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. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697529

Poster presentations

PMCID: PMC6475889
Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697025

Local implementation of AMS initiatives: a mixed-methods study

Rosalie Allison 1, Donna Lecky 2, Elizabeth Beech 3, Ceire Costelloe 4, Diane Ashiru-Oredope 5, Rebecca Owens 6, Cliodna McNulty 7

Abstract

Background

The NHS English Quality Premium recommends that inappropriate antibiotic prescribing is reduced; there are a range of national antimicrobial stewardship (AMS) initiatives to support this.

Aim

The aim of this study is to assess AMS activities in primary care across England. The findings will be used to inform how the RCGP, PHE and NHS can help optimise stewardship activities.

Method

Qualitative interviews: with AMS leads within Clinical Commissioning Groups’ (CCGs) and Commissioning Support Units’ (CSUs) medicines management teams. Questionnaire: informed by the qualitative data, sent to all 209 CCGs in England in 2017.

Results

In total, 89% (187/209) of CCGs returned a questionnaire; 82% of AMS leads reported spending only 0.1 whole-time equivalent on AMS activities, as it was only one role within a wider remit, so dedicating time is challenging. 99% (167/169) of CCGs had delivered AMS education in the last 2 years: 140 face-to-face; 121 via e-learning. 99% (184/186) actively promoted the TARGET Antibiotics Toolkit; 94% (175/187) actively promoted TARGET patient leaflets: 92% The Treating Your Infection (TYI) leaflet. 90% (166/185) used the PHE managing common infections guidance: 81% (149/185) modify or localise; 41/185 (22%) signpost directly to it. Eighty-six CCGs reported using CCG audit tools and 82 CCGs reported using TARGET’s audit tools. 85% (142/168) fed back antimicrobial prescribing data to the CCG/CSU board; 100% (169/169) to general practices and 33% (56/169) to out-of-hours providers.

Conclusion

Although CCGs reported promoting these AMS activities, there was little evaluation of uptake by primary care practitioners. Future work should focus on measuring AMS uptake; having staff dedicated solely to AMS could facilitate this.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697037

Developing the capacity of general practice staff to support healthier weight status in children

Raheelah Ahmad 1, Vida Cunningham 2, Bimpe Oki 3, Fiona Sim 4

Abstract

Background

Lambeth has implemented a healthy weight care pathway including capacity building of multi-agency staff. Successes include being the only borough in the country to see statistical reductions in childhood obesity over 5 years; but the challenge of 39.2% of 10–11-year olds leaving primary school as overweight/obese persists. When families approach GPs to validate the National Child Measurement Programme feedback, challenges include interpretation and explanation of body mass index (BMI). GPs have also felt uncomfortable raising the issue in routine consultations.

Aim

To understand potential enablers to raising the issue of unhealthy weight in children in general practice.

Method

70 staff (GPs 58%; Nurses 25%; GP registrar/trainee 7%; and HCA/other 10%) completed a bespoke childhood obesity capacity building workshop (accredited by the Royal College of GPs). Using scenario-based activities and end of session written questionnaire we gathered: knowledge and perceptions of weight measures, role of diet, nutrition and physical activity, as well as current blocks and potential enablers for brief intervention.

Results

Less than 5% of participants were able to identify a very overweight child by visual inspection. Confidence in raising the issue was reported due to enhanced knowledge of energy intake, physical activity and provision of a BMI wheel (40%), new ways of raising the issue (30%), understanding of supportive services in Lambeth (30%).

Conclusion

Supportive measures identified within a whole systems approach including role of schools, government, public health and the CCG are informing future planning.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697049

Presenting primary care teams to the public: a qualitative exploration of general practice websites

Helen Anderson 1, Joy Adamson 2, Yvonne Birks 3

Abstract

Background

Increasing demand and expanded primary care provision, coupled with a reduced GP workforce present challenges for primary care. New workforce models aim to reduce general practitioner workload by directing patients to a variety of alternative clinicians. Concurrently, the principle of patient choice in relation to healthcare providers has gained prominence. It is, therefore, necessary to provide patients with sufficient information to negotiate access to appropriate primary healthcare professionals.

Aim

To explore how practice websites present three exemplar healthcare professional groups (GPs, advanced nurse practitioners [ANPs], and practice nurses [PNs]) to patients and the implications for informing appropriate consultation choices.

Method

Qualitative thematic analysis of a sample of general practice websites. 79 accessible websites from a district in England were thematically analysed in relation to professional representation and signposting of the three identified professional groups.

Results

Information about each group was incomplete, inconsistent and sometimes inaccurate across the majority of general practice websites. There was a lack of coherence and strategy in representation and direction of website users towards appropriate primary healthcare practitioners.

Conclusion

Limited and unclear representation of professional groups on general practice websites may have implications for the direction of patients to the wider clinical healthcare team. Patients may not have appropriate information to make choices about consulting with different healthcare practitioners. This constitutes a missed opportunity to signpost patients to appropriate clinicians and enhance understanding of different professional roles. Potential for websites to disseminate information to the public is not being maximised.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697061

‘I’m not sure if there is any point to all this doc?’: a qualitative study into GPs responses to existential questions

Alistair Appleby 1, John Swinton 2, Philip Wilson 3

Abstract

Background

Very few studies address how GPs react to situations where patients express doubt or perplexity about the meaning of their existence.

Aim

To assess the range of responses which GPs make to a theoretical scenario, where a patient says ‘Doc, I’m not sure there is any point to all this?’. To discuss the significance of these responses within a clinical and philosophical context.

Method

We interviewed 19 GPs in Scotland and analysed transcripts using an approach informed by grounded theory.

Results

The context of these questions, patients’ other complaints, and the comfort of the GP in this area of discussion, affected the GP response. Responses included discomfort and diverting the conversation, exploring the contribution of physical pain, or, most commonly, considering the questioning to indicate mental health problems. Some GPs felt the questioning was fuelled by unmet emotional needs or by social and relational crises. GP responses included prescribing medication or pragmatic ‘just get on with it’ suggestions to the perceived unknowability of rational answers. Other GPs considered this represented a philosophical question worthy of legitimate debate and response, or with therapeutic potential.

Conclusion

This raises questions about whether existential questioning, is best regarded as pathological, normative or potentially therapeutic. Our study indicates that GPs own philosophy and approach may define the scope of the discussion and therapeutic options. Consultations which permit legitimate existential discussion, while considering a wide range of health associations, generate the greatest range of therapeutic approaches, but further work on outcomes is justified.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697073

Influenza vaccination uptake in an Irish obstetric cohort

Tina Barrett 1, R Drew 2, F O’Reilly 3, AO’Carroll 4, A O’Shea 5, E McEntee 6, B Cleary 7

Abstract

Background

Influenza infection during pregnancy can lead to significant maternal morbidity. There are limited data on influenza vaccination uptake and determinants of uptake in Irish obstetric populations.

