Health and lifestyle advisors in support of primary care: An evaluation of an innovative pilot service in a region of high health inequality.

INTRODUCTION: A health and lifestyle advisor service embedded within primary care was piloted in Kingston-upon-Hull from January 2021. We aimed to evaluate the first two years of service delivery by identifying patient demographics referred to the service, reason for referral, determine uptake and retention rates, and monitor individual lifestyle-related risk factor changes following discharge. METHODS: Anonymised data were extracted from the SystmOne database for all patients referred to the service between January 2021 and January 2023. RESULTS: In the initial two years of the service, 705 unique patients were referred at a mean rate of ∼29 per month. Each unique patient received a median (robust median absolute deviation; [MAD]) of 3 (Steel N, et al 2018) planned consultations prior to discharge over this period. The majority of referrals were for symptom management and health promotion purposes (95%). Of those referred, 69% attended their appointments, and 14% did not attend. The majority of referrals were white British (55%), however, the service did receive a substantial number of referrals from minority ethnic groups, with only 67% of referrals speaking English as their main language. Eighteen distinct languages were spoken. Most referrals were classified as class I obese (59.4%). Across initial and final appointments, median (robust MAD) systolic blood pressure was 130 (15) mmHg and 130 (15) mmHg, and median (robust MAD) waist circumference was 103.0 (13.3) cm and 101.0 (13.3) cm. CONCLUSION: The evaluation highlighted the demand for this service embedded within primary care settings in Kingston-upon-Hull. Service engagement was evident, and a large proportion of those who engaged were from minority ethnic groups. A high proportion of referrals presented with obesity and/or hypertension which requires further investigation.

Mitigating inequalities at a large COVID-19 vaccination centre.

Introduction: The COVID-19 vaccination service is a key component in the UK approach to reducing disease morbidity and mortality. Groups within the population at increased risk of severe outcomes from COVID-19 overlap with groups that are less likely to take up the offer of vaccination. This article outlines some learning from approaches within a large vaccination centre in the UK to reduce inequalities. Solution: Continuous quality improvement processes were used to operationalise the mitigations to inequalities with vaccination uptake that were identified by a systematic equality impact assessment framework and continuous service feedback. Outcome: Quality improvement processes and community engagement enabled tailored mitigations to vaccination uptake. Engagement with community ambassadors strengthened community relationships and the co-creation of bespoke sessions encouraged vaccination uptake within specific groups. Conclusion: Recommendations for strengthening approaches to inequality reduction include having a systematic framework for assessment and mitigation of inequalities, embedding quality improvement, identifying resources, and taking a collaborative and co-design approach to services with underserved groups.

Barriers to and facilitators of the identification, management and referral of childhood anxiety disorders in primary care: a survey of general practitioners in England.

OBJECTIVES: Although anxiety disorders are the most common emotional disorders in childhood and are associated with a broad range of negative outcomes, only a minority of affected children receive professional support. In the UK, general practitioners (GPs) are seen as 'gate-keepers' to mental health services. The aim of this study was to examine the extent to which GPs experience barriers to and facilitators of identifying, managing and accessing specialist services for these disorders, as well as factors associated with GPs' confidence. DESIGN AND SETTING: Cross-sectional, self-report questionnaire in primary care, addressing identification, management and access to specialist services for children (under 12 years) with anxiety disorders. PARTICIPANTS: 971 GPs in England. PRIMARY OUTCOMES: The primary outcomes for this research was the extent to which GPs felt confident (1) identifying and (2) managing anxiety disorders in children. RESULTS: Only 51% and 13% of GPs felt confident identifying and managing child anxiety disorders, respectively. A minority believed that their training in identification (21%) and management (10%) was adequate. Time restrictions inhibited identification and management, and long waiting times was a barrier to accessing specialist services. Being female (Ex(B)=1.4, 95% CI 1.1 to 1.9) and being in a less deprived practice (Ex(B)=1.1, 95% CI 1 to 1.1) was associated with higher confidence identifying childhood anxiety disorders. Being a parent of a child over the age of 5 (Ex(B)=2, 95% CI 1.1 to 3.5) and being in a less deprived practice (Ex(B)=1.1, 95% CI 1 to 1.2) was associated with higher confidence in management. Receipt of psychiatric or paediatric training was not significantly associated with GP confidence. CONCLUSIONS: GPs believe they have a role in identifying and managing childhood anxiety disorders; however, their confidence appears to be related to their personal experience and the context in which they work, rather than their training, highlighting the need to strengthen GP training and facilitate access to resources and services to enable them to support children with these common but debilitating conditions.

