General Practice Organisations Research Articles

Towards local health system development in Wallonia: experiences with the HSO toolkit for integrated people centred health systems.

Since 2008 Belgium has been developing a more integrated care system. Today, the Belgian healthcare system is undergoing significant reform at national and sub-national levels. In primary care, at the federal level, the New Deal for general practice aims to improve the organisation of general practice and a new inter-federal plan for integrated care is currently under development. At the regional level, there are many initiatives. In Wallonia several projects are working towards greater inter-professional collaboration and clear territorial delimitations in order to cater for the needs of local populations in a more integrated fashion. 
 The project Proxisanté has been exploring the needs of professionals and patients by conducting consultations and workshops with actors within primary care to feed into a decree which will be presented at the end of 2022. Based on the outcome of this process, actions will be undertaken, starting in 2023, to implement this vision and develop a territorial network of local health systems. Our team is responsible for following and supporting this process of implementation by developing a transdisciplinary and innovative bottom-up methodological approach. For this we intend to rely, among other things, on the Integrated People-Centred Health Systems (IPCHS) Standard developed by the Health Standards Organisation (HSO), as well as the various tools created to facilitate the implementation of this standard. 
 The presentation will describe the preliminary work done to prepare for concrete support for the creation of local networks starting in 2023. Specifically, we will detail the methodology used to identify the priorities that need to be focused on to ensure successful implementation, Finally, we will present the key messages from meetings with different existing subsystems concerning their strengths and weaknesses, and the inspiring practices identified that will allow us to build a regional learning system dynamic.

The process of nurses' role negotiation in general practice: A grounded theory study.

To explain the process by which nurses' roles are negotiated in general practice. Primary care nurses do important work within a social model of health to meet the needs of the populations they serve. Latterly, in the face of increased demand and workforce shortages, they are also taking on more medical responsibilities through task-shifting. Despite the increased complexity of their professional role, little is known about the processes by which it is negotiated. Constructivist grounded theory. Semi-structured interviews were conducted with 22 participants from 17 New Zealand general practices between December 2020 and January 2022. Due to COVID-19, 11 interviews were via Zoom™. Concurrent data generation and analysis, using the constant comparative method and common grounded theory methods, identified the participants' main concern and led to the construction of a substantive explanatory theory around a core category. The substantive explanatory theory of creating place proposes that the negotiation of nurse roles within New Zealand general practice is a three-stage process involving occupying space, positioning to do differently and leveraging opportunity. Nurses and others act and interact in these stages, in accordance with their conceptualizations of need-responsive nursing practice, towards the outcome defining place. Defining place conceptualizes an accommodation between the values beliefs and expectations of individuals and pre-existing organizational norms, in which individual and group-normative concepts of need-responsive nursing practice are themselves developed. The theory of creating place provides new insights into the process of nurses' role negotiation in general practice. Findings support strategies to enable nurses, employers and health system managers to better negotiate professional roles to meet the needs of the populations they serve, while making optimum use of nursing skills and competencies. Findings can inform nurses to better negotiate the complexities of the primary care environment, balancing systemic exigencies with the health needs of populations. What Problem Did the Study Address? In the face of health inequity, general practice nurses in New Zealand, as elsewhere, are key to meeting complex primary health needs. There is an evidence gap regarding the processes by which nurses' roles are negotiated within provider organizations. A deeper understanding of such processes may enable better use of nursing skills to address unmet health need. What Were the Main Findings? Nurses' roles in New Zealand general practice are determined through goal-driven negotiation in accordance with individual concepts of need-responsive nursing practice. Individuals progress from occupying workspaces defined by the care-philosophies of others to defining workplaces that incorporate their own professional beliefs, values and expectations. Negotiation is conditional upon access to role models, scheduled dialogue with mentors and decision-makers, and support for safe practice. Strong clinical and organizational governance and individuals' own positive personal self-efficacy are enablers of effective negotiation. Where and on Whom Will the Research Have Impact? The theory of Creating Space can inform organizational and individual efforts to advance the roles of general practice nurses to meet the health needs of their communities. General practice organizations can provide safe, supported environments for effective negotiation; primary care leaders can promote strong governance and develop individuals' sense of self-efficacy by involving them in key decisions. Nurses themselves can use the theory as a framework to support critical reflection on how to engage in active negotiation of their professional roles. The authors adhered to relevant EQUATOR guidelines using the COREQ reporting method. Researchers and participants currently working in general practice were involved in the development of this study. By the process of theoretical sampling and constant comparison, participants' comments helped to shape the study design. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: An understanding of the processes by which health professionals negotiate their roles is important to support them to meet the challenges of increased complexity across all health sectors globally.

