General Practice Organisations Research Articles

The impact of new forms of large-scale general practice provider collaborations on England's NHS: a systematic review.

Over the past decade, collaboration between general practices in England to form new provider networks and large-scale organisations has been driven largely by grassroots action among GPs. However, it is now being increasingly advocated for by national policymakers. Expectations of what scaling up general practice in England will achieve are significant. To review the evidence of the impact of new forms of large-scale general practice provider collaborations in England. Systematic review. Embase, MEDLINE, Health Management Information Consortium, and Social Sciences Citation Index were searched for studies reporting the impact on clinical processes and outcomes, patient experience, workforce satisfaction, or costs of new forms of provider collaborations between general practices in England. A total of 1782 publications were screened. Five studies met the inclusion criteria and four examined the same general practice networks, limiting generalisability. Substantial financial investment was required to establish the networks and the associated interventions that were targeted at four clinical areas. Quality improvements were achieved through standardised processes, incentives at network level, information technology-enabled performance dashboards, and local network management. The fifth study of a large-scale multisite general practice organisation showed that it may be better placed to implement safety and quality processes than conventional practices. However, unintended consequences may arise, such as perceptions of disenfranchisement among staff and reductions in continuity of care. Good-quality evidence of the impacts of scaling up general practice provider organisations in England is scarce. As more general practice collaborations emerge, evaluation of their impacts will be important to understand which work, in which settings, how, and why.

Preparing Pediatric Healthcare Professionals for End-of-Life Care Discussions: An Exploratory Study.

Preparedness to initiate end-of-life (EoL) discussions is a confronting and daunting task for all healthcare professionals. We conducted a group interview to explore healthcare professionals' experiences of preparing for EoL discussions with the patient and their family in a pediatric context. To identify what pediatric healthcare professionals consider important when preparing for an EoL discussion. A qualitative design using a group interview. Two open-ended questions were asked: (1) How could preparedness to initiate EoL care discussions between healthcare professionals and the patient and family be enhanced? (2) What education resources/strategies could be developed to support preparation for EoL care discussions? Healthcare professionals, including medical, nursing, and allied health professionals working in pediatric palliative care settings across Queensland, Australia. These settings included major tertiary hospitals, general practice, community, and nongovernment organizations. A convenience sample of 36 healthcare professionals consented to participate in the study. An analysis of the data identified seven themes that had relevance for preparing for an EoL discussion: communication, healthcare professional perspectives, interdisciplinary team role, patient and family perspectives, practical issues, addressing mistakes, and healthcare professional education. Pediatric healthcare professionals confirmed that gaps exist in preparing for an EoL discussion. The findings support a need for further research in two areas. First, a systematic review of interdisciplinary resources that are available to support healthcare professionals in preparing for EoL discussions is recommended. Second, evidence-based interdisciplinary interventions to support pediatric EoL discussions need to be developed and evaluated.

Smoking Cessation Care for People with a Mental Illness: Family Carer Expectations of Health and Community Services

Introduction: Smoking prevalence remains high among people with a mental illness, contributing to higher levels of morbidity and mortality. Health and community services are an opportune setting for the provision of smoking cessation care. Although family carers are acknowledged to play a critical role in supporting the care and assistance provided by such services to people with a mental illness, their expectations regarding the delivery of smoking cessation care have not been examined.Aims: To explore family carer expectations of smoking cessation care provision by four types of health services, to clients with a mental illness, and factors associated with expectations.Methods: A cross-sectional survey was conducted with carers of a person with a mental illness residing in New South Wales, Australia. Carers were surveyed regarding their expectations of smoking cessation care provision from four types of health services. Possible associations between carer expectation of smoking cessation care provision and socio-demographic and attitudinal variables were explored.Results: Of 144 carers, the majority of carers considered that smoking cessation care should be provided by: mental health hospitals (71.4%), community mental health services (78.0%), general practice (82.7%), and non-government organisations (56.6%). The factor most consistently related to expectation of care was a belief that smoking cessation could positively impact mental health.Conclusions: The majority of carers expected smoking cessation treatment to be provided by all services catering for people with a mental illness, reinforcing the appropriateness for such services to provide smoking cessation care for clients in an effective and systematic manner.

