A study of role expansion: a new GP role in cardiology care.

BACKGROUND: The National Health Service is reconfiguring health care services in order to meet the increasing challenge of providing care for people with long-term conditions and to reduce the demand on specialised outpatient hospital services by enhancing primary care. A review of cardiology referrals to specialised care and the literature on referral management inspired the development of a new GP role in Cardiology. This new extended role was developed to enable GPs to diagnose and manage patients with mild to moderate heart failure or atrial fibrillation and to use a range of diagnostics effectively in primary care. This entailed GPs participating in a four-session short course with on-going clinical supervision. The new role was piloted in a small number of GP practices in one county in England for four months. This study explores the impact of piloting the Extended Cardiology role on the GP's role, patients' experience, service delivery and quality. METHODS: A mixed methods approach was employed including semi-structured interviews with GPs, a patient experience survey, a quality review of case notes, and analysis on activity and referral data. RESULTS: The participating GPs perceived the extended GP role as a professional development opportunity that had the potential to reduce healthcare utilisation and costs, through a reduction in referrals, whilst meeting the patient's wishes for the provision of care closer to home. Patient experience of the new GP service was positive. The standard of clinical practice was judged acceptable. There was a fall in referrals during the study period. CONCLUSION: This new role in cardiology was broadly welcomed as a model of care by the participating GPs and by patients, because of the potential to improve the quality of care for patients in primary care and reduce costs. As this was a pilot study further development and continuing evaluation of the model is recommended.

Forming a new clinical team for frail older people: can a group development model help?

Integrated services which utilise the expertise of team members along care pathways are evolving. Changes in service structure and subsequent team working arrangements can be a challenge for practitioners expected to redefine how they work with one another. These services are particularly important for the care of frail older people. This exploratory study of one newly forming team presents the views of staff involved in establishing an interprofessional healthcare advisory team for older people within an acute hospital admissions unit. Staff experiences of forming a new service are aligned to a model of team development. The findings are presented as themes relating to the stages of team development and identify the challenges of setting up an integrated service alongside existing services. In particular, team process issues relating to the clarity of goals, role clarification, leadership, team culture and identity. Managers must allow time to ensure new services evolve before setting up evaluation studies for efficiency and effectiveness which might prove against the potential for interprofessional teamworking.

The impact of patient participation direct enhanced service on patient reference groups in primary care: a qualitative study.

BACKGROUND: NHS policy documents continue to make a wide-ranging commitment to patient involvement. The Patient Participation Direct Enhanced Service (PP-DES), launched in 2011, aimed to ensure patients are involved in decisions about the range and quality of services provided and commissioned by their practice through patient reference groups (PRGs). The aim of this exploratory study is to review the impact of the PP-DES (2011-13) on a sample of PRGs and assess how far it has facilitated their involvement in decisions about the services of their general practices. METHODS: A qualitative methods design, using semi- structured interviews and focus groups, was employed to explore the experiences and views of GP practice staff (n = 24), PRG members (n = 80) at 12 GP practices, and other stakeholders (n = 4). RESULTS: Wide variation in the role and remit of the participating PRGs was found, which broadly ranged from activities to improve practice resources to supporting health promotion activities. The majority of PRG members were unfamiliar with the PP-DES scheme and its aims and purpose. Stakeholders and practice staff felt strongly that the main success of the PP-DES was that it had led to an increase in the number of PRGs being established in the locality. CONCLUSION: The PP-DES scheme has been a catalyst to establish PRGs. However, the picture was mixed in terms of the PRGs involvement in decisions about the services provided at their general practice as there was wide variation in the PRGs role and remit. The financial incentive alone, provided via the DES scheme, did not secure greater depth of PRG activity and power, however, as social factors were identified as playing an important role in PRGs' level of participation in decision making. Many PRGs have to become more firmly established before they are involved as partners in commissioning decisions at their practice.

Improving the management of obesity in adults: a pilot of a method to identify important barriers to change and tailor interventions to address them.

BACKGROUND: A tailored approach to implementation can facilitate the routine use of best evidence, and so improve the quality of care delivered. Tailored implementation involves investigating the context and barriers to change before selecting appropriate interventions. However, there is little evidence on the methods of tailoring. This study investigated the tailoring undertaken by two implementation groups as part of a study to improve adherence to NICE guidelines on adult obesity in primary care. METHODS: Data were collected from interviews with healthcare professionals and patients on barriers and enablers to implementing NICE guidelines on adult obesity along with practice performance data on body mass index (BMI) recording and use of interventions for obesity. Findings were presented to medical practitioners, university and NHS staff (n = 12) who formed two implementation groups to independently identify the most important barriers and enablers, and to suggest interventions to facilitate the implementation of the NICE guidelines. Each group had a facilitator and were observed by researchers whose notes were used to understand the group processes and assess the usefulness of this method. RESULTS: Within the time available both implementation groups reached consensus on the most important barriers and enablers and, led by those who had personal experience of managing patients with weight problems, made practical proposals for interventions to improve the implementation of the NICE guidelines. The role of the facilitator was crucial in ensuring barriers, enablers and interventions were all discussed and agreed upon in the time available. CONCLUSIONS: The facilitated implementation groups method succeeded in identifying appropriate and similar barriers, enablers and implementation interventions, which suggests some justification for this approach to tailoring. However, further research into methods of tailoring is required. Improvements to the implementation group approach may be realised by careful selection of group members and provision of sufficient preparation time prior to group discussions.