Changes in work tasks and organization of general practice in Norway during the COVID-19 pandemic: results from a comparative international study

BackgroundThe COVID-19 pandemic led to huge and rapid changes in general practice in Norway as in the rest of Europe. This paper aims to explore to what extent the COVID-19 pandemic changed the work tasks and organization of Norwegian general practice.Material and methodWe analysed data from the Norwegian part of the international, cross-sectional PRICOV-19 study, collecting data from general practice via an online self-reported questionnaire. We included 130 Norwegian general practices, representing an estimated 520 Norwegian general practitioners (GPs). All Norwegian GPs were invited to participate. In the analyses, we focused on items related to the use of alternatives to face-to-face consultations, changes in the workload, tasks and delegated responsibilities of both the GPs and other personnel in the GP offices, adaptations in routines related to hygiene measures, triage of patients, and how the official rules and recommendations affected the practices.ResultsThere was a large and significant increase in the use of all forms of alternative consultation forms (digital text-based, video- and telephone consultations). The use of several different infection prevention measures were significantly increased, and the provision of hand sanitizer to patients increased from 29.6% pre-pandemic to 95.1% since the pandemic. More than half of the GPs (59.5%) reported that their responsibilities in the practice had increased, and 41% were happy with the task shift. 27% felt that they received adequate support from the government; however, 20% reported that guidelines from the government posed a threat to the well-being of the practice staff. We found no associations with the rurality of the practice location or size of the municipalities.ConclusionNorwegian GPs adapted well to the need for increased use of alternatives to face-to-face consultations, and reported a high acceptance of their increased responsibilities. However, only one in four received adequate support from the government, which is an important learning point for similar situations in the future.

Healthy Life Style as the First Choice Management of NAFLD

Objectives: The aim of this article was to review the effectiveness of healthy diet and regular exercise to manage patients with NAFLD (Non alcoholic fatty live disease). Methods: > I performed a search over several published articles, different medical official websites and general practice organisations to identify peer reviews of similar subject by using search term ‘NAFLD’. I considered only papers written in English, with emphasis on more recent published articles. Results: The current body of scientific research consistently emphasizes the need for exercise and lifestyle therapies as crucial components in managing non-alcoholic fatty liver disease (NAFLD). The combination of empirical observations, supported by thorough research, provides evidence for the therapeutic solid possibilities of customized exercise routines, dietary adjustments, and comprehensive lifestyle changes. Conclusion: Aerobic exercise and strength training have been shown to empirically reduce non-alcoholic fatty liver disease (NAFLD). These workout methods have reduced hepatic lipid buildup and improved metabolic indicators. The combination of exercise’s molecular pathways has several effects on the complicated pathophysiology of non- alcoholic fatty liver disease. Nutritional changes are also necessary for NAFLD treatment. Nutrient-dense diets are beneficial, including whole grains, fruits, vegetables, and lean protein. A balanced diet and enough food consumption may slow hepatic lipid accumulation and metabolic dysfunction. The symbiotic relationship between physical activity and nutrition highlights a fundamental principle of great importance. The powerful alliance described beyond a simple addition of numbers, resulting in an output surpassing each modality’s influence. Integrating exercise-induced physiological adaptations and nutritional improvements creates a comprehensive approach beyond a single intervention, resulting in a holistic strategy to address the various underlying .....

O.2.1-2 How do social prescribing interventions for physical activity work from a complex intervention research perspective: a narrative review on mechanisms of change

