A national survey of services for the prevention and management of falls in the UK.

BACKGROUND: The National Health Service (NHS) was tasked in 2001 with developing service provision to prevent falls in older people. We carried out a national survey to provide a description of health and social care funded UK fallers services, and to benchmark progress against current practice guidelines. METHODS: Cascade approach to sampling, followed by telephone survey with senior member of the fall service. Characteristics of the service were assessed using an internationally agreed taxonomy. Reported service provision was compared against benchmarks set by the National Institute for Health and Clinical Excellence (NICE). RESULTS: We identified 303 clinics across the UK. 231 (76%) were willing to participate. The majority of services were based in acute or community hospitals, with only a few in primary care or emergency departments. Access to services was, in the majority of cases, by health professional referral. Most services undertook a multi-factorial assessment. The content and quality of these assessments varied substantially. Services varied extensively in the way that interventions were delivered, and particular concern is raised about interventions for vision, home hazard modification, medication review and bone health. CONCLUSION: The most common type of service provision was a multi-factorial assessment and intervention. There were a wide range of service models, but for a substantial number of services, delivery appears to fall below recommended NICE guidance.

Knowledge and information needs of informal caregivers in palliative care: a qualitative systematic review.

OBJECTIVES: To review current understanding of the knowledge and information needs of informal caregivers in palliative settings. DATA SOURCES: Seven electronic databases were searched for the period January 1994--November 2006: Medline, CINAHL, PsychINFO, Embase, Ovid, Zetoc and Pubmed using a meta-search engine (Metalib). Key journals and reference lists of selected papers were hand searched. REVIEW METHODS: Included studies were peer-reviewed journal articles presenting original research. Given a variety of approaches to palliative care research, a validated systematic review methodology for assessing disparate evidence was used in order to assign scores to different aspects of each study (introduction and aims, method and data, sampling, data analysis, ethics and bias, findings/results, transferability/generalizability, implications and usefulness). Analysis was assisted by abstraction of the key details of each study into a table. RESULTS: Thirty-four studies were included from eight different countries. The evidence was strongest in relation to pain management, where inadequacies in caregiver knowledge and the importance of education were emphasized. The significance of effective communication and information sharing between patient, caregiver and service provider was also emphasized. The evidence for other caregiver knowledge and information needs, for example in relation to welfare and social support, was weaker. There was limited literature on non-cancer conditions and the care-giving information needs of black and minority ethnic populations. Overall, the evidence base was predominantly descriptive and dominated by small-scale studies, limiting generalizability. CONCLUSIONS: As palliative care shifts into patients' homes, a more rigorously researched evidence base devoted to understanding caregivers knowledge and information needs is required. Research design needs to move beyond the current focus on dyads to incorporate the complex, three-way interactions between patients, service providers and caregivers in end-of-life care settings.

Graduate entry medicine: curriculum considerations.

Graduates entering medicine need to achieve the same learning outcomes as school leaver medical students in less time. Time is not the only consideration, and rather than just compress five-year courses into a four-year time-frame, curriculum planners have often taken the opportunity to introduce innovations for small cohorts as schools begin these new programmes. This article considers how the particular needs of graduate entrants can be met by UK medical curricula and reviews accumulating evidence around the design considerations, especially that of problem-based learning. Graduate entry courses have been at the forefront of curriculum planning for new professionalism in doctors.

Graduate entry medicine: high aspirations at birth.

Four-year fast-track courses for graduates started in the UK in 2000, and are now offered at 14 UK medical schools. Graduate entry medicine (GEM) started five years earlier in Australia, and of course in the USA it has been the norm for students to begin studying medicine after university graduation. This paper reviews the aspirations for GEM and looks at the early evidence on delivery against those aspirations. Particular reference is made to the experience at Warwick Medical School which was one of the two pioneers of GEM in the UK, has the largest GEM intake and continues to admit only graduates.

General practices as emergent research organizations: a qualitative study into organizational development.

