Discontinuity of care at end of life: a qualitative exploration of OOH end of life care.

OBJECTIVE: This study aimed to understand the experiences of palliative care patients when accessing or making decisions about out of hours (OOH) services. It also aimed to illuminate barriers and enablers to accessing appropriate and timely care following the introduction of the 2004 New General Medical Services Contract. METHOD: Longitudinal prospective qualitative study using semi-structured interviews and telephone interviews over 6 months and analysed for thematic content. 32 patients defined as receiving palliative care in six General Practices and three hospices selected on the basis of size and rural/urban location in Southern England were recruited. RESULTS: Continuity of care was highly valued. Participants described the importance of being known by the healthcare team, and the perceived positive implications continuity could have for the quality of care they received and the trust they had in their care. Various factors prevented participants from seeking help or advice from OOH services, despite having health concerns that may have benefitted from medical assistance. Prior poor experience, limited knowledge of services and knowing who to call and, indeed, when to call were all factors that reportedly shaped participants' use of OOH services. CONCLUSIONS: Interpersonal or relationship continuity and management continuity are vital to the process of optimising the patient experience of OOH palliative care. While recent service innovations are tackling some of the issues highlighted, this research reinforces the value patients with palliative care needs places on continuity and the need to improve this aspect of care management.

Improving services for back pain: putting the patient at the centre of interprofessional education.

INTRODUCTION: Studies exploring the role of patients in interprofessional education (IPE) are found primarily in undergraduate programmes with few reporting on the postgraduate (continuing professional development) setting. This paper describes an interprofessional quality improvement project around the management of back pain in a primary care setting where patients were part of the practice team. METHODS: Patients participated in eight half-day IPE workshops delivered to nine general practice teams in the UK. Educational content included knowledge about quality improvement and evidence-based back pain knowledge, with teamwork, experiential and didactic learning approaches. On-site practice support from a quality improvement facilitator occurred between the workshops to strengthen practice-based learning. Forty-four practice staff and 11 patients attended the workshops and the facilitated project meetings. Evaluation occurred through focus groups with practice teams (including patients) both before and after the workshops. These were recorded, transcribed and analysed by coding and the inductive development of themes. RESULTS: The context of managing back pain was particularly challenging. Focus group participants indicated that patient involvement was highly valued as it gave practitioners a greater understanding of the effects of back pain on their lives whilst permitting patients to hear the experiences of others and to understand their own world better. Listening was important to patients' experiences of healthcare and practitioners' experiences of the workshops. Learning together emerged as particularly important and finally the challenge of finding time to learn together infiltrated the entire endeavour and was a prominent concern. DISCUSSION: Patients sharing their experience of back pain appeared to be a particularly pivotal point in the learning for practice teams. Meaningful engagement with users in IPE was highly valued and provided a catalyst for behavioural change, where professionals relinquished an unhelpful medical model in favour of an integrative biopsychosocial one.

Can sharing stories change practice? A qualitative study of an interprofessional narrative-based palliative care course.

A series of six interprofessional palliative care meetings used narrative, with participants sharing stories from their professional experience in facilitated small groups. The course was attended by doctors, nurses, social workers and emergency care practitioners. The course was evaluated by telephone interview with 19 of the 28 participants. Respondents reported effects including changed behaviours and benefit to patients. The use of narrative, as a starting point for shared learning, discussion and evaluation is unusual. Five months after the end of the course, many participants described changed professional behaviour which they believed led to improved patient outcomes.

Learning in interprofessional teams: AMEE Guide no 38.

This guide is for health and social care professionals who teach or guide others' learning before and after qualification, in formal courses or the workplace. It clarifies the understanding of interprofessional learning and explores the concept of teams and team working. Illustrated by examples from practice, the practicalities of effective interprofessional learning are described, and the underlying concepts of patient-centred care, excellent communication, development of capacity and clarity of roles that underpin this explored.

Parents' difficulties with decisions about childhood immunisation.

Uptake of childhood immunisation fluctuates in the UK. Convenience, access and parents' relationships with professionals influence uptake. This study explores the decision-making by parents about their children's immunisation through focus groups with analysis to identify categories of concern. Issues raised in focus groups included fear, risk, anger, worry and guilt, confusion, difficulty of decision-making and trust of professionals. The parents of completely and incompletely immunised children shared areas of concern, but there were also significant differences. There was a subset of parents of incompletely immunised children who had decided that their children would not have full immunisation, and this group had little trust in information provided by healthcare professionals. Simply providing more information is unlikely to change their decision.

