A study of role expansion: a new GP role in cardiology care.

BACKGROUND: The National Health Service is reconfiguring health care services in order to meet the increasing challenge of providing care for people with long-term conditions and to reduce the demand on specialised outpatient hospital services by enhancing primary care. A review of cardiology referrals to specialised care and the literature on referral management inspired the development of a new GP role in Cardiology. This new extended role was developed to enable GPs to diagnose and manage patients with mild to moderate heart failure or atrial fibrillation and to use a range of diagnostics effectively in primary care. This entailed GPs participating in a four-session short course with on-going clinical supervision. The new role was piloted in a small number of GP practices in one county in England for four months. This study explores the impact of piloting the Extended Cardiology role on the GP's role, patients' experience, service delivery and quality. METHODS: A mixed methods approach was employed including semi-structured interviews with GPs, a patient experience survey, a quality review of case notes, and analysis on activity and referral data. RESULTS: The participating GPs perceived the extended GP role as a professional development opportunity that had the potential to reduce healthcare utilisation and costs, through a reduction in referrals, whilst meeting the patient's wishes for the provision of care closer to home. Patient experience of the new GP service was positive. The standard of clinical practice was judged acceptable. There was a fall in referrals during the study period. CONCLUSION: This new role in cardiology was broadly welcomed as a model of care by the participating GPs and by patients, because of the potential to improve the quality of care for patients in primary care and reduce costs. As this was a pilot study further development and continuing evaluation of the model is recommended.

The impact of patient participation direct enhanced service on patient reference groups in primary care: a qualitative study.

BACKGROUND: NHS policy documents continue to make a wide-ranging commitment to patient involvement. The Patient Participation Direct Enhanced Service (PP-DES), launched in 2011, aimed to ensure patients are involved in decisions about the range and quality of services provided and commissioned by their practice through patient reference groups (PRGs). The aim of this exploratory study is to review the impact of the PP-DES (2011-13) on a sample of PRGs and assess how far it has facilitated their involvement in decisions about the services of their general practices. METHODS: A qualitative methods design, using semi- structured interviews and focus groups, was employed to explore the experiences and views of GP practice staff (n = 24), PRG members (n = 80) at 12 GP practices, and other stakeholders (n = 4). RESULTS: Wide variation in the role and remit of the participating PRGs was found, which broadly ranged from activities to improve practice resources to supporting health promotion activities. The majority of PRG members were unfamiliar with the PP-DES scheme and its aims and purpose. Stakeholders and practice staff felt strongly that the main success of the PP-DES was that it had led to an increase in the number of PRGs being established in the locality. CONCLUSION: The PP-DES scheme has been a catalyst to establish PRGs. However, the picture was mixed in terms of the PRGs involvement in decisions about the services provided at their general practice as there was wide variation in the PRGs role and remit. The financial incentive alone, provided via the DES scheme, did not secure greater depth of PRG activity and power, however, as social factors were identified as playing an important role in PRGs' level of participation in decision making. Many PRGs have to become more firmly established before they are involved as partners in commissioning decisions at their practice.

Improving the management of obesity in adults: a pilot of a method to identify important barriers to change and tailor interventions to address them.

BACKGROUND: A tailored approach to implementation can facilitate the routine use of best evidence, and so improve the quality of care delivered. Tailored implementation involves investigating the context and barriers to change before selecting appropriate interventions. However, there is little evidence on the methods of tailoring. This study investigated the tailoring undertaken by two implementation groups as part of a study to improve adherence to NICE guidelines on adult obesity in primary care. METHODS: Data were collected from interviews with healthcare professionals and patients on barriers and enablers to implementing NICE guidelines on adult obesity along with practice performance data on body mass index (BMI) recording and use of interventions for obesity. Findings were presented to medical practitioners, university and NHS staff (n = 12) who formed two implementation groups to independently identify the most important barriers and enablers, and to suggest interventions to facilitate the implementation of the NICE guidelines. Each group had a facilitator and were observed by researchers whose notes were used to understand the group processes and assess the usefulness of this method. RESULTS: Within the time available both implementation groups reached consensus on the most important barriers and enablers and, led by those who had personal experience of managing patients with weight problems, made practical proposals for interventions to improve the implementation of the NICE guidelines. The role of the facilitator was crucial in ensuring barriers, enablers and interventions were all discussed and agreed upon in the time available. CONCLUSIONS: The facilitated implementation groups method succeeded in identifying appropriate and similar barriers, enablers and implementation interventions, which suggests some justification for this approach to tailoring. However, further research into methods of tailoring is required. Improvements to the implementation group approach may be realised by careful selection of group members and provision of sufficient preparation time prior to group discussions.