BACKGROUND: An increasing proportion of research in primary care is locally undertaken in designated research practices. Capacity building to support high quality research at these grass roots is urgently needed and is a government priority. There is little previously published research on the process by which GP practices develop as research organizations or on their specific support needs at organizational level. METHODS: Using in-depth qualitative interviews with 28 key informants in 11 research practices across the UK, we explored their historical accounts of the development of research activity. We analysed the data with reference to contemporary theories of organizational development. RESULTS: Participants identified a number of key events and processes, which allowed us to produce a five-phase model of practice development in relation to research activity (creative energy, concrete planning, transformation/differentiation, consolidation and collaboration). Movement between these phases was not linear or continuous, but showed emergent and adaptive properties in which specific triggers and set-backs were often critical. CONCLUSION: This developmental model challenges previous categorical taxonomies of research practices. It forms a theory-driven framework for providing appropriate support at the grass roots of primary care research, based on the practice's phase of development and the nature of external triggers and potential setbacks. Our findings have important implications for the strategic development of practice-based research in the UK, and could serve as a model for the wider international community.

Evaluation of an interactive educational tool for primary care researchers.

This paper describes an evaluation of a computer-assisted learning (CAL) resource for primary care researchers. A two-phase approach was adopted involving a questionnaire survey and follow-up telephone interviews with a purposive sample of respondents. Results indicate wide support for this approach to self-directed learning, particularly for those with less experience. Respondents emphasized the flexibility and accessibility of the resource, with Internet links encouraging users to branch out. Potential barriers included securing protected learning time and lack of interaction with peers.

Systematic review of recent innovations in service provision to improve access to primary care.

BACKGROUND: In England, there are particularly pressing problems concerning access to adequate primary care services. Consequently, innovative ways of delivering primary care have been introduced to facilitate and broaden access. AIMS: The aim of this study was to review the evidence of seven recent innovations in service provision to improve access or equity in access to primary care, by performing a systematic review of the literature. DESIGN OF STUDY: Systematic review. SETTING: Primary care in the United Kingdom (UK). METHOD: Seven electronic databases were searched and key journals were hand-searched. Unpublished and 'grey' literature were sought via the Internet and through professional contacts. Intervention studies addressing one of seven recent innovations and conducted in the UK during the last 20 years were included. Two researchers independently assessed the quality of papers. RESULTS: Thirty studies (32 papers and two reports) were identified overall. Variation in study design and outcome measures made comparisons difficult. However, there was some evidence to suggest that access is improved by changing the ways in which primary care is delivered. First-wave personal medical services pilots facilitated improvements in access to primary care in previously under-served areas and/or populations. Walk-in centres and NHS Direct have provided additional access to primary care for white middle-class patients; there is some evidence suggesting that these innovations have increased access inequalities. There is some evidence that telephone consultations with GPs or nurses can safely substitute face-to-face consultations, although it is not clear that this reduces the number of face-to-face consultations over time. Nurse practitioners and community pharmacists can manage common conditions without the patient consulting a general practitioner. CONCLUSION: The evidence is insufficient to make clear recommendations regarding ways to improve access to primary care. In the future, it is important that, as new initiatives are planned, well-designed evaluations are commissioned simultaneously.

Developing research management and governance capacity in primary care organizations: transferable learning from a qualitative evaluation of UK pilot sites.

BACKGROUND: The capacity and capabilities for undertaking primary care research have increased both within and outside of the UK in recent years. The UK Department of Health aims to facilitate this further by establishing a national network of primary care organizations (PCOs) ready to act as hosts for shared research governance systems. However, it is unclear which models offer the most effective option. In addition, there is confusion over new processes and concern that researchers may be deterred from addressing important questions. OBJECTIVES: The research ascertains how PCOs selected as pilot sites have organized research management and governance (RM&G). METHODS: We adopted a case study approach involving interviews with key informants in a purposive sample of eight pilot PCO (RM&G) sites. RESULTS: Motivating factors for PCOs to host RM&G included the possibility of additional resources and more effective use of research to improve service delivery. A range of organizational models were adopted, often reflecting existing strategic alliances. It is envisaged that it will not be effective or cost-effective for many PCOs to make individual arrangements for RM&G, and so models are already developing among groups of PCOs and partner organizations. The extent of partnerships between PCOs varied with concern over critical mass and dilution of expertise in larger groupings. The development and implementation of systems in pilot sites was facilitated by the support of the wider PCO in recognizing research as a valued and integral part of the organization; the effective management of relationships and the establishment of equal partnership arrangements for RM&G, and the effective use of existing R&D infrastructure and expertise. CONCLUSIONS: RM&G partnerships vary according to local circumstances. It is likely that groupings will develop in the future with increasing co-terminosity and across wider health organization boundaries, such as Strategic Heath Authorities (in the UK) or primary care research networks. Critical mass of RM&G arrangements is likely to be linked to levels of research activity. There are real concerns over the levels of bureaucracy associated with the implementation of research governance; however, those PCOs that develop as RM&G sites have the opportunity to enrich their organizations and expand clinically relevant R&D. Partnership working within PCOs and with primary care research networks, academic departments or acute trusts, may be the key to success. Those undertaking research within primary care settings outside of the UK can learn important lessons from the UK experience and ensure development of high quality research that informs improvements in patient care.

