A digital solution to streamline access to smoking cessation interventions in England; findings from a primary care pilot (STOPNOW study).

Objectives: Despite the proven efficacy of several smoking cessation medications that have been shown to improve long-term abstinence rates, approximately two-thirds of smokers report not having used medication in their most recent quit attempt. A main barrier could be delayed access to pharmacological interventions. This study investigated the utility of a primary care linked online portal to streamline timely access to pharmacological support to patients who want to quit smoking by making an asynchronous request for treatment to their general practitioner. Study design: Prospective cohort study. Methods: An online portal with added functionality was developed, which allowed patients with a unique link to make an asynchronous request for treatment. Two GP practices identified a total of 4337 eligible patients who received an SMS or email invite to engage with an online portal including an electronic survey to capture information about smoking behaviours and to request treatment. Portal informatics and patient level data were analysed to measure the efficacy of the online system in reducing the time between making a formal request to treatment and access to pharmacological support. The primary outcome measure was the time between making a formal request for treatment and access to pharmacological support from a designated community pharmacy. Results: 323 patients (7.4%) initiated the survey, but only 56 patients completed the survey and made a formal request for treatment. 94% of participants did not return to use the portal to make a second or follow-up request for treatment. Only 3 participants completed the 12-week pathway. A total of 75 medication items were prescribed and collected by 56 patients. The time difference between the formal request to treatment and GP review ranged between 20 h and 1 week. The time difference between approval of prescription by the GP and access to medication was 5 days ± 2.1 days (range = 1.9-7.0 days). Conclusion: The widespread adoption and diffusion of an IT enabled and asynchronous primary care led remote consultation pathway can streamline timely access to smoking cessation support without the need for the patient to see a GP or an independent prescriber in the first instance.

Improving patient safety in developing countries - moving towards an integrated approach.

Patient safety is a major public health issue. It has also been recognised as an area for improvement. The purpose of this article is to discuss the need for developing an integrated approach to patient safety improvement in developing countries. Relevant literature to identify the common themes and patterns associated with patient safety improvement was conducted through a search of the online databases (MEDLINE, EMBASE, PUBMED and Google Scholar) for the years 2000 to 2017. Lessons and interventions from developed countries have been taken into consideration to identify the themes needed for patient safety improvement in developing countries. This review provides an integrated approach based on best practice which can be used to guide the development of a national strategy for improving patient safety. Policy makers need to focus on developing a holistic and comprehensive approach to patient safety improvement that takes into account the themes discussed in this article.

Evaluating case studies of community-oriented integrated care.

This paper summarises a ten-year conversation within London Journal of Primary Care about the nature of community-oriented integrated care (COIC) and how to develop and evaluate it. COIC means integration of efforts for combined disease-treatment and health-enhancement at local, community level. COIC is similar to the World Health Organisation concept of a Community-Based Coordinating Hub - both require a local geographic area where different organisations align their activities for whole system integration and develop local communities for health. COIC is a necessary part of an integrated system for health and care because it enables multiple insights into 'wicked problems', and multiple services to integrate their activities for people with complex conditions, at the same time helping everyone to collaborate for the health of the local population. The conversation concludes seven aspects of COIC that warrant further attention.

Improving outcomes for patients discharged early using a home assessment scheme.

BACKGROUND: With increased delayed discharges from acute NHS hospitals, especially for older patients, solutions like the 'Discharge to Assess' (D2A) scheme aim to facilitate quicker discharge and improve experiences for patients and carers. SETTING: This report examines the quality process from the patient perspective of the D2A scheme implemented in a London Northwest Healthcare NHS Trust (LNWHT). A retrospective audit was conducted using the first cohort of patients discharged through this pilot scheme from April to July 2017. QUESTION: A brief study to explore patient views of their experience of the D2A scheme. METHODS: An opportunistic audit comprised of brief telephone interviews with patients following discharge from hospital through the D2A scheme. RESULTS: 30 patients who had been discharged with the D2A scheme, agreed to participate. Overall, patients were positive about their experience and valued the support and services provided. However, there were concerns on the issue of communication. The scheme effectiveness from the patient's perspective improved over the duration of the evaluation. DISCUSSION: Patients' views about their experiences changed over time, which included patients' perceptions of the discharge process, patients' expectations and the way in which they were able to access services.