Barriers and enablers to managing obesity in general practice: a practical approach for use in implementation activities.

BACKGROUND: In 2006, the National Institute of Health and Clinical Excellence (NICE) published guidelines for the prevention and management of overweight and obesity. To tailor the implementation of guidelines, information is needed about the prevailing barriers and enablers, and practical methods for identifying barriers and enablers. AIM: To uncover and describe barriers and enablers to implementing NICE's recommendations on the management of obesity in adults in general practice, using practical qualitative methods. METHODS: A qualitative study involving semistructured interviews with seven general practitioners, seven practice nurses and nine overweight or obese patients, exploring their views and experiences on the implementation of NICE guidelines on obesity. The interviews were undertaken and analysed by a health professional with support of a health service researcher; they were recorded and transcribed verbatim and analysed using a thematic framework approach. The analysis described the reported barriers and enablers. RESULTS: Barriers included: stigma, cost of private sector services, previous patient experience, practitioners not wanting to take responsibility for obesity management, lack of consistency in care, limited practitioner skills, perceived lack of NHS services and constraints imposed by commissioners. Trust between practitioners and patients, practitioners with the skills and confidence to raise the issue of obesity, practice-based procedures and weight management services being available were perceived as enablers to implementation. CONCLUSION: This pragmatic study found that there are many barriers to the implementation of NICE guidance on obesity, involving patients, practitioners and support services for primary care.

Placing interprofessional learning at the heart of improving practice: the activities and achievements of CLAHRC in Leicestershire, Northamptonshire and Rutland.

BACKGROUND: The National Institute for Health Research initiative 'collaborations for leadership in applied health research and care' (CLAHRC) in Leicestershire Northamptonshire and Rutland (LNR) is a partnership between the University of Leicester and NHS trusts in LNR that aims to reduce the second gap in translation (the long delay between conducting research and it having an impact on clinical practice). METHOD: CLAHRC-LNR appointed specialist staff as boundary spanners and knowledge brokers to improve links between academia and the NHS, and to facilitate a range of activities designed to increase the implementation of research evidence. An interprofessional and interdisciplinary approach is used and incorporates a range of activities including: applied research, service evaluation and pilot projects, education and training events, knowledge dissemination activities and developing networks to increase the use of research in the NHS partners. RESULTS: CLAHRC-LNR's close collaboration with partner NHS trusts has aided the development of a programme of applied research that aims to develop interprofessional teamworking to improve healthcare systems and patient outcomes. Co-ordinators (boundary spanners) have been appointed in trusts and have been crucial in facilitating interprofessional working. Activities include a successful programme of training and education courses within the NHS partner trusts using the principles of interprofessional education. CLAHRC-LNR is developing the use of knowledge exchange events and workshops as well as establishing communities of practice to bring together professionals from across LNR NHS trusts and the University of Leicester to share their expertise and build interprofessional relationships. CLAHRC fellows (knowledge brokers) are being appointed to work with co-ordinators to facilitate the use of research evidence in decision making in the trusts and clinical commissioning groups (CCGs). CONCLUSION: Interprofessional working is integral to the approach adopted by CLAHRC-LNR, running through many of its activities, and is proving vital to addressing and helping to close the second gap in translation.

The Prostate Care Questionnaire for Carers (PCQ-C): reliability, validity and acceptability.