Beliefs and behavior of deceivers in a randomized, controlled trial of anti-smoking advice at a primary care clinic in Kelantan, Malaysia.

Smoking deception is often ignored, but is important in health care. In this trial it was assessed at both study entry and outcome. At study entry, 1,044 males at a primary care clinic were asked smoking status and tested for breath carbon monoxide (CO). Of self-reported non-smokers, 57/402 (14%) were actually smokers, as were 59/251 (24%) of self-reported ex-smokers. The self-reported smokers (n=387) entered a randomized, controlled trial where the intervention comprised four questions on knowledge and beliefs about smoking, standardized verbal advice against smoking, and a leaflet. At follow-up, subjects were also questioned about beliefs. Follow-up was difficult, but 191/387 (49%) attended at three or six months. Of 27 who claimed to have quit, 6 (22%) were deceivers and 21 were confirmed quitters. Cessation did not differ between intervention and control groups. Overall confirmed cessation at six months was 16/387 (4.1 %). Confirmed quitters were significantly lighter smokers than deceivers and still smokers. There were non-significant trends between the outcome groups whereby deceivers had least knowledge and most lay beliefs, and quitters had most knowledge and fewest lay beliefs. The lay beliefs may prevent some smokers from quitting.

Lay beliefs about smoking in Kelantan, Malaysia.

Studies have shown that smokers rationalize smoking by self-exempting beliefs. This study explored lay beliefs about smoking in Kelantan, Malaysia, using focus groups among outpatients, medical students and staff, and a questionnaire survey of 193 male smokers. In focus groups, patients said they could do something to make smoking safe. When asked, 'Do you think there are any safe ways to smoke?' 132/193 (68%) male smokers described at least one way. The commonest were 'drink water' (69/193, 36%), 'use a filter' (60/193, 31%), 'smoke after food' (27/193, 14%), and 'take sour fruit' (21/193, 11%). At three- or six-month follow-up, numbers agreeing with these beliefs were: for 'drink water' 67/115 (58%), for 'take sour fruit' 61/115 (53%), and for 'smoke after food' 38/115 (33%), with 88/115 (77%) supporting at least one. The main explanations for water were that it cleaned or moistened the lungs or throat. Sour fruit was described as cleaning, and sometimes as 'sharp', able to scrape out the essence of cigarettes. The conclusion is that self-exempting false beliefs about smoking are widespread, and here they probably represent an extension of the traditional humoral system. Anti-smoking campaigns and health workers in smoking cessation services should address these beliefs.

General practice vocational training in the UK: what teaching is given in palliative care?