Towards a strategic alignment of public health and primary care practices at local levels - the case of severe and enduring mental illness.

The rapidly increasing number of people who have long-term conditions requires a system of coordinated support for self-care throughout the NHS. A system to support self-care needs to be aligned to systems that support shared-care and community development, making it easier for the multidisciplinary teams who provide care to also help patients and populations to help themselves. Public health practitioners need to work closely with clinicians to achieve this. The best place to coordinate this partnership is a community-based coordinating hub, or local health community - a geographic area of about 50,000 population where different contributions to self-care can be aligned. A shared vision for both health and disease management is needed to ensure consistent messaging by all. A three tier system of shared care can help to combine vertical and horizontal integration. This paper uses severe and enduring mental illness as an exemplar to anticipate the design of such a system.

Improving patient safety in Libya: insights from a British health system perspective.

Purpose Patient safety programmes aim to make healthcare safe for both patients and health professionals. The purpose of this paper is to explore the UK's patient safety improvement programmes over the past 15 years and explore what lessons can be learnt to improve Libyan healthcare patient safety. Design/methodology/approach Publications focusing on UK patient safety were searched in academic databases and content analysed. Findings Several initiatives have been undertaken over the past 15 years to improve British healthcare patient safety. Many stakeholders are involved, including regulatory and professional bodies, educational providers and non-governmental organisations. Lessons can be learnt from the British journey. Practical implications Developing a national patient safety strategy for Libya, which reflects context and needs is paramount. Above all, Libyan patient safety programmes should reference internationally approved guidelines, evidence, policy and learning from Britain's unique experience. Originality/value This review examines patient safety improvement strategies adopted in Britain to help developing country managers to progress local strategies based on lessons learnt from Britain's unique experience.

How primary care can contribute to good mental health in adults.

The need for support for good mental health is enormous. General support for good mental health is needed for 100% of the population, and at all stages of life, from early childhood to end of life. Focused support is needed for the 17.6% of adults who have a mental disorder at any time, including those who also have a mental health problem amongst the 30% who report having a long-term condition of some kind. All sectors of society and all parts of the NHS need to play their part. Primary care cannot do this on its own. This paper describes how primary care practitioners can help stimulate such a grand alliance for health, by operating at four different levels - as individual practitioners, as organisations, as geographic clusters of organisations and as policy-makers.

Key priority areas for patient safety improvement strategy in Libya: a protocol for a modified Delphi study.

INTRODUCTION: Patient safety is a global public health problem. Estimates and size of the problem of patient safety in low-income and developing countries are scarce. A systems approach is needed for ensuring that patients are protected from harm while receiving care. The primary objective of this study will be to use a consensus-based approach to identify the key priority areas for patient safety improvement in Libya as a developing country. DESIGN: A modified Delphi study. METHODS AND ANALYSIS: A three-phase modified Delphi study will be conducted using an anonymous web-based questionnaires. 15 international experts in the field of patient safety will be recruited to prioritise areas of patient safety that are vital to developing countries such as Libya. The participants will be given the opportunity to rank a list of elements on five criteria. The participants will also be asked to list five barriers that they believe hinder the implementation of patient safety systems. Descriptive statistics will be used to evaluate consensus agreement, including percentage agreement and coefficient of variation. Kendall's coefficient of concordance will be used to evaluate consensus across all participants. ETHICS AND DISSEMINATION: Ethical approval has been granted from Imperial College Research Ethics Committee (ICREC: 16IC3598). The findings of the study will be published in a PhD thesis. A manuscript will also be prepared for publication in a high-impact peer-reviewed journal describing the Delphi process and the findings of the study.

Status of patient safety culture in Arab countries: a systematic review.