Aim

The objectives of this study were to determine: the uptake of influenza vaccination during pregnancy; the determinants of vaccination uptake; knowledge, attitudes and concerns of postnatal women surrounding vaccination during pregnancy; and the recommendations of healthcare workers. Pertussis vaccination uptake was also determined.

Method

A standardised 24 item questionnaire was distributed to postnatal women between January and June 2016. Questions focused on maternal characteristics, vaccination status, sources of information, and reasons for receiving / declining the vaccine. The role of the healthcare professional in recommending and offering vaccination was addressed.

Results

330 surveys were disseminated, there was a 60% response rate. Of the 198 surveys, 109 (55.1%) respondents were vaccinated against Influenza and 64 (32.3%) against Pertussis. Women in the professional/manager/employer socioeconomic group were more likely to be vaccinated (aOR 3.4; 95% CI 1.11–10.42). There was a strong association between vaccination uptake and receiving information during pregnancy (aOR 12.8; 95% CI 2.65–62.5) and receiving the vaccine in a previous pregnancy (aOR 5.15; 95% CI 1.70–15.62). Unvaccinated women had concerns about the harm it may cause to their baby (53%; n=30) and concerns about side effects for themselves (55%; n=33).

Conclusion

A key determinant of vaccination was provision of information and a recommendation to vaccinate by a healthcare professional. Uncertainty over safety of the vaccine was evident. Consistent patient education by healthcare professionals could increase vaccine uptake.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697085

WikiRecs primary care: developing rapid recommendations for primary care through effective collaboration between systematic review and guideline teams

Trudy Bekkering 1, Bert Aertgeerts 2, Ton Kuijpers 3, Mieke Vermandere 4, Jako Burgers 5, Ilkka Kunnamo 6, Per Vandvik 7

Abstract

Background

The WikiRecs evidence summaries and recommendations for clinical practice are developed using trustworthy methods. The process is triggered by studies that may potentially change practice, aiming at implementing new evidence into practice fast.

Aim

To share our first experiences developing WikiRecs for primary care and to reflect on the possibilities and pitfalls of this method.

Method

In March 2017, we started developing WikiRecs for primary health care to speed up the process of making potentially practice-changing evidence in clinical practice. Based on a well-structured question a systematic review team summarises the evidence using the GRADE approach. Subsequently, an international panel of primary care physicians, methodological experts and patients formulates recommendations for clinical practice. The patient representatives are involved as full guideline panel members. The final recommendations and supporting evidence are disseminated using various platforms, including MAGICapp and scientific journals.

Results

We are developing WikiRecs on two topics: alpha-blockers for urinary stones and supervised exercise therapy for intermittent claudication. We did not face major problems but will reflect on issues we had to solve so far. We anticipate having the first WikiRecs for primary care available at the end of 2017.

Conclusion

The WikiRecs process is a promising method — that is still evolving — to rapidly synthesise and bring new evidence into primary care practice, while adhering to high quality standards.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697097

Impact of practice based clinical pharmacist led medication reviews on ambulatory patients with hyper polypharmacy

Lawrence D Brad 1, Steve Williams 2

Abstract

Background

Problematic polypharmacy is at the heart of medicines usage in patients with multimorbidity, and review by medicines experts in primary care is essential.

Aim

To assess the impact of medication reviews by a clinical pharmacist on ambulatory patients with hyper polypharmacy

Method

The study took place within a large urban practice in Dorset. Patients over ≥75 years old with ≥10 regular medicines were identified using the NHS Business Service Authority Polypharmacy database. Patients who were housebound, lived in a care home or with dementia were excluded and GP partners were asked to confirm the validity of these exclusions. Patients were sent a letter from their personalised GP inviting them to attend a 30-minute consultation with a clinical pharmacist prescriber employed by the practice. The age and frailty status of patients, number of medicines pre- and post-consultation, and the nature of medicines optimisation decisions were recorded. Patient satisfaction with the consultations was assessed using a 7-point Likert scale questionnaire.

Results

91 out of 17000 (0.5%) patients were receiving ≥ 10 medicines. 25 patients were excluded and to date 20/26 (77 %) patients invited had a consultation booked or been seen. Medicines optimisation changes varied in number and complexity and controversial changes discussed with patients’ individual GP. To date all patients rated the consultation as very good to outstanding (median score 6.5)

Conclusion

Ambulatory patients with hyper polypharmacy highly rated medication reviews with a clinical pharmacist and medication regimens in most were optimised through shared decision making.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697109

Reproducibility of a simple cardiac output response to stress test to diagnose and monitor heart failure in a primary care setting

Djordje Jakovljevic 1, Sarah J Charman 2, Nduka C Okwose 3, Renae J Stefanetti 4, Kristian Bailey 5, Jane Skinner 6, Mike Scott 7, Jonathan Mant 8, FD Richard Hobbs 9, Guy A MacGowan 10

Abstract

Background

We developed a simple non-invasive Cardiac Output Response to Stress (CORS) Test to improve diagnosis and monitoring of heart failure in primary care.

Aim

The aim of the present study was to assess test-retest reproducibility of the CORS test.

Method

Thirty-two healthy volunteers (age, 64±10, female n=18) were recruited. Cardiac output was measured continuously using bioreactance method in supine and standing position, and during a two 3-min stages of a step-exercise protocol (10 and 15 steps per minute) using a 15-cm height bench. The CORS test was performed twice i.e. Test 1 and Test 2.

Results

Cardiac output and stroke volume were not significantly different between the two tests at supine (6.2±1.4 versus 6.3±1.7 L/min, P = 0.84; 102±24 versus 108±32 ml/beat, P = 0.36), standing (5.7±2.1 versus 5.7±1.9 L/min, P = 0.99; 82±32 versus 83±29 ml/beat, P = 0.93), stage one step-exercise (8.5± 1.8 versus 8.2±1.9 L/min, P = 0.56; 104±26 versus 104±27 ml/beat, P = 0.99) and stage two step-exercise (9.9±1.7 versus 9.6±2.0 L/min, P = 0.51; 109±29 versus 111±26 ml/beat, P = 0.76). There was a significant positive relationship between Test 1 and Test 2 cardiac outputs (r=0.92, P<0.01 with coefficient of variation of 7.1%). The mean difference in cardiac output (with upper and lower limits of agreement) between Test 1 and Test 2 was 0.1 (−1.9 to 2.1) L/min, combining rest and exercise data.

Conclusion

The CORS test demonstrates acceptable reproducibility and can potentially be used in primary care to identify and monitor heart failure.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697121

Making sense of sadness: eliciting illness meaning and experience of depression in rural Irish males

Michael Creed 1, Harry Gijbels 2

Abstract

Background

To analyse and understand the illness experience of depression in rural Irish males. Secondary objectives are to identify their explanatory models of depression, inform mental health service provision in rural areas, and identify suitable interventions for future research.