Australian practice nursing: collaboration in context.

To explore whether or not the context of Australian practice nursing supports collaborative decision-making about organisation and delivery of patient care. Positive patient outcomes depend on Australian practice nurses participating in collaborative and interprofessional services, particularly for patients with chronic disease(s). It is unclear whether Australian practice nurses have the opportunity to collaborate in decision-making or how traditional organisational structures may support or hinder collaboration. This is a descriptive exploratory study. Semi-structured interviews were conducted using a purposive sample of practice nurses (n = 15). Thematic analysis was used to provide meaningful and contextual insights into how practice nurses participate in decision-making. An interview tool, based on available literature, was developed and consisted of thirty open-ended questions to direct discussion during telephone interviews. Transcribed data were imported into NVivo(tm) for analysis and interpretation. The collection, analysis and thematic interpretation of data were an iterative process. Participants fostered trusting interprofessional relationships, which enabled them to influence medical decision-making and thereby advocate for patient need. Trusting interprofessional relationships were perceived to alter the relative roles of the medical practitioner and practice nurse and enhance the opportunities for collaborative decision-making. Collaborative interprofessional care in Australian general practice must occur if increased demands for care are to be met. It is timely to consider how government policy, financial regulations and the organisation of Australian general practice can better support and enhance a collaborative contribution to care by practice nurses.

How do general practitioners experience providing care to refugees with mental health problems? A qualitative study from Denmark

BackgroundRefugees are a particularly vulnerable group in relation to the development of mental illness and many may have been subjected to torture or other traumatic experiences. General practitioners are gatekeepers for access to several parts of the psychiatric system and knowledge of their patients’ refugee background is crucial to secure adequate care. The aim of this study is to investigate how general practitioners experience providing care to refugees with mental health problems.MethodsThe study was conducted as part of an EU project on European Best Practices in Access, Quality and Appropriateness of Health Services for Immigrants in Europe (EUGATE). Semi-structured interviews were carried out with nine general practitioners in the vicinity of Copenhagen purposively selected from areas with a high proportion of immigrants. The analysis of the interviews is inspired by qualitative content analysis.ResultsOne of the main themes identified in the analysis is communication. This includes the use of professional interpreters and that communication entails more than sharing a common language. Quality of care is another theme that emerges and includes awareness of possible trauma history, limited possibilities for refugees to participate in certain treatments due to language barriers and feelings of hopelessness in the general practitioners. The general practitioners may also choose different referral pathways for refugees and they report that their patients lack understanding regarding the differences between psychological problems and physical symptoms.ConclusionGeneral practitioners experience that providing care to refugees differs from providing care for patients from the majority population. The different strategies employed by the general practitioners in the health care treatment of refugees may be the result of the great diversity in the organisation of general practice in Denmark and the lack of a national strategy in the health care management of refugees. The findings from this study suggest that the development of conversational models for general practitioners including points to be aware of in the treatment of refugee patients may serve as a support in the management of refugee patients in primary care.

A spatial analysis of the expanding roles of nurses in general practice

BackgroundChanges to the workforce and organisation of general practice are occurring rapidly in response to the Australian health care reform agenda, and the changing nature of the medical profession. In particular, the last five years has seen the rapid introduction and expansion of a nursing workforce in Australian general practices. This potentially creates pressures on current infrastructure in general practice.MethodThis study used a mixed methods, ‘rapid appraisal’ approach involving observation, photographs, and interviews.ResultsNurses utilise space differently to GPs, and this is part of the diversity they bring to the general practice environment. At the same time their roles are partly shaped by the ways space is constructed in general practices.ConclusionThe fluidity of nursing roles in general practice suggests that nurses require a versatile space in which to maximize their role and contribution to the general practice team.

