Consequently, there are significantly increasing job demands, not least from patients, for GPs to be better prepared to manage increasingly complex long-term conditions. To what extent do the current curriculum, the training provision, and the licensure assessments accommodate these changes? New evidence from a multi-source, multi-method job analysis study6 (involving interviews, focus groups, observations of GPs at work, a …