Aim

Isolation and rural masculinities are thought to predispose rural Irish males to depression. Despite high levels of depressive symptoms among men in rural areas, lack of awareness and a different language around depression, coupled with stoicism, social isolation, and feminized mental health services, results in reduced help-seeking, under-reporting and under-treatment of depression in this population.

Method

A purposive sample, selected through the West Cork and Galway/Roscommon Mental Health Services, and General Practitioners, of fourteen men, aged between 25 and 64 years of age, were interviewed in their homes. Data was collected through face-to-face interviews, using the McGill Illness Narrative Interview schedule. These interviews were recorded, transcribed to text, and analysed using a thematic content analysis. Results were integrated using the model of qualitative description.

Results

Most of the fourteen men reported alcohol and social isolation as precipitating factors of their depression. Suicidal intent and a stubborn attitude were common. Recovery-promoting behaviours included good social and family support, peer-support groups, religious practice and, universally, physical work.

Conclusion

Rural Irish men view their depression as a disconnection from community, masculinity can be engaged in a positive way to improve mental health, and a sense of belonging is key to recovery. Future research should focus on the development of interventions incorporating these findings, such as community farming initiatives.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697133

Testing the health literacy of twenty Bangladeshi patients before and 5 months after they begin to access their GP electronic record

Richard Fitton 1, Amir Hannan 2, Ingrid Brindle 3, Shafia Begum 4, Sarwar Shah 5

Abstract

Background

Patients with higher health literacy enjoy better health outcomes and are more compliant with treatment. Health literacy is a product of memory, reason and imagination. Patients who can access their records have potentially more memory (knowledge) and make less phone calls to and have less consultations with their GP, practice nurse, HCA and other professionals.

Aim

The study aims to measure the knowledge that twenty Bangladeshi patients with poor English have of their medical history before and after access to their electronic record.

Method

55% of patients at Thornley House have access to their medical records. A simple questionnaire was given to 20 Bangladeshi patients before and 5 months after access to their electronic record. The questionnaires recorded the patients’ knowledge of their medical histories. The scores of the completed before and after questionnaires were compared to see if record access had increased patients’ knowledge.

Results

Five patients completed before and after questionnaires. Each achieved a higher score after record access. The differences in scores for the five patients were 2, 5, 1, 10, and 1, respectively.

Conclusion

Health literacy for patients is similar to medical literacy for doctors. It requires knowledge, skills and attitudes. We will see whether record access can increase knowledge. Further studies might measure whether that increased knowledge improves skills and attitudes.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697145

‘I’m fine’: exploring patient and carer assertions of status in advanced chronic obstructive pulmonary disease (COPD) and implications for primary care

Carole Gardener 1, Caroline Moore 2, Morag Farquhar 3, Gail Ewing 4, Robbie Duschinsky 5

Abstract

Background

Patients can be reluctant to say that they need support, telling clinicians they are ‘fine’ despite having unmet needs. Research in mental health settings suggests patients who do this they are less likely to follow treatment plans, and their carers are at a risk of depression. To-date these findings have not been explored in patients with advancing physical health conditions, or their carers.

Aim

To explore the presence, role and impact of assertions of ‘I’m Fine’ in patients with advanced chronic obstructive pulmonary disease (COPD) and their carers.

Method

Criteria based on Attachment Theory were used to identify ‘I’m Fine’ cases from the Living with Breathlessness Study (LwB) dataset of 235 patients and 115 carers. Quantitative analysis explored variables such as health service use between ‘I’m Fine’ and non ‘I’m Fine’ cases, whilst narrative analysis is being used to explore discourses within cases.

Results

21 patients and six carers asserted they were ‘fine’ despite unmet needs. Patients’ minimised disease impact and symptoms, avoided thinking about the future and used stoical language. Despite ‘I’m Fine’ cases being more likely to report no exacerbations and more likely to score less on the COPD Assessment Test (CAT), all wanted to see more of their GP. Carers focused on the needs of the patient whilst downplaying their own problems.

Conclusion

The existence of a sub-group of patients with advanced COPD who assert that they are ‘fine’ may have implications for primary care. This will be explored in planned focus groups with clinicians.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697157

Validation of the Primary Care Patient Measure of Safety (PC PMOS) questionnaire

Sally J Giles 1, Sahdia Parveen 2, Andrea Hernan 3

Abstract

Background

The Primary Care Patient Measure of Safety (PC PMOS) questionnaire was developed to collect patient feedback on 15 latent conditions in the primary care environment that influence safety incidents. It provides a way for primary care organisations to learn about safety from the patient perspective, and to then make service improvements with the aim of reducing harm in this setting.

Aim

To undertake validation testing PC PMOS questionnaire.

Method

490 adult patients from nine general practices completed the PC PMOS, and 81 practice staff completed the AHRQ medical office survey on patient safety culture. Confirmatory factor analysis (CFA) was undertaken to assess the reliability and validity of the 10 factor PC PMOS.

Results

CFA demonstrated data did not fit the model well (CMIN/DF = 5.68; GFI = 0.61, CFI = 0.57, SRMR = 0.13 and RMSEA = 0.10), thus post hoc model fitting was conducted. This resulted in the removal of 22 items on the basis of large MIs (above 10), and SRs > ±2.58, and assessment of item content. The resulting 9 factor model consisting of 28 items was found to fit the data satisfactorily (CMIN/DF = 2.51; GFI = 0.87, CFI = 0.91, SRMR = 0.04 and RMSEA = 0.05). The new factors demonstrated good internal reliability. The PC PMOS did not demonstrate good convergent validity with the correlation between total PC PMOS score and practice staff patient safety score failing to reach statistical significance (r = −0.64, k = 9, P = 0.06). It demonstrated good discriminant validity between primary care practices (F = 2.64, df = 72, P<0.001).

Conclusion

Validation of the PC PMOS has led to a reliable and valid 28 item patient measure of patient safety in primary care. It could enhance or complement current data collection methods used in primary care to identify and prevent error, and is also a practical response to the growing need to find appropriate and effective ways of involving patients in improving patient safety.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697169

Doctors with dyslexia: researching experiences and support strategies

Rachel Locke 1, Sharon Kibble, Gail Alexander, Samantha Scallan, Richard Mann

Abstract

Background

An increase in the number of medical students disclosing dyslexia as a specific learning difficulty on entering medical school is leading to an increasing number of doctors disclosing dyslexia in the workplace. The degree to which dyslexia has an impact on workplace performance depends on the individual doctor’s level of self-awareness and skill in developing supportive strategies or ‘workarounds’. There is little research on experiences and such strategies in the context of medical education and engaging in research poses challenges.

Aim

Research was conducted to identify effective workarounds and how they help to minimise the effects of dyslexia for doctors.

Method

Data was collected in stages: a systematic review, FOI requests and primary data collection. Fourteen doctors took part in the primary data collection through interviews and surveys. Five key informants with knowledge about the support available participated in semi-structured interviews.

Results

Although most participants had experienced difficulties they had found individualised ways of coping to overcome the challenge presented by dyslexia. The main ones were to assist with revision and exams, writing and spelling, reading, memory, time management and organisation.

