Asylum seekers' and refugees' experiences of accessing health care: a qualitative study.

BACKGROUND: Asylum seekers and refugees (ASRs) often experience poor health in host countries. The United Nations High Commissioner for Refugees (UNHCR) requires hosts to ensure these sanctuary seekers have access to basic health care. AIM: To identify barriers and facilitators that affect access to health care by ASRs in Wales. DESIGN & SETTING: Participatory research approach using qualitative focus groups across Wales, which hosts 10 000 refugees. METHOD: Eight focus groups were undertaken with ASRs, support workers, and volunteers (n = 57). RESULTS: Specialist NHS-funded services and grant-aided non-governmental organisations (NGOs) facilitated access to health care, including primary care. Most ASRs understood the role of general practice in providing and coordinating care, but were unaware of out-of-hours services. Reported barriers included: language difficulties, health literacy, unrecognised needs, and the cost of travel to appointments. Participants recognised the importance of mental health, but were disappointed by the state of mental health care. Some feared seeking support for mental health from their GP, and few were aware they had the right to move practice if they were unhappy. Written information about health care was not as accessible to refugees as to asylum seekers (ASs). While some participants read such material before consulting, others struggled to access information when in need. Few participants were aware of health prevention services. Even when they knew about services, such as smoking cessation, these services' difficulty in accommodating ASRs was a barrier. CONCLUSION: The main barriers identified were: availability of interpreters; knowledge about entitlements; and access to specialist services.

Can knowledge tests and situational judgement tests predict selection centre performance?

OBJECTIVES: Written tests are an integral part of selection into general practice specialty training in the UK. Evidence supporting their validity and reliability as shortlisting tools has prompted their introduction into the selection processes of other medical specialties. This study explores whether candidate performance on two written tests predicts performance on subsequent workplace-based simulation exercises. METHODS: A prospective analysis of candidate performance (n = 135) during the general practice selection process was undertaken. Candidates were shortlisted using their scores on two written tests, a clinical problem-solving test (CPST) and a situational judgement test (SJT). Successful candidates then undertook workplace-based simulation exercises at a selection centre (SC). Scores on the CPST and SJT were correlated with SC scores. Regression analysis was undertaken to explore the predictive validity of the CPST and SJT for SC performance. RESULTS: The data show that the CPST and SJT are predictive of performance in workplace-based simulations (r = 0.598 for the CPST, r = 0.717 for the SJT). The SJT is a better predictor of SC performance than the CPST (R(2) = 0.51 versus R(2) = 0.35). However, the two tests together provide the greatest degree of predictive ability, accounting for 57% of the variance seen in mean scores across SC exercises. CONCLUSIONS: The CPST and SJT play valuable roles in shortlisting and are predictive of performance in workplace-based SC exercises. This study provides evidence for their continued use in selection for general practice training and their expansion to other medical specialties.

The return to work discussion: a qualitative study of the line manager conversation about return to work and the development of an educational programme.

OBJECTIVE: To investigate the conversation between line manager and employee about return to work to inform the development of an online interactive educational programme for line managers to improve the effectiveness of their discussions. DESIGN: An inductive qualitative approach, using the principles of action research and motivational interviewing were adopted. The results informed the development of the educational programme for line managers. SUBJECTS: Middle grade line managers in a large public services employer in the UK. METHODS: Four discussion groups were conducted over a period of 8 months. Line managers explored the challenges of the return to work interview, analysed their interactions with employees and constructed the content of an educational programme. Multiple methods were used to build engagement with participants, including video and role-play. RESULTS: Nine line managers were recruited across 3 business areas. Managers recognised that their conversations focused on the organisations' policies and procedures and the outcome, rather than the interaction. They recognised the strength of shifting style to shared decision-making and guidance rather than process and instruction. These communication strategies were depicted in the educational programme. CONCLUSION: The content and flow of the return to work discussion is of high importance and influences employee behaviour and return to work outcomes.

Do general practice selection scores predict success at MRCGP? An exploratory study.