BACKGROUND: Palliative care is an integral part of the general practitioner's role and palliative care teaching and training should be available for GP registrars during vocational training. AIM: This study was carried out to evaluate the content, amount and nature of generic palliative care teaching during vocational training in the UK. METHOD: A postal questionnaire survey of all course organizers enquired as to whether palliative care teaching was included in the core training sessions; professional background of the teachers; teaching methods used; whether the local hospice was used as a resource and whether GP registrars were able to choose a post in a hospice within their training scheme. RESULTS: Three hundred and seventy-seven questionnaires were distributed and 240 were returned completed--a 64% response rate. A total of nine one-year schemes replied that they did not include any teaching in palliative care--the median amount of teaching given for one-year schemes was 4.75 hours and nine hours for the three-year schemes. Statistically significant differences were found in teaching on psychosocial issues and bereavement between one- and three-year schemes. Less than half of all schemes included teaching on financial issues related to palliative care. Several schemes cited difficulties in accessing hospice placements and in accessing hospice medical staff to provide teaching. CONCLUSION: There is wide disparity in both the amount and content of teaching about palliative care within UK vocational training schemes. Difficulty in accessing placements within hospices and in accessing staff from such units to undertake teaching may be a barrier to effective and comprehensive palliative care teaching for doctors working in primary care. We suggest that a national generic curriculum of palliative care within primary care be implemented.

Homelessness: a problem for primary care?

Homelessness is a social problem that affects all facets of contemporary society. This paper discusses the concept of homelessness in terms of its historical context and the dominance of the pervasive 'victim blaming' ideologies, which, together with the worldwide economic changes that have contributed to a fiscal crisis of the state, and the resultant policies and circumstances, have led to an increase in the number of 'new homeless' people. This paper attempts to challenge the dominant political discourse on homelessness. The widespread healthcare problems and heterogeneity of homeless people have a particular impact on health services, with many homeless people inappropriately accessing local accident and emergency (A&E) departments because of barriers inhibiting adequate access to primary care. A number of primary care schemes have been successfully implemented to enable the homeless to have better access to appropriate care. However, there is no consistency in the level of services around the United Kingdom (UK), and innovations in service are not widespread and by their nature they are ad hoc. Despite the successes of such schemes, many homeless people still access health care inappropriately. Until homeless people are fully integrated into primary care the situation will not change. The question remains, how can appropriate access be established? A start can be made by building on some of the positive work that is already being done in primary care, but in reality general practitioners (GPs) will be 'swimming against the tide' unless a more integrated policy approach is adopted to tackle homelessness.

An evaluation of personal medical services: the times they are a changin'.

The Personal Medical Services (PMS) pilot sites, launched in England in 1997 by the Secretary of State for the then Conservative government, introduced a local contract for primary care, aimed at promoting flexibility, innovation and policy participation. As part of the National Evaluation of PMS, this paper considers the professional and organisational relationships established between service providers working in those PMS sites which specifically set out to address inequalities in access to primary care for vulnerable populations. The introduction of PMS enabled a change of cultural values in primary care, particularly regarding GPs' relationships with nurses and practice staff. However, PMS has not necessarily led to equal partnerships within primary care teams. Rather,in the selected sites evaluated new interprofessional relationships emerged. There was evidence of intra and interprofessional partnerships being forged, providing the basis for further improved intersectoral collaboration. There was also evidence that the GP based medical model made way for a community oriented/public health model with emphasis on health maintenance for the vulnerable.

Breaking bones, breaking budgets: a clinical and economic evaluation of a prospective, randomized, practice controlled, intervention study in the prevention of accidents in primary care.

OBJECTIVE: This longitudinal study was designed to assess the effect of an educational training package for primary health care teams in accident prevention for older people, with reference to the incidence of accidents and their associated economic consequence. METHODS: Nineteen general practices in the West Midlands serving a population of 138 397 were allocated randomly at the practice level either to receive training or continue normal practice. Study data was collated from the initial telephone call, reporting an accident, to the surgery, advice/treatment given at the practice and/or the community, casualty, inpatient care, written correspondence to the patient's GP and any subsequent follow-up visits for accidents to people aged 65 years or older. RESULTS: One thousand, six hundred and sixty-six (8.2%) patients aged 65 years or older registered with the participating practices experienced one accident or more, costing the NHS pound 1.4 million. Extrapolated nationally, annual costs to the NHS for accidents to older people amount to pound 568 million. The educational package had no significant impact on the incidence of accidents. A paucity of general safety advice was given [48 (1.8%) occasions]. CONCLUSIONS: Budgets are being eroded and patients are suffering unnecessarily due to lack of accident prevention advice. This should be considered a priority within the primary health care team. Educational packages alone do not appear to be a cost-effective approach to accident prevention in primary care.