Conclusion

The ability to develop such personal strategies can be seen as a positive attribute of dyslexia: ‘The dyslexic learns to adapt and cope and create systems for themselves to get by’ (interviewee).

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697181

A systematic review to explore the impact of anxiety on quality of life and treatment outcomes in rheumatoid arthritis

Annabelle Machin 1, Randula Haththotuwa 2, Opeyemi Babatunde 3, Ian Scott 4, Nadia Corp 5, Carolyn Chew-Graham 6, Samantha Hider 7

Abstract

Background

Rheumatoid arthritis (RA) is the commonest inflammatory arthritis. Comorbid anxiety and depression are common, but under-recognised and under-treated. Depression in RA has been linked to reduced quality of life and treatment response and increased mortality. Past research into co-morbid mood problems in RA has mainly focused on the prevalence and impact of depression.

Aim

To complete a systematic review to explore the impact of anxiety on QOL and treatment outcomes in RA.

Method

The systematic review has been registered on PROSPERO. Databases (Web of Science, PsycINFO, CINAHL, Embase and Medline) have been systematically searched for relevant studies. Titles and abstracts have been independently screened by two reviewers. Data extraction and quality appraisal of studies will be carried out using a customized and piloted data extraction tool and the Newcastle-Ottawa Scale. Disagreements will be resolved through discussion or by a third reviewer. A narrative synthesis framework will be used to develop a theory of how anxiety impacts on QOL and treatment response and a meta-analysis performed.

Results

The search has identified 6404 articles. After title screening, 284 abstracts have been reviewed and 48 full texts are being reviewed for inclusion. Full text review is ongoing, and results of the analysis will be presented.

Conclusion

Highlighting the impact of anxiety on outcomes in RA may suggest areas for future implementation studies to improve patient outcomes, potentially reducing associated morbidity and mortality.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697193

The mediating role of medical professionalism on financial self-interest GPs

David McCaffrey 1, Chris O’Riordan 2, Felicity Kelliher 3

Abstract

Background

While no normative definition exists, medical professionalism emphasises a set of values, behaviours and relationships that underpin public trust in a physician. The empirical setting for this study is the Irish health care system where GPs receive income through a unique mix of private fee income and state funded capitation. GPs’ income per patient has fallen by 33% under state schemes between 2008 and 2013 due to changes in health policy and national fiscal constraints.

Aim

This paper examines how general practitioners conceptualise and operationalise medical professionalism and financial self-interest in the Irish healthcare system.

Method

To address this research aim, a historical documentary analysis (2009–2016) of national and medical newspapers was used to investigate GPs’ expressions of medical professionalism and financial self-interest.

Results

The vagueness of language in differing definitions of medical professionalism may lead to a GP having a fluid interpretation depending on the situation. While general practitioners expressed core humanistic values, such as empathy and compassion, the expression of altruistic values were limited when practitioners indicated there was constraint on the financial resources of a practice.

Conclusion

Central to the analysis of a medical practitioner’s treatment of patients and receipt of fee income is the tension between medical professionalism and financial self-interest. Developing an understanding of this tension has implications for those undertaking healthcare policy initiatives and the recruitment and retention of general practitioners in primary care.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697205

Improving vaccine uptake: a new uptake reporting tool

Elise Tessier 1, Richard Pebody 2, Nicki Boddington 3, Michael Edelstein 4, Joanne White 5, Sonia Rafeeq 6, Tim Hopson 7

Abstract

Background

Vaccine uptake data is automatically extracted from all GP practices in England via the web-based reporting system, ImmForm, on behalf of Public Health England. In 2016/17, an Uptake Summary Tool was introduced on ImmForm for practice managers, clinical commissioning groups (CCGs) and screening and immunisation teams (SCRIMMS) to help facilitate local and regional management of the influenza programme. The tool allows practices to view and evaluate influenza uptake rates by target cohorts, comparing them against the previous season and CCG average/overall national uptake each week.

Aim

To assess how many practices use the Uptake Summary Tool and whether there is a difference in vaccine uptake among practices that use the tool compared with those that don’t during the 2016/17 and 2017/18 influenza seasons.

Method

Practice level use of the Uptake Summary Tool was examined for the 2016/17 influenza season and vaccine uptake compared between practices that used the tool and those that did not.

Results

An average of 1272 practices used the tool each week during the 2016/17. Vaccine uptake was on average 2.9% greater for targeted cohorts in practices that used the tool than practices that did not during the 2016/17 season.

Conclusion

When used on a regular basis the Uptake Summary Tool can help GP practices, CCGs and SCRIMMS monitor vaccine and may be associated with increased vaccine uptake. Uptake for the 2017/18 season will be monitored and assessed throughout the current season. We aim to expand the tool to other vaccine collections in the near future.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697229

Patient consent to medical students in general practice

Matthew Webb 1, Sarah Thirlwall 2, Bob McKinley 3

Abstract

Background

Informed consent is required for active participation of patients in medical education. At Keele Medical School, we require practices to advertise that they teach undergraduate students and to obtain appropriate patient consent at various stages of the patient journey.

Aim

The study aimed to explore patients’ experience of consent to involvement in undergraduate medical education in general practice.

Method

During the final year at Keele University Medical School, students undertake a patient satisfaction survey. A questionnaire was attached to the reverse of this survey during the academic year 2016–2017. The questionnaire explored the stage of the patient journey consent was obtained, whether they were offered an alternative appointment and how comfortable they were with medical students being involved in their care.

Results

A total of 489 questionnaires were completed covering 62 GP practices. 97% of patients reported that consent was obtained at least once during their encounter and the majority reported that this occurred at booking. 98% of patients were comfortable or very comfortable with a medical student leading their consultation. However, 28% of those surveyed stated that they were either not given the option of not seeing the student or there was no other alternative appointment available.

Conclusion

The results indicate that in the vast majority of cases patient consent is obtained at least once during their attendance. Patients expressed a high level of satisfaction with medical students’ involvement in their care. Further work is required to evaluate the role of the data as a marker of individual practice teaching quality.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697241

How can we improve hepatitis B testing and management in primary care? A cross-sectional survey of GPs in England, 2015–2017

Z Amin 1, K Beebeejaun 2, L Letley 3, B Mahange 4, K Harrington 5, J Checkley 6, M Edelstein 7

Abstract

Background

Chronic hepatitis B (HBV) infection can lead to life-threatening liver disease. In the UK, approximately 180,000 people are carriers. The disease is underdiagnosed and undertreated.

Aim

As part of a nurse-led intervention aimed at improving HBV contact-tracing and management, we ascertained GPs’ understanding of HBV and their perceived barriers and enablers to HBV diagnosis.

Method

In 2015, we asked 1324 GPs across 2 England regions about HBV-related knowledge and practice, using a questionnaire. We reported the proportion of GPs answering each question, with 95% confidence intervals (95% CI).