Do General Practitioners Know Patients' Preferences? An Empirical Study on the Agency Relationship at an Aggregate Level Using a Discrete Choice Experiment

ObjectivesThis study investigated whether general practitioners (GPs) know patients' preferences regarding a number of organizational characteristics in general practice (i.e., waiting time on the telephone, opening hours, waiting time to the appointment, distance to the general practice, waiting time in the waiting room, consultation time, and whether the GP or assisting personnel performs routine tasks) to examine whether there is a basis for improving the agency relationship at an aggregate level. DataA total of 698 respondents from the Danish population and 969 GPs answered the questionnaire in May and September 2010. MethodsIn a discrete choice experiment, GPs and patients made both forced and unforced choices, allowing us to explore the congruence of preferences 1) when patients must choose a new GP and 2) when they can stay with their current GP. ResultsResults show that in the forced choice, preferences are seen to differ. In the unforced choice also, preferences differ—mainly because GPs overestimate their own importance to the patients. Rank orders, however, are similar for both GPs and patients. ConclusionsIt is concluded that GPs do not have a precise knowledge of patients' preferences. However, in the unforced choice, GPs do know on which attributes to compete although they underestimate the necessity of competition. The overall conclusion is that there is room for improving the agency relationship in the organization of general practice.

General practice training in Aboriginal and Torres Strait Islander health

This article reviews the history of general practice vocational training in Aboriginal and Torres Strait Islander health, identifies current initiatives and recommends future approaches based on recent evidence. General practice vocational training in Aboriginal and Torres Strait Islander health requires ongoing support and investment from governments and training and general practice organisations if the gains made to date are to be consolidated and health outcomes are to improve. In particular, investment in sustained and respectful partnerships with Aboriginal and Torres Strait Islander peoples and organisations will continue to provide the groundwork for effective training of general practitioners in this critical health area, and will also play an important role in capacity-building in Aboriginal and Torres Strait Islander communities.

Mala Morjaria: It's okay to look it up

SHOC: www.sexualhealthoncall.org Mala Morjaria is nurse practitioner for Looked After Children (LAC). Her remit is to develop holistic health services for children looked after by children’s services. Her work includes advising children on contraception, prevention of pregnancy and sexual health. Her current post is on secondment from Sexual Health On Call (SHOC), an organization which supports health promotion and the delivery of sexual health services in general practice and community health organizations. Mala has worked at SHOC for 8 years. SHOC develops and implements evidence-based sexual health campaigns targeted at specific groups, such as condom distribution to young people (the SAFE card Campaign), raising awareness of HIV and addressing female genital mutilation.

From the bush to the big smoke - development of a hybrid urban community based medical education program in the Northern Territory, Australia

The Northern Territory (NT) of Australia is a unique setting for training medical students. This learning environment is characterised by Aboriginal health and an emphasis on rural and remote primary care practice. For over a decade the NT Clinical School (NTCS) of Flinders University has been teaching undergraduate medical students in the NT. Community based medical education (CBME) has been demonstrated to be an effective method of learning medicine, particularly in rural settings. As a result, it is rapidly gaining popularity in Australia and other countries. The NTCS adopted this model some years ago with the implementation of its Rural Clinical School; however, urban models of CBME are much less well developed than those in rural areas. There is considerable pressure to better incorporate CBME into medical student teaching environment, particularly because of the projected massive increase in student numbers over the next few years. To date, the community setting of urban Darwin, the NT capital city, has not been well utilised for medical student training. In 2008, the NTCS enrolled its first cohort of students in a new hybrid CBME program based in urban Darwin. This report describes the process and challenges involved in development of the program, including justification for a hybrid model and the adaptation of a rural model to an urban setting. Relationships were established and formalised with key partners and stakeholders, including GPs and general practices, Aboriginal medical services, community based healthcare providers and other general practice and community organisations. Other significant issues included curriculum development and review, development of learning materials and the establishment of robust evaluation methods. Development of the CBME model in Darwin posed a number of key challenges. Although the experience of past rural programs was useful, a number of distinct differences were evident in the urban setting. Change leadership and inter-professional collaboration were key strengths in the implementation and ongoing evaluation of the program. The program will provide important information about medical student training in urban community settings, and help inform other clinical schools considering the adoption of similar models.

Christopher M Callahan and German E Berrios, Reinventing depression: a history of the treatment of depression in primary care, 1940–2004, Oxford University Press, 2005, pp. xvii, 214, £30.50 (hardback 0-19-516523-3).