Abstract Purpose Social prescribing (SP) interventions for physical activity (PA) remain to reveal consistent findings on health outcomes, partly because suboptimal research methods have been applied. The purpose of this study was to synthesise the behaviour-related mechanisms and socio-economic considerations of SP interventions for PA based on a narrative literature review. The synthesis was then used to develop a logic model inspired by the methodology from complex intervention research, illustrating how these interventions may improve health outcomes. Methods A narrative review was performed using Medline, Embase and PsycINFO to identify scientific literature on SP interventions for PA. The literature search was executed on February 20-21, 2023. Inclusion criteria were; studies investigating person-centred mechanisms and/or system-based mechanisms. Any population was eligible, and no source restrictions were applied. Findings were synthesised and illustrated in a comprehensive logic model on SP interventions for PA. Results A total of 340 studies were identified from the electronic literature search, and 11 studies met the inclusion criteria. Person-centred mechanisms for successful SP intervention were identified as: (1) Integrating medical and social needs in the referral process; (2) Trusted and informed relationships in the linking process; and (3) Meaningful relationships in a non-stigmatising setting in the engagement process. System-based mechanisms for successful SP intervention were identified as the need to fully integrate the SP interventions in the General Practice and community organisations. In addition, successful SP intervention was, among other findings, explained through emotional buy-in from all SP agents and clients. Conclusion The present study display mechanisms of SP interventions for PA, suggesting that they should include socio-economic considerations and preferably system thinking. We also urge for more complex intervention thinking in developing and evaluating SP interventions for PA to clarify the mechanisms of what works for whom and under which circumstances. Support/Funding Source No funding source was applied for this study.

UTI in Primary Care: Are we Prescribing Too Much?

Objectives: The aim of this article were to review usefulness of early clinical detection of UTI without lab tests as diagnostic tool for UTI in primary care and to describe when to start antibiotic treatment for management of UTI according to international guidelines. The emphasis of this review is uncomplicated UTI. Methods: A search was conducted on PubMed and official webpages of major urological, infectious diseases and general practice organisations to identify peer reviewed original articles and reviews, using the search terms ‘UTI’. I considered only papers written in English, with emphasis on more recent articles published up to July 2023. Results: There is a variation in recommendations between guidelines can be a source of confusion and controversy for clinicians in primary care. However, early detection and treatment, education of patients and removal of risk factors may reduce the number of symptomatic episodes, antibiotics usage and antimicrobial resistance in primary care. Conclusion: The diagnosis of acute uncomplicated cystitis in healthy women can be made with reasonable certainty by evaluation of symptoms and signs without a doctor’s visit or urine tests. Individualised assessment of risk factors and previous clinical history is needed to choose the most suitable antimicrobial treatment. Immediate antimicrobial therapy with Trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days), Nitrofurantoin (100 mg twice daily for 5-7 days), or Fosfomycin (3g in a single dose) is indicated for acute cystitis in adult women. However, local guidelines advice that immediate antibiotic treatment was not considered necessary for women with uncomplicated lower UTI. Antimicrobial resistance have complicated treatment of UTI worldwide.

How do primary care providers and autistic adults want to improve their primary care? A Delphi-study.

Autistic adults often encounter different types of healthcare barriers. Because autistic adults also have an increased risk for health problems, the aim of this study was to evaluate barriers and to explore how primary care providers and autistic adults want to improve their primary healthcare. In this co-created study, semi-structured interviews with three autistic adults, two parents of autistic children and six care providers were performed to evaluate barriers in Dutch healthcare. Next, in the survey-study (using the Delphi-method including controlled feedback in three consecutive questionnaires), 21 autistic adults and 20 primary care providers rated the impact of barriers and the usefulness and feasibility of recommendations to improve primary healthcare. In the interviews, 20 barriers in Dutch healthcare for autistic people were found. In the survey-study, the primary care providers rated the negative impact of most barriers lower than the autistic adults. This survey-study resulted in 22 recommendations to improve primary healthcare focused on: primary care providers (including education in collaboration with autistic people), autistic adults (including improvement of preparation for general practitioner-appointments) and organization of general practice (including improvement of continuity in care). In conclusion, primary care providers seem to view healthcare barriers as less impactful than autistic adults. In this co-created study, recommendations to improve primary healthcare for autistic adults were identified, based on the needs of autistic adults and primary care providers. These recommendations provide a basis for primary care providers, autistic adults and their support network to start conversations about, for example, strategies to improve primary care providers' knowledge, autistic adults' preparation for a general practitioner-appointment and organization of primary care.