OBJECTIVES: To explore the status of patient safety culture in Arab countries based on the findings of the Hospital Survey on Patient Safety Culture (HSPSC). DESIGN: Systematic review. METHODS: We performed electronic searches of the MEDLINE, EMBASE, CINAHL, ProQuest and PsychINFO, Google Scholar and PubMed databases, with manual searches of bibliographies of included articles and key journals. We included studies that were conducted in the Arab countries that were focused on patient safety culture. 2 reviewers independently verified that the studies met the inclusion criteria and critically assessed the quality of the studies. RESULTS: 18 studies met our inclusion criteria. The review identified that non-punitive response to error is seen as a serious issue which needs to be improved. Healthcare professionals in the Arab countries tend to think that a 'culture of blame' still exists that prevents them from reporting incidents. We found an overall similarity between the reported composite score for dimension of teamwork within units in all of the reviewed studies. Teamwork within units was found to be better than teamwork across hospital units. All of the reviewed studies reported that organisational learning and continuous improvement was satisfactory as the average score of this dimension for all studies was 73.2%. Moreover, the review found that communication openness seems to be a concerning issue for healthcare professionals in the Arab countries. CONCLUSIONS: There is a need to promote patient safety culture as a strategy for improving the patient safety in the Arab world. Improving patient safety culture should include all stakeholders, like policymakers, healthcare providers and those responsible for medical education. This review was limited only to English language publications. The varied settings in which the HSPSC was used may have influenced the areas of strengths and weaknesses as healthcare workers' perception of safety culture may differ.

The prevalence of comorbidities among people living with HIV in Brent: a diverse London Borough.

Background HIV has changed from a rapidly deteriorating illness to a complex chronic disease, with increasing incidences of comorbidity, including cancer, and liver, lung and cardiovascular diseases. North West London has 6719 individuals living with the human immunodeficiency virus (HIV), 873 of whom reside in the London Borough of Brent. Traditionally, commissioning services have focused on HIV therapy alone without considering how comorbidity affects treatment outcome and total service costs. Setting The setting for the study was NHS Brent Primary Care Trust, London UK. Question What associated comorbidities are present in people in Brent (London, UK) living with HIV, and how common are they? Methods A point-prevalence audit of retrospective data was conducted on all HIV-positive patients in Brent (financial year 2011/12). Data were collected from genito-urinary medicine (GUM) services, community services and general practitioners (GPs) on HIV diagnosis, patient demographics and past/current comorbidities: hepatitis B and C, cardiovascular disease, diabetes and mental health disorders. Results This study identified that 29% of people living with HIV/AIDS (PLWHA) in Brent have at least one comorbidity. The most common was hepatitis, followed by mental health disorders and cardiovascular disease (CVD). Comorbidity was more likely in older male patients (in particular CVD and diabetes) and White patients (except for diabetes which was more common in Asian groups). Discussion/Conclusion Many PLWHA in Brent suffer from a number of other conditions, which appear largely independent of HIV. Findings confirm the need to treat HIV as a long-term condition, including patient education, empowerment and encouraging self-management. The multi-morbidity of many PLWHA suggests a role for both primary care and collaborative, holistic, patient-centred and individualised healthcare. Service providers and commissioners need to consider comorbidities in their treatment of and provision of services for PLWHA. This study also highlighted the need for services to address limitations of their data collection systems.

Characterizing emergency admissions of patients with sickle cell crisis in NHS brent: observational study.