BACKGROUND: Patient experience is commonly monitored in evaluating and improving health care, but the experience of carers (partners/relatives/friends) is rarely monitored even though the role of carers can often be substantial. For carers to fulfil their role it is necessary to address their needs. This paper describes an evaluation of the reliability, validity and acceptability of the PCQ-C, a newly developed instrument designed to measure the experiences of carers of men with prostate cancer. METHODS: The reliability, acceptability and validity of the PCQ-C were tested through a postal survey and interviews with carers. The PCQ-C was posted to 1087 prostate cancer patients and patients were asked to pass the questionnaire on to their carer. Non-responders received one reminder. To assess test-retest reliability, 210 carers who had responded to the questionnaire were resent it a second time three weeks later. A subsample of nine carers from patients attending one hospital took part in qualitative interviews to assess validity and acceptability of the PCQ-C. Acceptability to service providers was evaluated based on four hospitals' experiences of running a survey using the PCQ-C. RESULTS: Questionnaires were returned by 514 carers (47.3%), and the majority of questions showed less than 10% missing data. Across the sections of the questionnaire internal consistency was high (Cronbach's alpha ranging from 0.80 to 0.89), and test-retest stability showed moderate to high stability (intraclass correlation coefficients ranging from 0.52 to 0.83). Interviews of carers indicated that the PCQ-C was valid and acceptable. Feedback from hospitals indicated that they found the questionnaire useful, and highlighted important considerations for its future use as part of quality improvement initiatives. CONCLUSIONS: The PCQ-C has been found to be acceptable to carers and service providers having been used successfully in hospitals in England. It is ready for use to measure the aspects of care that need to be addressed to improve the quality of prostate cancer care, and for research.

The prostate care questionnaire for patients (PCQ-P): reliability, validity and acceptability.

BACKGROUND: In England, prostate cancer patients report worse experience of care than patients with other cancers. However, no standard measure of patient experience of prostate cancer care is currently available. This paper describes an evaluation of the reliability, validity and acceptability of the PCQ-P, a newly developed instrument designed to measure patient experience of prostate cancer care. METHODS: The reliability, acceptability and validity of the PCQ-P were tested through a postal survey and interviews with patients. The PCQ-P was posted to 1087 prostate cancer patients varying in age, occupation, and overall health status, sampled from five hospitals in England. Nonresponders received one reminder. To assess criterion validity, 935 patients were also sent sections of the National Centre for Social Research Shortened Questionnaire; and to assess test-retest reliability, 296 patients who responded to the questionnaire were resent it a second time three weeks later. A subsample of 20 prostate cancer patients from one hospital took part in qualitative interviews to assess validity and acceptability of the PCQ-P. Acceptability to service providers was evaluated based on four hospitals' experiences of running a survey using the PCQ-P. RESULTS: Questionnaires were returned by 865 patients (69.2%). Missing data was low across the sections, with the proportion of patients completing less than 50% of each section ranging from 4.5% to 6.9%. Across the sections of the questionnaire, internal consistency was moderate to high (Cronbach's alpha ranging from 0.63 to 0.80), and test-retest stability was acceptable (intraclass correlation coefficients ranging from 0.57 to 0.73). Findings on criterion validity were significant. Patient interviews indicated that the PCQ-P had high face validity and acceptability. Feedback from hospitals indicated that they found the questionnaire useful, and highlighted important considerations for its future use as part of quality improvement initiatives. CONCLUSION: The PCQ-P has been found to be acceptable to patients and service providers, and is ready for use for the measurement of patient experience in routine practice, service improvement programmes, and research.

The National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Leicestershire, Northamptonshire and Rutland (LNR): a programme protocol.

BACKGROUND: In October 2008, the National Institute for Health Research launched nine new research projects to develop and investigate methods of translating research evidence into practice. Given the title Collaborations for Leadership in Applied Health Research and Care (CLAHRC), all involve collaboration between one or more universities and the local health service, but they are adopting different approaches to achieve translation. METHODS: The translation and implementation programme of this CLAHRC has been built around a pragmatic framework for undertaking research to address live concerns in the delivery of care, in partnership with the managers, practitioners, and patients of the provider organisations of the CLAHRC. Focused on long-term conditions, the constituent research themes are prevention, early detection, self-management, rehabilitation, and implementation. Individual studies have various designs, and include both randomised trials of new ways to deliver care and qualitative studies of, for example, means of identifying barriers to research translation. A mix of methods will be used to evaluate the CLAHRC as a whole, including use of public health indicators, social research methods, and health economics. DISCUSSION: This paper describes one of the nine collaborations, that of Leicestershire, Northamptonshire, and Rutland. Drawing a distinction between translation as an organising principle for healthcare providers and implementation as a discrete activity, this collaboration is built on a substantial programme of applied research intended to create both research generation and research use capacity in provider organisations. The collaboration in Leicestershire, Northamptonshire, and Rutland has potential to provide evidence on how partnerships between practitioners, patients, and researchers can improve the transfer of evidence into practice.