LIC in the time of COVID: experiences of LIC tutors during the COVID-19 pandemic in Scotland

ABSTRACT In March 2020, due to the escalating global coronavirus (COVID-19) pandemic, clinical placements for most medical students in the UK were suspended. A phased resumption of clinical placements started at the beginning of academic year 2020/2021. For the Scottish Graduate Entry Medicine programme (ScotGEM), 2020/21 was the first year that Dundee School of Medicine’s comprehensive LIC was extended to all 54 students in the penultimate year of the ScotGEM programme. This cross-sectional qualitative study explored aspects of tutors’ experiences of supporting LIC students in their practices. Thematic analysis of the data identified significant themes relating to the effects of the coronavirus pandemic on the organisation of the LIC placements and the experiences of the tutors, and the ways in which they adapted placements to the rapidly changing clinical and social landscapes. The changes necessitated by the pandemic posed significant challenges for practice-based tutors in ensuring that students had valuable educational experiences despite the constraints of social distancing requirements and the reduction in face-to-face consultations. However, tutors also identified several positive aspects of the changes which will be of interest to those involved in the organisation and delivery of both LIC and shorter General Practice based clinical attachments. Positive relationships between LIC students and practices enhanced the success of LIC placements. We will discuss how lessons learned from the experience of tutors in the pandemic could be used in the longer term to enrich the LIC experience and General Practice placements more generally.

Guideline of guidelines: management of recurrent urinary tract infections in women.

To compare recurrent urinary tract infection (rUTI) guidelines from major urological and non-urological organisations internationally and identify areas of consensus and discrepancy. PubMed, Google Scholar and the official webpages of major urological, gynaecological, infectious diseases and general practice organisations were searched for rUTI guidelines in March 2022. Nine guidelines were included for review: European Association of Urology, National Institute for Health and Care Excellence (NICE), Society of Obstetricians and Gynaecologists of Canada, American Academy of Family Physicians, Mexican College of Gynaecology and Obstetrics Specialists, Swiss Society of Gynaecology and Obstetrics, Spanish Society of Infectious Diseases and Clinical Microbiology, German Association of Scientific Medical Societies, and the combined American Urological Association/Canadian Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction. The definition and evaluation of rUTIs, and antibiotic prophylaxis strategies, were mostly consistent across guidelines, and emphasised the importance of obtaining urine cultures and limiting cystoscopy and upper tract imaging in women without risk factors. Variable recommendations were noted for symptomatic treatment, self-initiated antibiotics, and antibiotic-sparing preventative strategies such as cranberry, vaginal oestrogen, immunoactive prophylaxis with OM-89, intravesical glycosaminoglycan instillation, and phytotherapeutics. Recent randomised evidence supports the use of methenamine hippurate. Either continuous or post-coital prophylactic antibiotics were supported by all guidelines. None of the guidelines were tailored to the management recurrent complicated UTI. Multiple rUTI guidelines were identified and mostly limited their recommendations to otherwise healthy non-pregnant women with uncomplicated cystitis. Variation was noted, particularly in antibiotic-sparing preventative strategies. Some conflicting recommendations are due to more recent guidelines including updated evidence. Future guidelines should consider recommendations to assist management of complex patient groups, such as recurrent complicated UTI.

Examining positive views from students, trainees and GPs about general practice: a generational problem? A set of qualitative studies in France

ObjectiveThis study aimed to explore the positive factors related to working in general practice in France, from a student studying medicine, trainee general practitioner (GP) and GP point of view.SettingPrimary...

Developing an applied model for making decisions towards the end of life about care for someone with dementia.

Many people with dementia reach the end-of-life without an advance care plan. Many are not ready to have conversations about end-of-life, and decision-making is left to their families and professionals when they no longer have capacity. Carers may benefit from further support with decision-making. To develop this support, it is important to understand the decision-making process. Explore with family carers and people living with dementia the decision-making process and factors that influence decision-making in dementia end of life care, to produce a model of decision-making in the context of dementia end-of-life care. Semi-structured interviews with 21 family carers and 11 people with dementia in England (2018-2019) from memory clinics, general practice and carer organisations. Interviews were analysed using thematic analysis and findings were mapped onto the Interprofessional Shared Decision Making model, refined to produce a modified model of decision-making in dementia. Participants described five key decisions towards the end-of-life as examples of decision making. We used these experiences to produce a modified model of decision-making in dementia end-of-life-care. The model considers the contextual factors that influence the decision-making process, including: personal preferences; advance care planning and Lasting Power of Attorney; capacity and health and wellbeing of the person with dementia; support from others and clarity of roles. The decision-making process consists of seven inter-linked stages: 1) identifying the decision maker or team; 2) sharing and exchanging information; 3) clarifying values and preferences; 4) managing and considering emotions; 5) considering the feasibility of options; 6) balancing preferred choice and the actual choice; and 7) implementation and reflecting on outcomes. The modified model breaks down the decision-making process and attempts to simplify the process while capturing the subtle nuances of decision making. It provides a framework for conversations and supporting decisions by carers.