"You feel so hopeless": a qualitative study of GP management of acute back pain.

BACKGROUND: Biopsychosocial management of non-specific back pain in general practice has been problematical, with frequent inappropriate referral for imaging and secondary care interventions and lack of self-confidence in the ability to provide evidence-based care. AIMS: To examine GP attitudes to managing back pain as a biopsychosocial problem in order to inform future educational strategies that may improve practice. METHODS: Twenty-one GPs from separate practices within the Dorset and Somerset Strategic Health Authority area (UK) participated in telephone interviews leading to the development of vignettes to refine the theoretical framework for subsequent focus group interviews about evidence-based back pain management. Transcripts were analysed thematically. RESULTS: There were 5 main emergent themes. These were generally negative and dominated by concerns about doctor-patient interaction. They included feelings of frustration, mismatches of perceptions in the doctor-patient relationship, problems in relation to time, challenges and discord between stakeholders in the process (for example, over sickness certification) and a lack of resources for education, awareness and local services to refer to. Psychosocial aspects of the actual care process were rarely raised. Participants favoured education that is multidisciplinary, in small group format and involves the participation of patients. CONCLUSIONS: This study illustrates the difficulties that GPs may have in applying the relevant evidence for the successful management of back pain. A desire to avoid conflict in the relationship with patients explained much of the problem of implementing evidence in general practice. This indicates a need for insightful educational strategies that involve active GP participation.

The effect of patient self-completion agenda forms on prescribing and adherence in general practice: a randomized controlled trial.

BACKGROUND: What the patient wants from a general practice consultation and what the doctor believes they want are not always the same thing. This mismatch may lead to unwanted and unnecessary prescribing. AIM: To study the effect of a one-page form completed by patients before their consultation and given to the doctor at the start of the consultation, in terms of a reduction in prescribing, satisfaction with the consultation and adherence with prescribed medication. DESIGN: Randomized controlled trial. SETTING: Ten general practices in Devon and Dorset, UK. METHODS: Unselected patients attending general practice appointments were randomised to receive (or not) a self-completed agenda form (SCAF) asking five questions, including whether the patient considered they should receive a prescription. RESULTS: Approximately 4125 patients were offered entry; 3124 (76%) agreed to randomisation. In 1783 (57%) of these prescribing or satisfaction outcomes were identified. 457 of 811 (56.4%) of SCAF patients received a prescription, at a median (IQR) cost of pound 5.60 (inter-quartile range pound 2.12- pound 16.10), compared with 418 of 799 (52.3%) of controls, at a median cost of pound 5.94 ( pound 2.46- pound 18.90); both results non-significant (P=0.10 for prescribing and 0.30 for cost). Satisfaction was also similar in both groups: mean satisfaction score in SCAFs 5.37 and in controls 5.40 (P=0.64), as was adherence: at 12 weeks, adherence of 75% or greater was reported by 92 of 136 SCAF patients (68%) and 105 of 145 controls (72%) (P=0.31). CONCLUSION: The negative result could have two explanations. Either the intervention did not achieve the intention of communicating the patients' agendas, or if it did, patients may have been persuaded by doctors' explanations in the consultation.

One Dorset practice's experience of using a quality improvement approach to practice professional development planning.

There has been considerable discussion on and recommendation of the idea that Practice Professional Development Plans (PPDPs) should develop the whole practice as a healthcare resource, integrating and improving the educational process. In this study the PPDP concept was launched in a practice in Dorset, following the Bournemouth PPDP framework. The practice linked the educational activities of individuals, small working groups and the whole team to meeting the needs of the patients using a continuous quality improvement approach. The learning needs of the practice team were identified and learning actions were planned leading to a better response to patients' needs.

The Dorset Seedcorn Project: interprofessional learning and continuous quality improvement in primary care.

There is a need to develop models of practice-based learning that are effective in bringing about improvement in the quality of care that patients receive. This paper describes a facilitated practice-based project where five general practices in Dorset formed interprofessional teams that worked over a six-month period using a continuous quality improvement (CQI) approach to make a change in areas of importance to them. All the teams completed the project and planned and implemented demonstrable changes. Qualitative enquiry showed changes in relationships and teamworking that extended beyond the specific topic of the project with teams reporting an enhanced sense of competence and achievement. The project facilitators were able to develop a model of learning that acknowledges and utilises the depth of experience and understanding within interprofessional practice teams. Protected time and an environment and processes that encourage full partcipation of a wide range of team members is essential.