Brief encounters of aggression and violence in primary care: a team approach to coping strategies.

OBJECTIVES: Our aim was to investigate the extended primary care team's experience of aggression and violence from patients, in order to promote the formulation of multiprofessional team procedures for critical incident management and organizational development. METHODS: A qualitative study based on in-depth interviews and focus groups with primary health care teams and community staff was carried out in one inner London and one outer London health authority area. Key issues and themes were derived from transcripts of 30 individual interviews and five focus group discussions. RESULTS: Key issues identified during interviews informed focus group discussions. The focus groups identified existing and proposed responses to the problem of aggressive encounters. No practice had a protocol for dealing with incidents, and few kept records, but the incidence of violence and aggression was perceived to be increasing. Receptionists were most at risk, and relied on experience to cope with incidents. Due to being usually excluded from team meetings, they were not able to benefit from peer support and advice. Negative management tactics, such as patient appeasement or exclusion, were the norm. Recommendations include formal record keeping, communication skills training and team responsibility for incident management and for the development of practice protocols to ensure the consistency of response. Improvements to the working environment need to balance staff security with patient-friendliness, and constitute only one aspect of a measured response to the problem. CONCLUSIONS: The success of the focus group format in this context suggests that entire primary care teams could be led in workshops to review their experiences and formulate responses on an inclusive, multidisciplinary basis. These findings fit in with the concept of systems analysis in risk management protocols. We recommend that the team collectively formulate protocols for managing threatening encounters, with agreed mechanisms and thresholds for recording and reporting. Together with improved support systems within the extended teams and post-incident analysis of adverse events, this would allow a formal approach to identifying systematic weaknesses and solutions that benefit the staff involved.

Should health professionals screen women for domestic violence? Systematic review.

OBJECTIVE: To assess the evidence for the acceptability and effectiveness of screening women for domestic violence in healthcare settings. DESIGN: Systematic review of published quantitative studies. SESRCH STRATEGY: Three electronic databases (Medline, Embase, and CINAHL) were searched for articles published in the English language up to February 2001. INCLUDED STUDIES: Surveys that elicited the attitudes of women and health professionals on the screening of women in health settings; comparative studies conducted in healthcare settings that measured rates of identification of domestic violence in the presence and absence of screening; studies measuring outcomes of interventions for women identified in health settings who experience abuse from a male partner or ex-partner compared with abused women not receiving an intervention. RESULTS: 20 papers met the inclusion criteria. In four surveys, 43-85% of women respondents found screening in healthcare settings acceptable. Two surveys of health professionals' views found that two thirds of physicians and almost half of emergency department nurses were not in favour of screening. In nine studies of screening compared with no screening, most detected a greater proportion of abused women identified by healthcare professionals. Six studies of interventions used weak study designs and gave inconsistent results. Other than increased referral to outside agencies, little evidence exists for changes in important outcomes such as decreased exposure to violence. No studies measured quality of life, mental health outcomes, or potential harm to women from screening programmes. CONCLUSION: Although domestic violence is a common problem with major health consequences for women, implementation of screening programmes in healthcare settings cannot be justified. Evidence of the benefit of specific interventions and lack of harm from screening is needed.

Primary Care Research Team Assessment (PCRTA): development and evaluation.