Results

254 GPs (18%) replied. Of those, 189(74%, 95%CI 68–79%) correctly identified hepatitis B surface antigen as a marker of current HBV infection, and 154 (61%, 95% CI = 54 to 66%) recognised IgM anti-HBc as a marker for differentiating acute from chronic cases. 219 GPs (86%, 95% CI = 81 to 90%) believed HBV knowledge among patients to be one of the main enablers to improved testing uptake and 208 (82%, 95% CI = 77 to 86%) identified lack of HBV knowledge among patients as a barrier to testing. Of all GP responders, 227 (89%, 95% CI = 85 to 93%) reported HBV training and education would be beneficial, and 185 (73%, 95% CI = 67 to 78%) reported knowledge of treatment options as a knowledge gap.

Conclusion

GPs perceive gaps in knowledge among patients and healthcare professionals as a factor potentially contributing to the under-ascertainment of chronic hepatitis B in England. Improving HBV awareness and knowledge among patients, their contacts, and increasing HBV-focused training for GPs, particularly in the interpretation of laboratory results and the treatment options, can improve case ascertainment and chronic HBV management in primary care.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697265

Integrated care: learning from East London

Sonia Bussu 1

Abstract

Background

Despite a growing body of literature on integrated, there remains a relatively small evidence base to suggest which elements of integrated care are most effective and how to implement them successfully. This might also be due to the fact that policy thinking around integrated care is struggling to translate into organisation change at the point of delivery. Better understanding of patterns of collaborations and integrated pathways is crucial to understand frontline staff’s OD needs and provide adequate support.

Aim

This paper focuses on the frontline level to assess progress towards integrated care in East London.

Method

We use admission avoidance (Rapid Response service) and discharge services (Discharge to Assess) as a lens to examine how frontline staff from secondary care, community health services and social service work together to deliver more integrated care. The study uses the Researcher in Residence (RiR), where the researcher is embedded in the in the organisations she is evaluating, as a key member of the delivery team.

Results

Initial findings suggest that while work on integrated care has enabled some level of collaborative working at strategic levels in partner organisations, on the frontline professionals are grappling with issues such as professional identity, professional boundaries, mutual trust and accountability, as new services and roles struggle to be fully embedded within the local health system.

Conclusion

The paper sheds light on to the complexity on integrated care at the point of delivery. Better understanding of integrated care pathways is crucial to evidence patterns of collaboration across organisations; assess how these new roles and teams are embedding themselves within the local health economy; identify organisation development needs; and provide adequate support to frontline staff.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697277

PREP — The Preoperative Risk Education Package: an online educational resource for primary care clinicians to encourage community based prehabilitation prior to major surgery

James Durrand 1, F McHardy 2, E Land 3, Z Llewellyn 4, C Norman 5, T Goh 6, S Fenton 7, G Danjoux 8

Abstract

Background

Prehabilitation prior to major surgery mandates cross-sector working. Utilising the preoperative window from referral requires clinician engagement. Awareness of perioperative risk factors is crucial. A national survey uncovered gaps in knowledge and understanding.

Aim

Create an open-access, online educational resource for primary care clinicians.

Method

Our multidisciplinary team developed a focused CPD resource targeting lifestyle factors and chronic health conditions influencing perioperative risk (www.prepwell.co.uk).

Results

PREP highlights seven risk factors influencing perioperative risk: Smoking, alcohol, inactivity, anaemia, cognitive impairment, frailty and low BMI. A case study frames each factor alongside perioperative impact and prehabilitation strategies.

Conclusion

PREP is the first educational resource of its type. Early evaluation through local clinicians, the RCGP and RCOA has resulted in very positive feedback. We are working with Royal College representatives to gain formal endorsement and facilitate wider scale rollout, a major step towards raised clinician awareness and enhanced collaboration for improved perioperative outcomes.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697289

A scoping review of the role of GPs in the management of obesity

Nicholas Elmitt 1, Elizabeth Sturgiss 2, Emily Haesler 3, Chris van Weel 4, Kirsty Douglas 5

Abstract

Background

GPs are caring for more adults with obesity. Research in primary health care has provided insight on the components of effective interventions. However, the most appropriate and effective role for GPs in these interventions remains unclear.

Aim

A scoping review was undertaken to examine the literature for descriptions of the role of the GP in managing adults who are overweight or have obesity in: primary research interventions, guidelines, and the role expectations expressed by opinion leaders.

Method

Black and grey literature were searched based on the terms ‘obesity’, ‘doctor’ and ‘primary care’. A customised data extraction tool was used to identify the specific role of GPs and the explicit use of general practice values, including whole person care and person-centred care.

Results

282 articles were reviewed in full, with a majority of the interventions originating in the US. Poor description of the involvement of healthcare professionals made it difficult to determine if GPs had been involved. When described, GPs were rarely actively involved. Most guidelines explicitly name GPs in obesity management and suggest wide ranging roles for them. Opinions from experts on GP involvement have become more positive in recent years.

Conclusion

GPs are minimally involved in obesity interventions in primary care research, but are promoted in obesity guidelines as essential to patient care. There is a need for an international standard on how to accurately describe which healthcare professionals were involved in intervention delivery and their specific role.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697301

Validating the Support Needs Approach for Patients (SNAP) tool in primary care: a person-centred approach for patients with advanced chronic obstructive pulmonary disease (COPD)

Carole Gardner 1, Gail Ewing 2, Morag Farquhar 3

Abstract

Background

Primary care is at the forefront of COPD management. A person-centred approach is advocated, yet patients have difficulty in articulating their needs to health care professionals (HCPs). The Support Needs Approach for Patients (SNAP) tool aims to enable patients to identify and express their support needs but its validity is unknown.

Aim

To establish the face, content and criterion validity of the SNAP tool in advanced COPD.

Method

Two-stage mixed method primary care study involving patients with advanced COPD, and their carers. Stage 1: Face and content validity assessed though focus groups involving patients and carers (n = 12), considering the appropriateness, relevance and completeness of the SNAP tool. Data analysed using thematic analysis within a Framework Approach. Stage 2: Content and criteria validity assessed in a postal survey through patient self-completion of the SNAP tool and disease impact measures (Chronic Respiratory Questionnaire, COPD Assessment Test, and Hospital Anxiety and Depression Scale). Content validity assessed using summary statistics; criterion validity via correlations between tool items and impact measures.

Results

The SNAP tool has good face, content and criterion validity. Patients and carers found the tool patient-friendly and potentially useful. No items on the tool were redundant, and clear correlations were found between tool items and the majority of items/sub-scales of the impact measures.

Conclusion

The SNAP tool has good face validity; content and criteria validity will be reported. It has the potential to facilitate person-centred care by enabling patients to express their support needs to HCPs. Future work will pilot SNAP in clinical practice.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697313

The Learning Disabilities Mortality Review (LeDeR) programme

Pauline Heslop 1, Matt Hoghton 2

Abstract

Background

Since the 1990s reports have consistently highlighted health inequalities faced by people with learning disabilities. Data from the Primary Care Research Database suggests an all-cause standardised mortality ratio for people with learning disabilities of 3.18, and that people with learning disabilities die approximately 20 years sooner than people without learning disabilities.