Over the last ten years, according to the WHO, depression has emerged as the leading cause of disability amongst young adults in developed countries. It is estimated that 3 per cent of the global population now suffer from the disease and over twenty million take Prozac. The apparent growth of this illness and the appearance of new treatments (especially the SSRIs) has attracted widespread critical comment. Sceptical psychiatrists, such as David Healey and Elliot Valenstein, have traced the role of the major pharmaceutical companies in the identification and marketing of psychiatric conditions and pharmaceutical solutions; bioethicists and therapists, such as Carl Elliott and Peter Kramer, have argued that we are entering an era of cosmetic pharmacology as new pharmaceutical treatments make possible new conceptions of identity and agency. Yet despite the considerable critical and philosophical comment that the rise of the new anti-depressant treatments has attracted, few have engaged in any serious examination of the actual coalface of depression treatment—the frontline prescribing work of general practitioners and family doctors in Britain and the USA. Reinventing depression does just this. It provides a welcome and necessary intervention in both the debate over anti-depressant use and the historiography of late-twentieth-century psychiatry. Callahan and Berrios argue that the persistence of depression in industrialized countries can be attributed to the ongoing attempt to treat mental illness as a clinical rather than a public health problem. The appearance of new pharmaceutical treatments has moved in tandem with the development of materialist models of the disease. This faith in neurobiological aetiologies has led, the authors argue, to our under-estimation of the social and psychological factors that contribute to the illness and to the under-recognition of the burden of depression in the wider community. The failure of our current approach to depression does not arise from any particular inadequacy in the newer forms of drug treatments or clinical investigation, rather it is an artefact of wider political changes in the status and organization of general practice and primary care psychiatry. In their exploration of the connections between our changing conceptions of depressive illness and the changing practice of primary care, Callahan and Berrios have produced an exemplary and deeply nuanced piece of medical history. They begin their case contesting the myths of the “old time doctor” and the idea (advanced by Edward Shorter) of a traditional empathic doctor–patient relationship. Instead they draw on early post-war surveys of primary care by J S Collings and Stephen Taylor to argue for a long tradition of overworked and under-funded local practitioners prescribing non-specific sedatives and hypnotics to patients presenting for psychological distress. They claim that levels of psychiatric morbidity in the community have remained fairly constant although they recognise that the clinical profiles of certain mental diseases are mutable and reflect wider social and environmental transformations. Callahan and Berrios make perceptive connections between the changing clinical profile of depression, new developments in pharmacology and epidemiology and the political organization of general practice. They demonstrate the limited impact of the new anti-depressants of the 1950s (chlorpromazine, imipramine and the monoamine oxidase inhibitors) outside asylum psychiatry, arguing that it was market driven promotion of the non-specific minor tranquillizers that established the treatment regime for emotional disorders in primary care. Likewise the development of new gradualist models of morbidity in cardiology (notably Pickering's work on hypertension) led to new measurements of the severity of depression, which in turn supported new epidemiological investigations into the under-reporting of emotional distress in the wider community. My only minor cavil with this sophisticated reading is that it tends to under-estimate the role of general practitioners themselves in the development of new psychiatric treatment regimes. Certainly many of the authors' arguments for the unique opportunities afforded to the general practitioner for longitudinal studies of the history and context of emotional disorder were made by visionary general practitioners like C A H Watts back in the early 1950s. Similarly the role of the Royal College of General Practitioners in fostering primary care research into psychiatric epidemiology is not acknowledged, which is surprising given that this contributed in part to the new assessment of psychiatric morbidity described in the volume. These are, however, very minor quibbles in what is an extremely thoughtful and impressive piece of work.

“What is it with menˈs health?” Men, their health and the system: a personal perspective

With united, sustained action, general practice organisations and practitioners can help stop our men dying or diseasing too early.