BACKGROUND: Selection into general practice training is undertaken using a competency based approach. The clear advantage of this approach over traditional methods has been demonstrated through evaluation of its validity and reliability. However, the relationship between selection and performance in the Royal College of General Practitioner examinations (MRCGP) has yet to be explored. The MRCGP comprises of an applied knowledge test (AKT), a clinical skills assessment (CSA) and workplace-based assessments (WPBA). AIM: To explore the predictive validity of general practice selection scores using the AKT and CSA elements of the MRCGP as a final outcome measure. METHODS: This study carried out a retrospective analysis of 101 trainees from the Wales Deanery who were successfully selected on to general practice training in 2007. Selection data consisted of an overall selection score as well as scores from each individual stage of selection. Correlation was used to explore associations between selection scores and examination scores. RESULTS: The score for overall performance at selection achieved statistically significant correlation with examination performance (r = 0.491 for the AKT and r = 0.526 for the CSA, P <0.01). CONCLUSIONS: The general practice selection process is predictive of future performance in the MRCGP.

Making an objective assessment of a colleague's performance.

BACKGROUND: Historically, assessment of good medical practice has focused on clinical skills and knowledge. However, performance assessments and appraisal today encompasses the review of both non-clinical, or behaviourial skills and the assessment of clinical practice. CONTEXT: There is an increasing trend towards the systematic, multifaceted assessment of doctors' performance. For doctors in training this has facilitated the earlier identification of performance concerns as they arise. Doctors in training have clear goals and accept regular assessments as a requirement of their progression through medicine. This is perhaps not quite the same for more senior colleagues where, for some, the introduction of performance assessments based upon appraisals and revalidation may have historically been uncharted territory. INNOVATION: Skilful peer assessment is not easy, and the boundaries between roles, responsibilities and relationships when managing senior colleagues can often feel blurred. Performance issues are often complex, multifactorial, and include both clinical and behavioural issues. To make an objective assessment of performance requires a comprehensive understanding of the problems raised. This includes the collection of appropriate detailed information alongside clarity of the local and national processes involved in assessing and managing performance issues. IMPLICATIONS: The provision of local, specific support for more senior colleagues is at present not well formulated. This in turn leads to concerns very often being ignored until they have become a disciplinary issue. With the introduction of revalidation there is a need to address training around the management of performance issues to improve the experience for both the appraiser and the appraisee.

Assessing organisational development in European primary care using a group-based method: a feasibility study of the Maturity Matrix.

PURPOSE: The Maturity Matrix is a tool designed in the U.K. to assess family practice organisational development and to stimulate quality improvement. It is practice-led, formative and undertaken by a practice team with the help of trained facilitators. The aim of this study is to assess the Maturity Matrix as a tool and an organisational development measure in European family practice settings. DESIGN/METHODOLOGY/APPROACH: Using a convenience sample of 153 practices and 11 facilitators based in the U.K., Germany, The Netherlands, Switzerland and Slovenia, feasibility was assessed against six criteria: completion; coverage; distribution; scaling; translation; and missing data. Information sources were responses to evaluation questionnaires by facilitators and completed Maturity Matrix profiles. FINDINGS: All practices taking part completed the Maturity Matrix sessions successfully. The Netherlands, the U.K. and Germany site staff suggested including additional dimensions: interface between primary and secondary care; access; and management of expendable materials. Maturity Matrix scores were normally distributed in each country. Scaling properties, translation and missing data suggested that the following dimensions are most robust across the participating countries: clinical performance audit; prescribing; meetings; and continuing professional development. Practice size did not make a significant difference to the Maturity Matrix profile scores. ORIGINALITY/VALUE: The study suggests that the Maturity Matrix is a feasible and valuable tool, helping practices to review organisational development as it relates to healthcare quality. Future research should focus on developing dimensions that are generic across European primary care settings.

Exploring the perceptions of out-of-hours training for GP registrars in Wales.