Aim

This presentation will provide an overview of the Learning Disabilities Mortality Review (LeDeR) programme. LeDeR aims to contribute to improvements in the quality of health and social care for people with learning disabilities in England through retrospective mortality reviews.

Method

Initial reviews are undertaken of all deaths notified to the LeDeR programme of people with learning disabilities aged 4 years and over. Where indicated, a full multiagency review is conducted. Deaths of young people aged 18–24, and of people from Black and Minority Ethnic communities are subject to priority themed review; each of these receive a full multiagency review.

Results

The LeDeR programme will be fully rolled out across England by the end of 2017. In this presentation we will share some of the learning from reviews that are particularly pertinent to GPs, and some of the service improvements that have resulted.

Conclusion

To our knowledge, this is the first national programme of mortality reviews of people with learning disabilities in the world. Its focus is service improvement: it is about learning lessons and making changes to improve the lives of, and support for people with learning disabilities.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697325

Exploring the experience of a ‘diagnosis’ of pre-diabetes and factors influencing uptake of a lifestyle intervention programme in areas of socio-economic deprivation

Victoria Hodges 1, Chloe Hobbis 2, Helen Twohig 3, Caroline Mitchell 4

Abstract

Background

People living in socio-economically deprived areas are at higher risk of developing diabetes and have worse health outcomes when they do. A Diabetes Prevention Programme (DPP) is being rolled out across England with eligibility linked to a HbA1c screening test to ‘diagnose’ pre-diabetes (42–47 mmol/mol). The DPP is a lifestyle intervention offering a 9-month individualised programme aiming to reduce progression to diabetes, through optimization of diet and physical activity to achieve weight loss. Previous studies suggest that patients from lower socioeconomic groups are less likely to engage with and benefit from lifestyle interventions. The DPP may increase health inequalities unless barriers to engagement are considered.

Aim

To explore patients’ understanding of and reactions to a ‘diagnosis’ of pre-diabetes and to identify the barriers and facilitators to uptake of a lifestyle intervention programme in a socio-economically deprived, pre-diabetic population.

Method

A literature review will inform development of a topic guide. A purposive sample of ‘pre-diabetic’ patients who have been offered referral to the DPP and are registered at practices within the Yorkshire and Humber ‘Deep End’ Research Cluster will be invited to participate in a semi-structured interview study. Data will be systematically analysed to identify emerging concepts and themes. Interviews will continue until data saturation is reached. A thematic framework will be developed, justified by and linked to the interview data.

Results

Health literacy, relationship with healthcare provider and level of activation all influence how the diagnosis is received and the decision to engage with the programme. Practical barriers to engaging with the programme exist but are secondary to other factors.

Conclusion

A ‘diagnosis of ‘pre-diabetes’ provokes healthy lifestyle change without causing anxiety. Healthcare professionals have considerable influence in determining whether a patient engages with the DPP.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697337

REVISIT, the next stage: developing plans for wider application of a retrospective review of prescribing of GPs in training

Richard Knox 1, Ndeshi Salema 2, Gill Gookey 3, Kate Marsden 4, Brian Bell 5, Raj Mehta 6, Sarah Roders 7, Karen McCartney 8, Tony Avery 9

Abstract

Background

The GMC PRACtICe study identified prescribing errors in general practice occurring at a rate of 5%. GPs in training (GP AiTs) were highlighted as a group who may benefit from further help to reduce their prescribing errors. A recent pilot study explored the effect of reviewing 100 sequential prescriptions issued by ten GPs AiTs. The error rate in this small cohort (the REVISIT study) was found to be nearly double that reported in the PRACtICe study (9%). Three-month follow-up interviews with GP AiTs and their trainers provided useful insight into prescribing behaviour and rationale for behaviour change.

Aim

Should the revisit intervention be rolled out or is further development required?

Method

Interviews with 30 stakeholders or stakeholder organisations were performed during which results from the REVISIT study were presented, and plans for development explored. Stakeholders included organisations involved with training and regulating GPs and pharmacists, as well as other interested parties such as GP AiTs and members of the public. Interviews were recorded, transcribed and analysed for emergent themes.

Results

There was broad support for further development of the REVISIT programme, with several stakeholders expressing surprise that this intervention is not already everyday practice. Caution was expressed about the way in which such an intervention could be viewed by participants: a supportive, developmental approach was preferred. Stakeholders also discussed the stage of training that such an intervention should occur within, and postulated other groups of prescribers who may benefit from similar interventions.

Conclusion

Findings from the REVISIT study confirmed that GP AiTs benefited from personalised prescribing review. By conducing systematic stakeholder interviews we aim to elucidate whether a larger intervention study is required, or whether the REVISIT process can be implemented universally or in a targeted format.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697349

Uncertainty about cellulitis and unmet patient information needs: a mixed methods study

Anna Lalonde 1, Emma Teasdale 2, Ingrid Muller 3, Joanne Chalmers 4, Peter Smart 5, Julie Hooper 6, Magdy El-Gohary 7, Kim S Thomas 8, Miriam Santer 9

Abstract

Background

Cellulitis is a common painful infection of the skin and underlying tissues that recurs in approximately a third of cases. Patients’ ability to recover from cellulitis or prevent recurrence is likely to be influenced by their understanding of the condition.

Aim

To explore patients’ perceptions of cellulitis and their information needs.

Method

Mixed methods study comprising semi-structured, face-to-face interviews and cross-sectional survey, recruiting through primary care, secondary care and advertising. Adults aged 18 or over with a history of cellulitis (first or recurrent) were invited to complete a survey, take part in an interview or both. Qualitative data was analysed thematically.

Results

Thirty interviews were conducted between August 2016 and July 2017. Qualitative data revealed low prior awareness of cellulitis, uncertainty around diagnosis, concern/surprise at the severity of cellulitis, and perceived insufficient information provision. People were surprised they had never heard of the condition and that they had not received advice or leaflets giving self-care information. Some sought information from the internet and found this bewildering. Two hundred and forty surveys were completed (response rate 17%). These showed that, while most people received information on the treatment of cellulitis (60.0%, n = 144), they reported receiving no information about causes (60.8%, n = 146) or prevention of recurrence (73.3%, n = 176).

Conclusion

There is a need for provision of basic information for people with cellulitis, particularly being informed of the name of their condition, how to manage acute episodes, and how to reduce risk of recurrence.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697361

Impact of telephone triage in managing patient demand for same-day appointments? A before-after study in a UK general practice

Jeffrey Chirk Fan Lau 1, Sadia Rashid 2

Abstract

Background

Telephone consultations are increasingly being utilised to manage patient demand for GP appointments. It’s true impact on patient care remains to be answered as existing evidence has shown mixed results.