Involving practice nurse and other assistant clinical staff members in the management of low back pain: A qualitative interview study from Danish general practice.

Objectives:Involving practice nurse and other assistant clinical staff members in providing information and education to patients with low back pain at follow-up appointments may release more time and improve care in general practice. However, this requires a shift in the division of tasks, and general practitioners’ barriers and facilitators for this are currently unknown. The objectives were to explore general practitioners’ experiences and perceptions of including assistant clinical staff members in the management of low back pain.Methods:This is a semi-structured interview study in Danish general practice. General practitioners with a variation in demographics and experience with task-delegation to clinical staff were recruited for in-depth interviews. We used a phenomenological approach to guide the data collection and the analysis in order to gain insight into the subjective experiences of the general practitioners and to understand the phenomenon of ‘delegating tasks to practice staff’ from the perspective of the general practitioners’ lifeworld. Analysis was conducted using an inductive descriptive method. The sample size was guided by information power.Results:We conducted five interviews with general practitioners. All general practitioners had experience with task delegation, but there was a variation in which tasks the general practitioners delegated and to which types of clinical staff members. The following themes were derived from the analysis: general practice organisation, delegating to clinical staff members, doctor–patient relationship, exercise instruction, clinical pathway for patients and external support.Conclusion:General practitioners consider patients with low back pain to be a heterogeneous group with a variety of treatment needs and a patient group without any predetermined content or frequency of consultations; this can be a barrier for delegating these patients to clinical staff members.

Clinical academic careers for general practice nurses: a rapid evidence assessment.

Clinical academics are health professionals who provide direct patient care alongside engaging in health research. Despite the generally agreed consensus that such roles enhance evidence-based care, availability and uptake has been sporadic in non-medical professions. With no data readily available regarding general practice nurses undertaking clinical academic roles, there is a need to understand the barriers and enabling factors that impact general practice nurses considering or pursuing a clinical academic career. This review aims to address the question 'What are the barriers and enablers relevant to general practice nurses in the UK pursuing clinical academic careers?' by providing an overview of the relevant existing literature and drawing out the implications for policy and practice. Literature published in the past 10 years was systematically searched. Using agreed inclusion criteria, papers were first screened on titles and abstracts, with papers included at this stage reviewed as full texts. Thirteen papers met the criteria for inclusion. The extraction and synthesis of findings allowed for the development of three themes: roles and responsibilities; embarking on a clinical academic career; and organisational research culture. Findings suggest that infrastructure developments are required across higher education institutions and general practice organisations to bring about a cultural change to equip and empower general practice nurses to consider and pursue clinical academic careers.

The Valued Life Activities Scale (VLAs): linguistic validation, cultural adaptation and psychometric testing in people with rheumatic and musculoskeletal diseases in the UK

BackgroundThe Valued Life Activities Scale (VLAs) measures difficulty in daily activities and social participation. With various versions involving a different number of items, we have linguistically and culturally adopted the full VLAs (33-items) and psychometrically tested it in adults with rheumatic and musculoskeletal diseases in the United Kingdom.MethodsParticipants with Rheumatoid Arthritis, Ankylosing Spondylitis, Chronic Pain/ Fibromyalgia, Chronic Hand/ Upper Limb Conditions, Osteoarthritis, Systemic Lupus, Systemic Sclerosis and Primary Sjogren’s Syndrome were recruited from out-patient clinics in National Health Service Hospitals, General Practice and patient organisations in the UK. Phase1 involved linguistic and cultural adaptation: forward translation to British English; synthesis; expert panel review and cognitive debriefing interviews. In Phase2 participants completed postal questionnaires to assess internal construct validity using (i) Confirmatory Factor Analysis (CFA) (ii) Mokken scaling and (iii) Rasch model.ResultsResponders (n = 1544) had mean age of 59 years (SD13.3) and 77.2% women. A CFA failed to support a total score from the 33-items (Chi Square 3552:df 464: p < 0.0001). Mokken scaling indicated a strong non-parametric association between items. Fit to the Rasch model indicated that the VLAs was characterised by multidimensionality and item misfit, which may have been influenced by clusters of residual item correlations. An item banking approach resolved a 25-item calibrated set whose application could accommodate the ‘does not apply to me’ response option.ConclusionsThe UK version of the VLAs failed to satisfy classical and modern psychometric standards for complete item sets. However, as the scale is not usually applied in complete format, an item bank approach calibrated 25 items with fit to the Rasch model. Suitable Computer Adaptive Testing (CAT) software could implement the item set, giving patients the choice of whether an item applies to them, or not.