BACKGROUND: Since the early 1990s the United Kingdom (UK) Department of Health has explicitly promoted a research and development (R&D) strategy for the National Health Service (NHS). General practitioners (GPs) and other members of the primary care team are in a unique position to undertake research activity that will complement and inform the research undertaken by basic scientists and hospital-based colleagues and lead directly to a better evidence base for decision making by primary care professionals. Opportunities to engage in R&D in primary care are growing and the scope for those wishing to become involved is finally widening. Infrastructure funding for research-active practices and the establishment of a range of support networks have helped to improve the research capacity and blur some of the boundaries between academic departments and clinical practice. This is leading to a supportive environment for primary care research. There is thus a need to develop and validate nationally accepted quality standards and accreditation of performance to ensure that funders, collaborators and primary care professionals can deliver high quality primary care research. Several strategies have been described in national policy documents in order to achieve an improvement in teaching and clinical care, as well as enhancing research capacity in primary care. The development of both research practices and primary care research networks has been recognised as having an important contribution to make in enabling health professionals to devote more protected time to undertake research methods training and to undertake research in a service setting. The recognition and development of primary care research has also brought with it an emphasis on quality and standards, including an approach to the new research governance framework. PRIMARY CARE RESEARCH TEAM ASSESSMENT: In 1998, the NHS Executive South and West, and later the London Research and Development Directorate, provided funding for a pilot project based at the Royal College of General Practitioners (RCGP) to develop a scheme to accredit UK general practices undertaking primary care R&D. The pilot began with initial consultation on the development of the process, as well as the standards and criteria for assessment. The resulting assessment schedule allowed for assessment at one of two levels: Collaborative Research Practice (Level I), with little direct experience of gaining project or infrastructure funding Established Research Practice (Level II), with more experience of research funding and activity and a sound infrastructure to allow for growth in capacity. The process for assessment of practices involved the assessment of written documentation, followed by a half-day assessment visit by a multidisciplinary team of three assessors. IMPLEMENTATION--THE PILOT PROJECT: Pilot practices were sampled in two regions. Firstly, in the NHS Executive South West Region, where over 150 practices expressed an interest in participating. From these a purposive sample of 21 practices was selected, providing a range of research and service activity. A further seven practices were identified and included within the project through the East London and Essex Network of Researchers (ELENoR). Many in this latter group received funding and administrative support and advice from ELENoR in order to prepare written submissions for assessment. Some sample loss was encountered within the pilot project, which was attributable largely to conflicting demands on participants' time. Indeed, the preparation of written submissions within the South West coincided with the introduction of primary care groups (PCGs) in April 1999, which several practices cited as having a major impact on their participation in the pilot project. A final sample of 15 practices (nine in the South West and six through ELENoR) underwent assessment through the pilot project. EVALUATION: A formal evaluation of the Primary Care Research Team Assessment (PCRTA) pilot was undertaken by an independent researcher (FM). This was supplemented with feedback from the assessment team members. The qualitative aspect of the evaluation, which included face-to-face and telephone interviews with assessors, lead researchers and other practice staff within the pilot research practices, as well as members of the project management group, demonstrated a positive view of the pilot scheme. Several key areas were identified in relation to particular strengths of research practices and areas for development including: Strengths Level II practices were found to have a strong primary care team ethos in research. Level II practices tended to have a greater degree of strategic thinking in relation to research. Development areas Level I practices were found to lack a clear and explicit research strategy. Practices at both levels had scope to develop their communication processes for dissemination of research and also for patient involvement. Practices at both levels needed mechanisms for supporting professional development in research methodology. The evaluation demonstrated that practices felt that they had gained from their participation and assessors felt that the scheme had worked well. Some specific issues were raised by different respondents within the qualitative evaluation relating to consistency of interpretation of standards and also the possible overlap of the assessment scheme with other RCGP quality initiatives. NATIONAL IMPLEMENTATION OF THE PRIMARY CARE RESEARCH TEAM ASSESSMENT: The pilot project has been very successful and recommendations have been made to progress to a UK scheme. Management and review of the scheme will remain largely the same, with a few changes focusing on the assessment process and support for practices entering the scheme. Specific changes include: development of the support and mentoring role of the primary care research networks increased peer and external support and mentoring for research practices undergoing assessment development of assessor training in line with other schemes within the RCGP Assessment Network work to ensure consistency across RCGP accreditation schemes in relation to key criteria, thereby facilitating comparable assessment processes refinement of the definition of the two groups, with Level I practices referred to as Collaborators and Level II practices as Investigator-Led. The project has continued to generate much enthusiasm and support and continues to reflect current policy. Indeed, recent developments include the proposed new funding arrangements for primary care R&D, which refer to the RCGP assessment scheme and recognise it as a key component in the future R&D agenda. The assessment scheme will help primary care trusts (PCTs) and individual practices to prepare and demonstrate their approach to research governance in a systematic way. It will also provide a more explicit avenue for primary care trusts to explore local service and development priorities identified within health improvement programmes and the research priorities set nationally for the NHS.