Aim

To report the impact of telephone triage on: number of face-to-face (F2F) appointments offered; unplanned re-consultations with GP or urgent care services within 24 hours; and total consultation duration per patient episode.

Method

A retrospective cohort study in a single suburban practice in Kent, comparing outcomes between the new telephone triage and old walk-in F2F appointment systems in managing patient requests for same-day appointments. Data was sampled across 1 week, at 3-monthly intervals over each 12-month period before and after the system change-over in April 2016.

Results

1198 patient encounters matched the inclusion criteria. F2F appointments were offered to 34.7% of patients after telephone triage. Although unplanned re-consultations were four times more prevalent since the system changed compared to the previous year (P<0.001), no difference was seen between those consulted by telephone only, or offered a F2F appointment after telephone triage. Overall, patient consultations by telephone triage were 2.37 minutes shorter than consultations under its predecessor (P <0.001).

Conclusion

Telephone triage was able to manage majority of patient problems by telephone alone, with significant reduction in consulting time per patient episode. Telephone consulting was not shown accountable for the increase in unplanned re-consultations.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697373

Promotion of HIV testing in primary care in east London through a research programme: an MRC phase IV implementation study

Werner Leber 1, Lee Beresford 2, Claire Nightingale 3, Farah El-Shogri 4, Heather McMullen 5, Kambiz Boomla 6, Jane Anderson 7, Sarah Creighton 8, Danna Millett 9, Jose Figueroa 10, Jane Hutchinson 11, Claudia Estcort 12, Maryam Shahmanesh 13, Naomi Fulop 14, Chris Griffiths 15

Abstract

Background

HIV remains underdiagnosed. Guidelines recommend routine HIV testing in primary care but evidence on implementing testing is lacking.

Aim

We aimed to determine the effectiveness of post-trial implementation of a cluster randomised controlled trial (RHIVA2) promoting HIV testing in Hackney general practice.

Method

The RHIVA2 intervention (2010–12) comprised initial education and training, nomination of a practice lead nurse, external quality assurance, and referral of newly diagnosed patients to HIV services. Post-trial implementation (2012–2015) included additional intervention training, and audit of antiretroviral co-prescribing and missed HIV diagnoses. Monthly computerised HIV testing data, remotely extracted by the clinical effectiveness group, were analysed using interrupted time series analysis.

Results

Following RHIVA2 (20 intervention and 20 control practices), an additional 12 practices (11 former trial control, one former non-participating) received the intervention, and training was reinforced in six former trial intervention practices; a total of 31 practices (13 former trial intervention, 15 former trial control, and three former non-participating) completed the audit. HIV testing rates in intervention practices (trial or post-trial) increased immediately following the intervention by 85% (IRR = 1.85, 95% CI 1.72 to 1.99), and a similar effect (IRR 1.82, 95% CI 1.72 to 1.93) was observed when including comparator practices that didn’t receive the intervention at any point. The change in the effect of the intervention during the three years following the intervention decreased significantly (IRR = 0.99, 95% CI 0.99 to 0.99).

Conclusion

Post-trial implementation of a research intervention increased testing activity but may require regular support for sustainability.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697385

Changing attitudes to childhood immunisation in English parents

Joanne Yarwood 1, Louise Letley 2

Abstract

Background

Sustained vaccine coverage is essential to protect the population against vaccine-preventable diseases. It requires high level of confidence in the national vaccine programme.

Aim

We surveyed parental attitudes to childhood vaccinations in 2015 and compared them to attitudes in the previous 10 years.

Method

We randomly selected 275 locations in England. Interviewers identified eligible carers of children aged <5 years and interviewed them. The questionnaire covered all aspects of the immunisation process, vaccines administered in pregnancy and from infancy to pre-school with a maximum of 86 mixed questions.

Results

1792 parents were interviewed. Confidence in the vaccination programme was high. Only 2% of parents reported refusing vaccination whilst 90% reported vaccinating their children automatically when due. 97% of parents consulted web-based resources for information on vaccination. Parents who used chat rooms or discussion forums for this purpose were significantly more likely to say they had seen something that would make them doubt having their child(ren) immunized (31% compared to 8% amongst all parents). Health professionals and the NHS were seen as the most trusted source of advice on immunisation (90% agreed/strongly agreed with each). Very few parents did not trust these sources (4% and 3% disagreed, respectively).

Conclusion

Health professionals remain extremely important in communicating information about vaccination and are highly trusted by parents; a trust that has increased in recent years. Despite most parents seeking information on the Internet, trust in and advice from health care professionals appeared to be key factors influencing parental decisions.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697397

Practice funding and socioeconomic deprivation in English general practices: a longitudinal study 2013–2017

Louis S Levene 1, Richard Baker 2, John Bankart 3, Nicola Walker 4, Christopher Williams 5, Andrew Wilson 6

Abstract

Background

The NHS general practice payment formula has no specific measures of socio-economic deprivation, an important health determinant. Variables related to population health needs are poor predictors of cross-sectional variations in practice payments. Additional years of payments data allow longitudinal analyses.

Aim

Do deprivation scores predict variations in the slope over time of NHS practice payments, after adjusting for organisational and population factors?

Method

The sample was 6898 English practices with more than 500 patients, studied over 4 financial years, 2013–2014 to 2016–2017. The dependent variable was total NHS payments per registered patient (after deductions). The independent variable was the Index of Multiple Deprivation (IMD) 2015 score for each practice (range: 3.2 to 66.5). 17 Confounders were selected for conceptual plausibility and data availability at practice level, and included organisational variables and population variables A random intercepts and random slopes model was fitted to adjust for clustering of measurements within practices. The linear effects of independent variables on payments over time were modelled by fitting interaction terms (product of variable with year). Descriptive statistics and univariable analyses were undertaken.

Results

Practice IMD scores were very weak predictors of longitudinal variations in total payments’ slopes (4.9p/patient/1 unit increase in IMD). We also found that our confounders had very small predictive effects, and payments and IMD were not correlated in any year (Spearman correlation coefficients ranging from 0.01 to 0.06). The median of payments increased from £102.77 (2013–2014) to £115.43 (2016–2017).

Conclusion

Total payments increased very slightly more in practices with higher deprivation scores. This suggests that the NHS general practice payment formula may not adequately compensate practices whose populations have greater health needs.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697409

Learning and the development of professional practice of GP appraisers

Rachel Locke 1, Jane Bell 2, Samantha Scallan 3, Bee Ozguler 4, Susi Caesar 5

Abstract

Background

An additional portfolio role GPs can take on is as an appraiser. Whilst clinical and education roles are well-defined, less is known about how appraisers learn the skills to appraise and develop their own repertoire of practice.

Aim

Participating in groups can be a way of learning and improving professional practice. This study uses insights from ‘communities of practice’ (COP) as a way of understanding an under-explored aspect of the development of appraisers.