Development of the prototype concise safe systems checklist tool for general practice

BackgroundIn the course of producing a patient safety toolkit for primary care, we identified the need for a concise safe-systems checklist designed to address areas of patient safety which are under-represented in mandatory requirements and existing tools. This paper describes the development of a prototype checklist designed to be used in busy general practice environments to provide an overview of key patient safety related processes and prompt practice wide-discussion.MethodsAn extensive narrative review and a survey of world-wide general practice organisations were used to identify existing primary care patient safety issues and tools. A RAND panel of international experts rated the results, summarising the findings for importance and relevance. The checklist was created to include areas that are not part of established patient safety tools or mandatory and legal requirements. Four main themes were identified: information flow, practice safety information, prescribing, and use of IT systems from which a 13 item checklist was trialled in 16 practices resulting in a nine item prototype checklist, which was tested in eight practices. Qualitative data on the utility and usability of the prototype was collected through a series of semi-structured interviews.ResultsIn testing the prototype four of nine items on the checklist were achieved by all eight practices. Three items were achieved by seven of eight practices and two items by six of eight practices. Participants welcomed the brevity and ease of use of the prototype, that it might be used within time scales at their discretion and its ability to engage a range of practice staff in relevant discussions on the safety of existing processes. The items relating to prescribing safety were considered particularly useful.ConclusionsAs a result of this work the concise patient safety checklist tool, specifically designed for general practice, has now been made available as part of an online Patient Safety Toolkit hosted by the Royal College of General Practitioners. Senior practice staff such as practice managers and GP partners should find it a useful tool to understand the safety of less explored yet important safety processes within the practice.

Exploring the relationship between nursing identity and advanced nursing practice: An ethnographic study.

To consider the relationship between professional nursing identity and advanced practice by exploring intra-professional relationships between advanced nurse practitioners (ANPs) and nursing colleagues. Advanced nursing practice continues to develop internationally. Previous studies suggest advanced practice may lack support within nursing, which may lead to underutilisation, retention and patient safety issues. However, the relationship between the wider nursing profession and advanced practice is poorly understood and the theory that professional identity creates cultural barriers to advanced practice has received little empirical attention. Ethnographic methodology was used. Fieldwork methods were participant observation and semi-structured interviews. Participants were ANPs (n=9) and nursing colleagues (n=5) across two primary care general practice organisations. Data were analysed thematically using framework analysis, underpinned a priori by professional identity theories. Reporting was guided by COREQ. Three themes were identified which indicated how intra-professional relationships were conducted: Conciliating Nursing, where ANPs took responsibility for developing positive relationships with other nurses; Vertical Discounting, where nursing colleagues were dismissive and undermined ANPs, who themselves behaved similarly towards other nurses; and Lateral Othering, where ANPs undermined other ANPs. Vertical Discounting and Lateral Othering destabilised advanced practice. Intra-professional relationships, and the broader nursing profession, shape advanced practice. We theorise this is underpinned by threats to professional identity, while weak professional identity amongst even established advanced practitioners exacerbates lack of support. Highlighting these issues allows space to develop alternative strategies to negotiate intra-professional relationships, informed by professional identity theories, which support rather than inhibit advanced practice. As advanced practice expands throughout primary and secondary care, and across allied health professions, the impact of professional identity and relationships on health care will likely increase and the importance of strong advanced practice identity will become increasingly relevant.