Men's and carers' experiences of care for prostate cancer: a narrative literature review.

OBJECTIVE: To review studies of patients' and carers' experience of prostate cancer care. DESIGN: Narrative literature review. METHODS: Search strategies were developed for the following databases: MEDLINE (1966-2006), EMBASE (1980-2006), CINAHL (1982-2006) and PsycINFO (1987-2006). A search of SIGLE (System for Information on Grey Literature in Europe) was also undertaken. Experience was defined as patients' and carers' reports of how care was organized and delivered to meet their needs. A narrative summary of the included papers was undertaken. RESULTS: A total of 90 relevant studies were identified. Most studies reported on experiences of screening, diagnosis, the treatment decision, treatment and post-initial treatment. Few studies reported on experiences of the stages of referral, testing, and further treatment and palliative care, and no studies reported on monitoring or terminal care. CONCLUSIONS: Although some phases of care have not been investigated in detail, there is evidence that: (i) many patients have a low level of knowledge of prostate cancer; (ii) patients with prostate cancer and their carers need information throughout the care pathway to enable them to understand the diagnosis, treatment options, self-care and support available; and (iii) increasing patient knowledge and understanding of prostate cancer (e.g. through interventions) are often associated with a more active role in decision making (e.g. screening, treatment decision).

Patient-centred care: What are the experiences of prostate cancer patients and their partners?

OBJECTIVE: To gain an in depth understanding of the experiences of care of men with prostate cancer and their partners. METHODS: The study design was a qualitative analysis of semi-structured interviews of men (35) who had been diagnosed and treated for prostate cancer and their partners (10). They were recruited from two hospitals in the East Midlands of England and two charities. RESULTS: The interviews showed that although there was no widespread dissatisfaction with care, patients reported problems throughout care. The two main problems were that throughout care patients' and partners' information needs were often not identified or met, and patients' preferred role in decision-making about testing and treatment was not explored. CONCLUSIONS: If patients' experiences of prostate cancer care are to be improved, clinicians need to identify, and respond to, the information and decision-making needs of individual patients and their partners. PRACTICE IMPLICATIONS: Clinicians should identify and meet the needs of patients individually, use appropriate language and formats for communicating information, fully prepare patients for tests, explore and meet the needs of patients for involvement in decision-making, and recognise the important role that their partner plays. Systems and pathways of care should be designed to enable patients and partners to obtain information and participate in decision-making throughout all stages of care.

Is seeing a specialist nurse associated with positive experiences of care? The role and value of specialist nurses in prostate cancer care.

BACKGROUND: Specialist nurses may play an important role in helping to improve the experiences of patients with prostate cancer, however there is concern that the specialist nurse role is under threat in the UK due to financial pressures in the NHS. This study explored the role and value of specialist nurses in prostate cancer care via a survey and patient interviews. METHODS: This paper reports findings from two studies. A survey of patients from three hospitals across the UK (289/481, 60%), investigated whether patients who saw a specialist nurse had different experiences of information provision and involvement in decision-making, to those who did not. Qualitative interviews were also carried out with 35 men recently tested or treated for prostate cancer, recruited from two hospitals in the UK. Interviews explored patients' views on the role and value of the specialist nurse. RESULTS: Survey findings indicated that patients who saw a specialist nurse had more positive experiences of receiving written information about tests and treatment, and about sources of advice and support, and were more likely to say they made the treatment decision themselves. In interviews, patients described specialist nurse input in their care in terms of providing information and support immediately post-diagnosis, as well as being involved in ongoing care. Two key aspects of the specialist nurse role were seen as unique: their availability to the patient, and their ability to liaise between the patient and the medical system. CONCLUSION: This study indicates the unique role that specialist nurses play in the experience of patients with prostate cancer, and highlights the importance of maintaining specialist nurse roles in prostate cancer care.