GPs' experiences of children with anxiety disorders in primary care: a qualitative study.

BACKGROUND: Anxiety disorders have a median age of onset of 11 years and are the most common emotional disorders in childhood; however, a significant proportion of those affected do not access professional support. In the UK, GPs are often the first medical professional that families see so are in a prime position to support children with anxiety disorders; however, currently there is little research available on GPs' perspectives on and experiences of supporting children with these disorders. AIM: To explore the experiences of GPs in relation to identification, management, and access to specialist services for children (<12 years) with anxiety disorders. DESIGN AND SETTING: Twenty semi-structured interviews were conducted with GPs in primary care throughout England. METHOD: GPs reflected a diverse group in relation to the ethnic and socioeconomic profile of registered patients, GP age, sex, professional status, previous engagement with research, and practice size and location. Purposive sampling was used to recruit GPs until theoretical saturation was reached. Data were analysed using a constant comparative method of thematic analysis. RESULTS: Data from 20 semi-structured interviews were organised into three themes: decision making, responsibility, and emotional response, with an overarching theme of GPs feeling ill equipped. These themes were retrospectively analysed to illustrate their role at different stages in the primary care process (identification, management, and access to specialist services). CONCLUSION: GPs feel ill equipped to manage and support childhood anxiety disorders, demonstrating a need for medical training to include greater emphasis on children's mental health, as well as potential for greater collaboration between primary and specialist services.

"When I go to bed hungry and sleep, I'm not hungry": Children and parents' experiences of food insecurity.

Evidence demonstrates food insecurity has a detrimental impact on a range of outcomes for children, but little research has been conducted in the UK, and children have rarely been asked to describe their experiences directly. We examined the experiences of food insecure families living in South London. Our mixed-methods approach comprised a survey of parents (n = 72) and one-to-one semi-structured interviews with children aged 5-11 years (n = 19). The majority of parents (86%) described their food security during the preceding year as very low. Most reported they had often or sometimes had insufficient food, and almost all had worried about running out of food. Two thirds of parents had gone hungry. Most parents reported they had been unable to afford a nutritionally balanced diet for their children, and just under half reported that their children had gone hungry. Four themes emerged from the interviews with children: sources of food; security of food, nutritional quality of food, and experiences of hunger. Children's descriptions of insufficient food being available indicate that parents are not always able to shield them from the impact of food insecurity. The lack of school-meals and after-school clubs serving food made weekends particularly problematic for some children. A notable consequence of food insecurity appears to be reliance on low-cost takeaway food, likely to be nutritionally poor.

Infant feeding choices: experience, self-identity and lifestyle.

In England, 78% of mothers initiate breastfeeding and, in the UK, less than 1% exclusively breastfeed until 6 months, despite World Health Organization (WHO) recommendations to do so. This study investigated women's infant feeding choices using in-depth interviews with 12 mothers of infants aged 7-18 weeks. Using content analysis, four themes emerged: (1) information, knowledge and decision making, (2) physical capability, (3) family and social influences, (4) lifestyle, independence and self-identity. While women were aware of the 'Breast is Best' message, some expressed distrust in this information if they had not been breastfed themselves. Women felt their own infant feeding choice was influenced by the perceived norm among family and friends. Women described how breastfeeding hindered their ability to retain their self-identities beyond motherhood as it limited their independence. Several second-time mothers felt they lacked support from health professionals when breastfeeding their second baby, even if they had previously encountered breastfeeding difficulties. The study indicates that experience of breastfeeding and belief in the health benefits associated with it are important factors for initiation of breastfeeding, while decreased independence and self-identity may influence duration of breastfeeding. Intervention and support schemes should tackle all mothers, not just first-time mothers.