National survey of UK general practice pharmacy services

Abstract Background The Clinical Pharmacists in General Practice (CPGP) initiative aims to recruit over 2000 clinical pharmacists in general practice (GP) surgeries in England by 2020. This study aimed to explore the services delivered by all GP pharmacy professionals (GPPPs; pharmacists/pharmacy technicians) across the UK. Methods 30-item e-questionnaire was developed using SurveyMonkey platform and piloted during one-to-one cognitive interviews with GPPPs. The survey was distributed via the Primary Care Pharmacy Association, social media sites, collaborating GP organisations and via emails to participants of CPGP pilot. Three reminders were sent out 1 week apart. University ethics approval was obtained. Results Ninety-one responses were received between November 2018 and March 2019 (89% pharmacists, 52% from CPGP pilot). Participants provided an average of 9 services (95% CI 8.3-9.9). Over 90% of pharmacists delivered medication reviews and over 80% managed patients with polypharmacy. More pharmacists within than outside of the CPGP pilot managed repeat prescribing requests (70% vs. 47%, p = 0.035). Technicians took responsibility for primarily non-clinical services such as service commissioning (90%), management of safety alerts/drug recalls (80%), standard operating procedures (80%) and education &amp; training (80%). Over 40% of GPPPs not providing care home services wished to do so by 2024. Four technicians wanted to be more involved in medication reviews. The main perceived benefits of GP pharmacy services included identifying medicines-related issues (93%), utilisation of pharmacy professionals’ skills (93%) and a reduction in medication waste (92%). Conclusions GPPPs provide a range of clinical and non-clinical services which may benefit public health at an individual and healthcare system levels. Pharmacists within the pilot are more likely to deliver repeat prescribing services. Future GP pharmacy landscape will likely include additional services to care homes. Key messages GPPPs including pharmacy technicians provide clinical and non-clinical services, appropriate to their scope of practice, to benefit patients, healthcare systems and themselves. Developing future GP pharmacy services to care homes offers further opportunities to benefit a vulnerable group of patients with long-term illnesses.

A new model of patient-centred care for general practitioners: results of an integrative review.

GPs providing patient-centred care (PCC) is embedded in international health care policies due to its positive impact on patients and potential to lower health care costs. However, what is currently known about GP-delivered PCC is unknown. To synthesize literature investigating GP-delivered PCC and address 'what is currently known about GP-delivered PCC?' A systematic literature search was conducted between June and July 2018. Eligible articles were empirical, full-text studies published in English between January 2003 and July 2018, related to at least three of the four dimensions of PCC described by Hudon et al. (2011), and related to preventative, acute, and/or chronic care by GPs. Following screening, full-text articles were independently assessed for inclusion by two investigators. Data were extracted and quality assessed by two researchers. Findings on PCC were analysed thematically (meta-synthesis). Thirty medium- to high-quality studies met the inclusions criteria. Included studies utilized varied designs, with the most frequent being quantitative, cross-sectional. A theoretical model of PCC was synthesized from included studies and contained four major components: (i) understanding the whole person, (ii) finding common ground, (iii) experiencing time and (iv) aiming for positive outcomes. Harms of PCC were rarely reported. Four overarching theoretical components of PCC relate to elements of the consultation and experience of time. These components can be used to inform the development of toolkits to support GPs and general practice organizations in pursuit of PCC as well as tools to measure patient-centredness.

Overcoming the data drought: exploring general practice in Australia by network analysis of big data.

To investigate the organisation and characteristics of general practice in Australia by applying novel network analysis methods to national Medicare claims data. We analysed Medicare claims for general practitioner consultations during 1994-2014 for a random 10% sample of Australian residents, and applied hierarchical block modelling to identify provider practice communities (PPCs). About 1.7 million patients per year. Numbers and characteristics of PPCs (including numbers of providers, patients and claims), proportion of bulk-billed claims, continuity of care, patient loyalty, patient sharing. The number of PPCs fluctuated during the 21-year period; there were 7747 PPCs in 2014. The proportion of larger PPCs (six or more providers) increased from 32% in 1994 to 43% in 2014, while that of sole provider PPCs declined from 50% to 39%. The median annual number of claims per PPC increased from 5000 (IQR, 40-19 940) in 1994 to 9980 (190-23 800) in 2014; the proportion of PPCs that bulk-billed all patients was lowest in 2004 (21%) and highest in 2014 (29%). Continuity of care and patient loyalty were stable; in 2014, 50% of patients saw the same provider and 78% saw a provider in the same PPC for at least 75% of consultations. Density of patient sharing in a PPC was correlated with patient loyalty to that PPC. During 1994-2014, Australian GP practice communities have generally increased in size, but continuity of care and patient loyalty have remained stable. Our novel approach to the analysis of routinely collected data allows continuous monitoring of the characteristics of Australian general practices and their influence on patient care.

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.