National survey of spirometer ownership and usage in general practice in Australia

Despite the lack of data, it is believed that spirometry is underutilized in general practice. The aim of the present study was to determine the availability of spirometry and the level of spirometry training in general practice throughout Australia and compare with international data. In total, 5976 general practices throughout Australia were sent a questionnaire requesting details of spirometer ownership, usage and the level and source of spirometry training. To exclude response bias, a follow-up telephone survey was conducted of 160 practices that did not respond to the initial survey. Of practices 19.5% (1125) responded to the initial survey with 64.2% (722) of these owning a spirometer and 83.9% in the follow-up sample. Common reasons for not owning a spirometer were equipment cost (53.3%) and insufficient remuneration (32.8%). Most practices (67.0%) performed one or more tests per week. Practices commonly used spirometry to diagnose (89.5%) and manage (93.9%) asthma, assess breathlessness (83.4%) and to detect and manage other diseases such as COPD (77.7%). Spirometer accuracy was never checked using a syringe 77.8% of practices and 40% did not test a healthy subject as part of their quality assurance programme. Spirometry training was received most commonly through courses run by general practice organizations (38.2%), and the duration of training courses was <2 h in 40% of cases. Despite high spirometer ownership in general practice, the frequency of use is low. Low rates of verification of spirometer accuracy and performance suggest the need for reliable, stable spirometers to be available to general practitioners. Regular and more comprehensive training in spirometry is needed.

Mental Health Research in General Practice

To explore problems in carrying out a mental health research project in the general practice setting. Open-ended interviews were conducted with general practice stakeholders, focusing on impediments to the conduct of mental health research in general practice and possible means for improving the participation of general practitioners in such research. Participants in the consultations were members of five divisions of general practice, senior staff within an academic department of general practice, four general practitioners and a research group engaged with general practice research. The discussions were recorded in detailed interview notes, and key issues and themes emerging from consultations were derived by the researchers. Three main themes summarized most of the issues reported through the consultations, including structural issues (e.g. disruption of practice, time limitations and lack of remuneration), process issues (e.g. researcher-general practice communication, researcher-imposed issues and need for partnerships) and content issues (e.g. study design, study procedures and methods). The consultations revealed similar findings to previously published reports concerning general practice research, with an emphasis on the need for partnerships between researchers and general practice organizations in the conduct of such research.

Developing a framework of, and quality indicators for, general practice management in Europe

To develop a framework for general practice management made up of quality indicators shared by six European countries. Two-round postal Delphi questionnaire in the setting of general practice in Belgium, France, Germany, The Netherlands, Switzerland and the United Kingdom. Six national expert panels, each consisting of 10 members, primarily primary care practitioners and experts in the field of quality in primary care participated in the study. The main outcome measures were: (a) a European framework with indicators for the organization of primary care; and (b) ratings of the face validity of the usefulness of the indicators by expert panels in six countries. Agreement was reached about a definition of practice management across five domains (infrastructure, staff, information, finance, and quality and safety), and a common set of indicators for the organization of general practice. The panellist response rate was 95%. Sixty-two indicators (37%) were rated face valid by all six panels. Examples include out of hours service, accessibility, the content of doctors' bags and staff involvement in quality improvement. No indicators were rated invalid by all six panels. It proved to be possible to develop a European set of indicators for assessing the quality of practice management, despite the differences in health care systems and cultures in the six different countries. These indicators will now be used in a quality assessment procedure of practice management in nine European countries. While organizational indicators are part of the new GMS contract in the UK, this research shows that many practice management issues within primary care are also of relevance in other European countries.

Mapping research in primary care nursing: Current activity and future priorities

Capacity building for research in primary care is a government priority. There is little systematic information available on research activity in the field of primary care nursing or on its future priorities for research and development (R&amp;D). This paper reports on the work of the nursing sub-group of the Primary Care Topic Review group, which formed part of the NHSE R&amp;D Directorate Strategic Review. The UK mapping exercise carried out in 1999 identified a total of 243 projects from 115 organizations. These were mostly funded, descriptive and reflected a wide range of inquiry. The mapping exercise helped to inform a consultation exercise with key players from the NHS, academic departments of nursing, health services research, general practice, and user organisations who developed a framework, and identified research priorities and strategies to overcome perceived barriers. This was achieved in a consensus meeting and progressively refined through consultation with a wider network. The paper seeks to draw some conclusions for building research capacity in primary care nursing.

Methodological issues in the development of a national database for primary care groups and trusts.