Intensive case management for severe psychotic illness: is there a general benefit for patients with complex needs? A secondary analysis of the UK700 trial data.

The UK700 trial failed to demonstrate an overall benefit of intensive case management (ICM) in patients with severe psychotic illness. This does not discount a benefit for particular subgroups, and evidence of a benefit of ICM for patients of borderline intelligence has been presented. The aim of this study is to investigate whether this effect is part of a general benefit for patients with severe psychosis complicated by additional needs. In the UK700 trial patients with severe psychosis were randomly allocated to ICM or standard case management. For each patient group with complex needs the effect of ICM is compared with that in the rest of the study cohort. Outcome measures are days spent in psychiatric hospital and the admission and discharge rates. ICM may be of benefit to patients with severe psychosis complicated by borderline intelligence or depression, but may cause patients using illicit drugs to spend more time in hospital. There was no convincing evidence of an effect of ICM in a further seven patient groups. ICM is not of general benefit to patients with severe psychosis complicated by additional needs. The benefit of ICM for patients with borderline intelligence is an isolated effect which should be interpreted cautiously until further data are available.

Forty-eight hour access to primary care: practice factors predicting patients' perceptions.

BACKGROUND: The government has proposed a 48-hour target for GP availability. Although many practices are moving towards delivering that goal, recent national patient surveys have reported a deterioration in patients' reports of doctor availability. What practice factors contribute to patients' perceptions of doctor availability? METHOD: A cross sectional patient survey (11,000 patients from 54 inner London practices, 7247 (66%) respondents) using the General Practice Assessment Survey. We asked patients how soon they could be seen in their practice following non-urgent consultation requests and related their aggregated responses to the characteristics of their practice. RESULTS: Three factors relating to practice administration and appointments systems operation independently predicted patients' reports of doctor availability. These were the proportion of patients asked to attend the surgery and wait to be seen, the proportion of patients seen using an emergency surgery arrangement, and the extent of practice computerization. CONCLUSION: Some practices may have difficulty in meeting the target for GP availability. Meeting the target will involve careful review of practice administrative procedures.

The effect of intensive case management on the relatives of patients with severe mental illness.

OBJECTIVE: Relatives play a vital role in caring for patients with severe mental illness but receive inadequate support from psychiatric services. Evidence suggests that although intensive case management is directed primarily at patients, relatives may benefit as well. This study examined whether relatives of patients who were receiving intensive case management had more contact with mental health professionals than relatives of patients who were receiving standard case management. It also examined whether relatives of patients receiving intensive case management appraised caregiving less negatively and experienced less psychological distress than relatives of patients receiving standard case management. METHODS: The sample was drawn from the pool of patients participating in the UK700 randomized controlled trial of intensive case management. Prospective data on contact between case managers and the relatives of 146 patients were collected over a two-year period. At a two-year follow-up assessment, relatives of 116 patients were interviewed with the Experience of Caregiving Inventory and the 12-item General Health Questionnaire. RESULTS: Considerably more relatives of patients receiving intensive case management had contact with a case manager during the study period than relatives of patients receiving standard case management (70 percent compared with 45 percent). However, relatives of patients receiving intensive case management did not appraise caregiving less negatively or experience less psychological distress than relatives of patients who were receiving standard case management. CONCLUSIONS: Reducing case managers' caseloads alone will not guarantee adequate support for relatives. Instead, providing more support will need to be an explicit aim, and staff will require specific additional training to achieve it.