OBJECTIVES: To characterize emergency admissions for patients with sickle cell crisis in NHS Brent and to determine which patients and practices may benefit most from primary care intervention. DESIGN: Observational study SETTING: Emergency departments attended by residents of the London borough of Brent PARTICIPANTS: Patients with sickle cell disease registered with a general practitioner (GP) in the borough of Brent MAIN OUTCOME MEASURES: Analysis of admissions between January 2008 and July 2010 that included length of stay (average and <2 days versus ≥2 days) by age group and registered GP practice. RESULTS: Thirty six percent of sickle cell disease admission spells resulted in a length of stay of less than two days. Seventy four percent of total bed days are associated with patients with more than one admission during the period of analysis, i.e. multiple admissions. Two general practices in Brent were identified as having the highest number of patients admitted to the emergency department for sickle cell crisis and may benefit most from primary care intervention. DISCUSSION: Patients with short length of stay and multiple admissions may be potentially amenable to primary care intervention. The practices which have the highest numbers of sickle cell disease patients who frequently seek emergency care will be earmarked for an education intervention designed to help further engage general practitioners in the care and management of their sickle cell patients.

Trends in hospital admissions for sickle cell disease in England, 2001/02-2009/10.

BACKGROUND: Sickle cell disease (SCD) is a rising cause of mortality and morbidity in England and consequently an important policy issue for the National Health Service. There has been no previous study that has examined SCD admission rates in England. METHODS: Data from Hospital Episode Statistics were analysed for all hospital episodes (2001/10) in England with a primary diagnosis of sickle cell anaemia with crisis (D57.0) or without crisis (D57.1). Secondary and tertiary diagnoses were examined among those patients admitted with either of these codes as their primary diagnosis. RESULTS: The overall SCD admission rate per 100 000 has risen from 21.2 in 2001/02 to 33.5 in 2009/10, a rise of over 50%. London accounts for 74.9% of all SCD admissions in England. 57.9% of patients admitted are discharged within 24 h. The largest rise in admission rates was seen among males aged 40-49 years where admission rates per 100 000 increased from 7.6 to 26.8 over the study period. CONCLUSIONS: Our data show that SCD admissions are rising in England, particularly in London. Over half of patients admitted with SCD were discharged within 24 h, suggesting that some of these admissions could be prevented through better ambulatory care of patients.

The challenges of facilitating primary healthcare discussions on traditional, complementary and alternative medicine for childhood eczema: piloting a computerized template.

OBJECTIVE: Healthcare practitioners (HCPs) experience barriers to changing routine consultation practice. Communication and recording of traditional, complementary and alternative medicines (TCAM) is inadequate. This pilot study explored the challenges of implementing a computerized template in primary care to facilitate communication on TCAM for paediatric eczema. METHODS: A computerized template to record TCAM use, with links to evidence-based TCAM databases, was designed, based on qualitative research with patients and HCPs. Four London general practices implemented the template integrated with usual practice. Twelve focus groups during the 6 month study period explored HCPs' knowledge, communication and information sources regarding TCAM and perceived barriers to template implementation. RESULTS: HCPs were initially enthusiastic about discussing TCAM, for improving communication and understanding patient's choices, but the template was used in under a third of consultations. HCPs were surprised at low TCAM use (10%) and lack of correlation with eczema or ethnicity. Reported barriers were time and remembering, due to busy, target-driven practice. CONCLUSION: HCPs recognize the importance of discussing TCAM use for childhood eczema, and potential benefits for HCP-patient communication. PRACTICE IMPLICATIONS: Future tools to facilitate TCAM discussion should prioritise use of existing IT systems and address barriers to use, especially lack of time.

Patients' views on improving sickle cell disease management in primary care: focus group discussion.

OBJECTIVES: To assess sickle cell disease (SCD) patient and carer perspectives on the primary care services related to SCD that they receive from their general practitioner (GP). DESIGN: A focus group discussion was used to elicit the views of patients about the quality of care they receive from their primary health-care providers and what they thought was the role of primary care in SCD management. The focus group discussion was video recorded. The recording was then examined by the project team and recurring themes were identified. A comparison was made with notes made by two scribes also present at the discussion. SETTING: Sickle Cell Society in Brent, UK. PARTICIPANTS: Ten participants with SCD or caring for someone with SCD from Northwest London, UK. MAIN OUTCOME MEASURES: Patients' perceptions about the primary care services they received, and a list of key themes and suggestions. RESULTS: Patients and carers often bypassed GPs for acute problems but felt that GPs had an important role to play around repeat prescriptions and general health care. These service users believed SCD is often ignored and deemed unimportant by GPs. CONCLUSION: Participants wanted the health service to support primary health-care providers to improve their knowledge and understanding of SCD. Key themes and suggestions from this focus group have been used to help develop an educational intervention for general practice services that will be used to improve SCD management in primary care.