This paper explores the perceptions of GP registrars about the quality of the training that they receive within out-of-hours (OOH) settings. Focus groups with trainers, clinical supervisors and GP registrars revealed three areas of interest: supervision, educational experience and system factors. Implications for OOH training are discussed.

Developing a facilitation model to promote organisational development in primary care practices.

BACKGROUND: The relationship between effective organisation of general practices and health improvement is widely accepted. The Maturity Matrix is an instrument designed to assess organisational development in general practice settings and to stimulate quality improvement. It is undertaken by a practice team with the aid of a facilitator. There is a tradition in the primary care systems in many countries of using practice visitors to educate practice teams about how to improve. However the role of practice visitors as facilitators who enable teams to plan practice-led organisational development using quality improvement instruments is less well understood. The objectives of the study were to develop and explore a facilitation model to support practice teams in stimulating organisational development using a quality improvement instrument called the Maturity Matrix. A qualitative study based on transcript analysis was adopted. METHOD: A model of facilitation was constructed based on a review of relevant literature. Audio tapes of Maturity Matrix assessment sessions with general practices were transcribed and facilitator skills were compared to the model. The sample consisted of two facilitators working with twelve general practices based in UK primary care. RESULTS: The facilitation model suggested that four areas describing eighteen skills were important. The four areas are structuring the session, obtaining consensus, handling group dynamics and enabling team learning. Facilitators effectively employed skills associated with the first three areas, but less able to consistently stimulate team learning. CONCLUSION: This study suggests that facilitators need careful preparation for their role and practices need protected time in order to make best use of practice-led quality improvement instruments. The role of practice visitor as a facilitator is becoming important as the need to engender ownership of the quality improvement process by practices increases.

Organizational assessment in general practice: a systematic review and implications for quality improvement.

BACKGROUND: Quality improvement of organizational aspects in general practice is receiving increasing attention. In particular, the impact of effective organization on preventative care has been recognized. Organizational assessments are typically used as part of professionally led accreditation schemes where there is a tension between externally led quality assurance and internally led quality improvement. The aim of this article is to inform the debate by reviewing the international-peer-reviewed literature on organizational assessments used in general practice settings. DESIGN: Systematic literature review. METHODS: The literature was searched for articles relating to organizational assessment. Titles and abstracts were examined by two independent reviewers and relevant articles obtained. Bibliographies were examined for follow-up references. Data were extracted on the development and use of assessment methods. RESULTS: Thirteen papers describing five organizational assessment instruments were included for detailed appraisal. CONCLUSION: This review discovered a developing field containing different approaches to the measurement of organizational aspects of general practice. Whilst professionally led accreditation is well-developed and dependent on externally led quality assurance, approaches to internally led quality improvement are less well-developed. There is a need for organizational assessment tools designed for the purpose of stimulating internal development.

Developing a measure of patient access to primary care: the access response index (AROS).

Access to appointments in primary care is not routinely measured, and there is no one standardized method for doing so. Any measurement tool has to take account of the dynamic status of appointment availability and the definitional problems of appointment types. The aim of this study was to develop and trial a method for measuring access that is valid, reliable, quick and provides a daily longitudinal record of access on an organizational basis (not for individual clinicians). Using the results of a literature review and following discussions with clinicians and managers a tool was designed following agreed specifications. After initial adjustments of the tool a feasibility study tested the acceptability of a data collection exercise on 11 practices of varying types, over a 4- to 8-week period. The development phase led to the design of a tool named the access response index (AROS). The method was well received in the practices, with a low incidence of missed days and only one practice failing to return data. The index measures the number of days' wait to the next available appointment with any general practitioner. The inclusion in the score of urgent appointments was abandoned due to definitional problems. A 5-day moving average was chosen to represent the data in graph form to demonstrate overall trends. AROS is a useful tool usable in any practice, and our feasibility study points to it being widely acceptable in the field. Data are represented in clear graphical daily format, either just for one practice or as an anonymous composite graph with other practices in the locality.