At the National Primary Care Research and Development Centre (NPCRDC) we have constructed a national database for all primary care groups (PCGs) in England. At its core, the database links information about population socio-economic and demographic characteristics to generic health status and to the organisation, resourcing and activities of general practice. In this paper we describe and discuss the problems with linking these data, and with defining the boundaries and the local populations of PCGs, given that they have been established on the basis of administrative expediency rather than geographical coherence. We then consider the implications of these difficulties for needs assessment in primary care groups.

Organizational values in general practice and public involvement: case studies in an urban district.

A multiple case study design was used to explore dimensions of organizational values in general practice with respect to developing public involvement. The study was undertaken in an urban district in England with data collected through in-depth individual and focus group interviews with service providers and service users. Four general practice organizations were randomly selected for study after sorting all in the district according to their record of developing involvement activities. The case studies provide evidence of how organizational values can differ markedly in general practice in relation to ideas of public involvement, with consequences for the quantity and quality of activities for involving local people and service users. The differences manifest themselves in the beliefs and attitudes of service providers about the purpose of the organization and the types of relationships that are appropriate with service users and local people. Service users appear to be very perceptive to the underlying ethos and purpose to their practice organization and this affects their responsiveness to initiatives for their involvement. The dimensions of the different values found in the study appear to be essentially the same as a number of established empirical findings of variations in values in general practice: an orientation to a narrow medical role and to general practice as a business are associated with a low valuation of involvement; an orientation to teamwork and to a broader social role appear more congruent with the development of involvement. Power is a critical issue in this setting with evidence in the study of the dominance of the medical practitioners in establishing organizational values and the nature of public involvement activities.

Involving the public in general practice in an urban district: levels and type of activity and perceptions of obstacles.

This paper reports on a study of the level and type of activity used to involve the public in general practice in a city district in the north of England. The association of these activities with features of the general practice organisation and environment were studied. Service providers' perceptions of obstacles were also studied. Data were collected in a survey of all general practice organisations in the district using a postal questionnaire completed by a practice manager. Interviews were conducted with health service managers responsible for primary care development in the district. The study showed that the district had a good track record for innovation in primary care development and in giving emphasis to developing public involvement. However, it also showed that it was difficult to translate policy rhetoric into practical initiatives at the general practice level without evidence of models of best practice, and with limited resources. The survey had a high response of over 84%. It showed that levels of activity were low across the district and only a small minority of general practice teams had undertaken a range of activities to involve the public. The socio-economic environment did not appear to be a factor, but small practices (one or two partners and/or practice population under 3000) were much less likely to develop activities. Pressures of existing workload, lack of resources and public apathy were given as among the main obstacles by survey respondents. The study indicates the challenges faced by Primary Care Groups in developing strands of public involvement. Primary care teams need a clear strategic framework, models of best practice, and adequate resources to manage, change and develop initiatives.

Integration between GPs andhospitals: lessons from a division-hospitalprogram

The aim of the study reported here was to evaluate current initiatives in GP-hospital integration and highlight areaswhere further research, development and evaluation are required. Seven pre-existing GP-hospital programs wereselected and given supplementary funding to allow for more effective evaluation. These local evaluations were thenincorporated into a national program on GP-hospital collaboration.We found that the seven projects made substantial progress towards their goals, and in the process highlighted importantaspects of successful collaboration. The collective evaluation of DHIP identified expected benefits of collaboration forpatients (improved access to services, reduced anxiety, and fewer post discharge complications), for GPs (increasedinvolvement in acute care and in hospital decision making), and for service organisations (stronger workingrelationships, increased capacity, and greater efficiency). Barriers to service integration were also identified, includingthe different cultures of Divisions and hospitals, their lack of internal coherence and the Commonwealth-state divide.The evaluation showed that much has been achieved in building the relationships and the capacity needed for GP-hospitalcollaboration, and that effective models exist. The current challenge is to extend successful models acrosshealth areas and make effective collaboration part of the normal system of care. Substantial progress towardsintegrated care relies on a shift from a focus on systems within general practice or hospital environments to a patientcentred approach. This will require general practice, hospitals, community services and consumer organisations toform long term partnerships and move beyond their currently disjointed view of acute and community care. Thedevelopment of practical indicators for integrated care will support the process and facilitate shared learning acrossCommonwealth and state divides.