Making a jigsaw puzzle in 10 minutes: is case management feasible in general practice?

Background Case management has been advocated as a method of optimising the care of patients with complex problems and reducing inappropriate use of hospital services, but its impact to date has been limited. It is not known whether case management earlier in the development of complex problems will be more effective. Aim To develop a case management protocol usable in general practice. Design Co-designed by practitioners using a technology development approach. Setting General practices and community nursing teams in one primary care trust (PCT). Method Nominal group techniques applied to six multidisciplinary workshops held over nine months, in order to design and refine a case management protocol. Then field testing of the protocol with selected patients in four practices. Results A modular case management protocol has been designed that can be used in routine practice and completed over successive consultations. The protocol asks the practitioner and patient about their different perspectives on need, and about mental health, social care needs, nutritional status, vision and hearing, bone fragility, pain, continence and where appropriate end-of-life plans. An electronic version can be partially populated automatically, from the existing medical record. Field testing suggests that a paper version can also be used as a patient-held record for other professionals to use. Conclusion This study has created a model of case management for general practice that appears to be useable in general practice. A wider feasibility study is now needed to test uptake of the protocol by practices.

Identification of patients with neuropathic pain using electronic primary care records.

BACKGROUND: Chronic neuropathic pain is a common condition which is challenging to treat. Many people with neuropathic pain are managed in the community, so primary care records may allow more appropriate subjects to be recruited for clinical studies. OBJECTIVE: We investigated whether primary care records can be used to identify patients with diseases associated with neuropathic pain. METHOD: We analysed demographic, diagnostic and prescribing data from over 100 000 primary care electronic patient records in one part of London, UK. RESULTS: The prevalence of diagnoses associated with chronic neuropathic pain was 13 per 1000, with the elderly, women and white patients experiencing the greatest burden of disease. CONCLUSION: Computerised health records offer an excellent opportunity to improve the identification of patients for clinical research in complex conditions like chronic neuropathic pain. To make full use of data from these records, standardisation of clinical coding and consensus on diagnostic criteria are needed.

Recording of adverse events in English general practice: analysis of data from electronic patient records.

BACKGROUND: Although the majority of patient contact within the UK's National Health Service (NHS) occurs in primary care, relatively little is known about the safety of care in this setting compared to the safety of hospital care. Measurement methods to detect iatrogenic diseases in primary care require extensive development. Routinely collected data have been successfully applied to develop patient safety indicators in secondary care. Given the availability of electronic health data in primary care, we explored the potential to build adverse event screening tools using computerised medical record systems. OBJECTIVE: To identify the rate and types of adverse events that might be recorded in primary care through routinely collected data. The findings will inform the development of administrative data-based indicators to screen for patient harm arising from primary care contact. METHOD: Descriptive analyses were performed on data extracted from the clinical information management systems (CIMS) at NHS Brent. The data were explored according to age, sex and ethnicity of patients. Potential or actual adverse events were identified by mapping to three Read code chapters. RESULTS: Records from the calendar year 2007 were available for 69 682 registered patients from 25 practices, consisting of 680 866 consultations. A number of adverse events could be detected through terms contained in certain chapters of the Read code system. These events include injuries due to surgical and medical care (0.72 cases of per 1000 consultations) and adverse drug reactions (1.26 reactions per 1000 consultations). Patterns in the rate of harm among patients from different ethnic groups tended to reflect the proportion of the respective groups in the overall Brent population, with more injuries occurring among patients of white and Asian ethnicities. CONCLUSION: These findings suggest that there is scope to develop more accurate and reliable means of safety surveillance in general practice using data obtained from electronic patient records.