Physical activity and sedentary behaviours of South Asian and white European children in inner city secondary schools in the UK.

BACKGROUND: People of South Asian (SA) origin have an increased risk of premature coronary heart disease. In children of SA origin, there is an increased prevalence of obesity and evidence of insulin resistance. Risk factors for cardiovascular disease in children often persist into adulthood. Low levels of physical activity are likely to be linked to the rise in obesity. OBJECTIVE: To determine levels of physical activity and sedentary behaviours in secondary school pupils in the UK, including comparison of SA and white European (WE) children and those with and without a family history of cardiovascular disease. METHOD: Questionnaire survey conducted within an action research study in five inner city secondary schools serving a predominantly SA population. RESULTS: We obtained 3601 responses from 76% of eligible pupils. WE pupils were more likely to have walked to and from school compared to SAs. However, overall we identified low levels of physical activity and higher levels of inactive behaviours in both ethnic groups. Almost half (46%) of respondents spent four or more hours per day watching television or videos or playing computer games. An overall low level of active behaviour during school breaks was particularly emphasized in girls. We found no evidence of an association between physical activity levels and family history of cardiovascular disease. CONCLUSIONS: There is an urgent need for those with responsibility for young people's health, including parents, schools and community health providers, to consider and address the need for effective interventions to encourage increased physical activity levels.

Dietary habits of young people attending secondary schools serving a multiethnic, inner-city community in the UK.

BACKGROUND: Childhood obesity is an escalating health concern with important implications, including increased risk of type 2 diabetes and cardiovascular disease. Although South Asians in the UK have an increased risk of developing these conditions, detailed studies on their lifestyles including the dietary habits of young people are scarce. METHODS: As part of an action research project, a food intake questionnaire was used to survey the dietary habits of 11-15-year olds attending five inner-city schools serving a predominantly South Asian population. Food choices were considered in the overall sample and in South Asians compared with white Europeans. RESULTS: 3418 (72% of registered pupils) responses were obtained. A subset of 3018 pupils could be categorised as either South Asian (86%) or white European (14%). Around one fifth of pupils started the school day without eating anything. Responses indicated high consumption of "negative" foods such as sweets, including Asian sweets (63%), but lower rates for "positive" foods such as vegetables (34%). In the full sample, 26% said they had consumed more than one can of sugar-sweetened fizzy drink and 17% reported eating more than one packet of full-fat crisps on the previous day. Poor dietary habits were indicated in both South Asian and white European pupils. CONCLUSIONS: Our large-scale survey confirmed poor dietary habits in secondary school pupils from a multiethnic community. Urgent efforts are needed to find ways of encouraging healthy lifestyles, particularly in populations with a high risk of developing cardiovascular disease and type 2 diabetes.

Death certification: issues from a pilot of the Shipman Inquiry's interim proposals.

This article investigates the issue of death certification in England and Wales. The Shipman Inquiry published interim proposals designed to make the system of death certification safer and more accurate. The proposed forms were piloted by doctors and relatives on a sample of deaths in one locality. They were then interviewed to assess the forms' feasibility and acceptability.

Involving patients to improve service quality in primary care.

A sample of 92 UK patients volunteered to take part in focus groups to discuss what elements of local primary care provision were important to them. Issues raised were prioritised by the patients and then fashioned into 18 quality indicators which nine local practices were invited to assess themselves against. At the assessment meeting three months later over 40 changes in service provision were noted in the nine participating practices. A patient questionnaire carried out in each practice, however, indicated a tendency for practices to overestimate the services they felt they provided. Patients rated the experience of generating standards as very worthwhile and enjoyed being asked. Further research needs to be carried out to assess the effectiveness of this methodology in different settings.

Primary care. More than words.

There are few models for involving patients in primary care. Research in one primary care group, involving 92 patients from nine general practices, established a list of 20 standards most important to patients. When asked to assess themselves against these standards, practices rated their services higher than patients did. The research found considerable resistance to patient involvement from GPs, which needs to be addressed if the government's aims are to be achieved.