Method

In-depth interviews with appraisers (both new and long established i.e. ‘lead appraisers’) were analysed using Saldana’s (2016) approach2 to coding and interpretation of qualitative data. The methodology foregrounds constructivist interpretation based on a theory of learning that situates learning within the social milieu of practice and a view of the world as socially constructed. The researchers’ part in this process is to make interpretations through engagement with data.

Results

COP is used as a conceptual framework drawing on ‘mutual engagement’, ‘joint enterprise’ and ‘shared repertoire’ as a priori codes.3 The setting is a country where a system of appraisal was introduced in 2009 and prior to this there was no formal system. Studying appraisers in a new, unfamiliar setting makes learning more apparent.

Conclusion

This study is part of on-going work looking at the role of the medical appraiser. The paper draws out implications for the development of this new professional group.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697421

Sharing a methodology to develop a satisfaction questionnaire in mental health care

Eva Ma 1, Rachael Johnson 2, Teresa Hagan 3, Alex Young 4, Rajinder Dhanjal 5, Dannielle Claridge 6, Shon Davies 7, Christopher Boyce 8, Marcus Glennon 9, Catherine Backhouse 10, Harriet Fletcher 11, Catharine Kay 12, Sarah Woods 13

Abstract

Background

This paper outlines a multi-method’ process for developing a satisfaction questionnaire (SQ) for completion by service users. Satisfaction is a mark of service quality. Both health and social care services are required to evidence this. Working collaboratively with those who use our services is essential for achieving transformation in healthcare.

Aim

In developing a SQ, the aim was to collaboratively identify key quality criteria of most importance to service users and carers.

Method

In the absence of a gold standard methodology for developing a SQ, we developed an iterative multimethod’ phased process. Phase 1 involved a focus group, attended by service users and carers (n = 20). Participants at the focus group developed a preliminary list of quality criteria. Phase 2 involved a review of existing feedback questionnaires to supplement our quality criteria, including the Friends & Family Test. Phase 3 aimed to build consensus to refine the criteria, using a process informed by the Delphi technique with participants from a service user forum. The final phase of refinement is now underway.

Results

Preliminary findings highlight the key quality indicators of a high-quality service, as defined by service users and carers.

Conclusion

It is useful to adopt and develop an iterative multi-method’ approach involving co-production and consensus building in developing a valid and meaningful SQ.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697433

Wales Interventions and Cancer Knowledge about Early Diagnosis (WICKED): findings of work package 2 of the WICKED research programme

Sadia Nafees 1, Rebecca-Jane Law 2, Maggie Hendry 3, Julia Hiscock 4, Marian A Stanciu 5, Ruth Lewis 6, Alun Surgey 7, Nia Goulden 8, Zoe Hoare 9, Katherine Brain 10, Stephanie Smits 11, Seow T Yeo 12, Rhiannon Tudor Edwards 13, Lynne Williams 14, Nefyn Williams 15, Clare Wilkinson 16, Richard D Neal 17

Abstract

Background

Cancer outcomes in the UK are worse than many countries with similar health structures. GPs play a pivotal role in improving cancer outcomes through earlier diagnosis.

Aim

To develop and evaluate a behavioural intervention to enable GPs to expedite cancer diagnosis.

Method

This ongoing programme is divided into four inter-related Work Packages (WPs) using a mixed methods approach. WP 2 comprises an all-Wales online GP questionnaire, 20 GP telephone interviews, and 4 practice-team focus groups. The questionnaire examined GPs’ perceptions and attitudes towards cancer diagnosis, and influences on cancer referral-related behaviour change. GPs’ individual beliefs and behaviours were explored in interviews; practice systems and norms were investigated in focus groups. Quantitative data were analysed descriptively, with conventional content analysis for free-text responses, and Framework analysis was used for qualitative data-sets.

Results

Early findings show that 269/1993 (13.5%) GPs completed the survey. Most agreed that ‘timelier diagnosis leads to better survival’, perceived themselves to be knowledgeable, confident and capable in managing cancer symptoms, reported recent changes in their cancer-related diagnostic activity, and believed in their ability to influence timely diagnosis. However, many thought that, if given the opportunity and support, there was still room to improve early cancer diagnosis. Preliminary analysis of six interviews revealed 5 themes including; ‘wanting referral behaviour to fit, ‘feeling untrusted by secondary care’, ‘practicing over-defensive medicine’, ‘support from colleagues, and ‘difficulty referring patients with vague symptoms’.

Conclusion

These findings will inform the development (WP3), and evaluation (WP4) of a behavioural intervention to expedite referral and diagnosis.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697445

Research activity and quality indicators in primary care - An explorative qualitative interview study

Helen Riding 1, S Haining 2, L Robinson 3

Abstract

Background

Emerging evidence suggests that research activity improves healthcare performance in secondary care. Staff who contribute and participate in research studies, tend to have a greater understanding, and use, of current evidence and guidelines. The engagement in research in primary care and correlation with quality indicators (QIs) is unclear.

Aim

The aim of this study is exploring the link between research activity and quality indicators in primary care.

Method

4 GPs and 4 practice managers consented and participated in semi-structured interviews conducted in spring 2017. A purposive sampling strategy was adopted until data saturation was achieved. The interviews were digitally recorded, transcribed verbatim and analysed using thematic framework analysis.

Results

Practices with a GP research champion were more likely to undertake research. Staff directly participating in the recruitment and follow-up and the research teams adopting a participatory and active research methodology is more likely to lead to improvement in quality. Including research as Enhanced Service may influence increased participation. The QOF is most likely to reflect improvement related to research, but opinions were mixed.

Conclusion

Clinical Commissioning Groups and NHS England should be encouraged to develop QIs for research. As the landscape changes with the creation of Accountable Care Systems, there is an opportunity address the inclusion of research into practice contracts. This paper is the first to explore this topic in primary care and the findings will contribute towards developing quantitative research to expand the findings of this exploratory study.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697457

How do primary care health professionals engage patients in the goal of CVD risk reduction?

Helen Stedeford 1, Georgia Black 2

Abstract

Background

Primary prevention of CVD is a key UK health strategy; its success depends on individuals with high risk becoming motivated to adopt a scientifically valid risk reduction strategy. This is assumed to be the automatic outcome of risk assessments by much of the literature, yet little is known about whether or how this happens in practice.

Aim

This qualitative study sought to explore professionals’ experience of discussing CVD risk with patients.

Method

Semi-structured interviews were conducted with 20 primary care staff, including GPs, practice nurses and allied health professionals. Interview transcripts underwent thematic analysis using an inductive approach.

Results

Professionals’ descriptions of patient responses to high risk status fell along a spectrum from full engagement with risk reduction to overt non-engagement. Erroneous lay beliefs regarding CVD risk are reportedly common and influential. Expert norms of individual agency regarding health and the future are often not shared by those in disadvantaged circumstances.

Conclusion

Negotiating a shared risk reduction agenda is often a long-term process shaped by specific clinician-patient relationships and wider social contexts. An accessible resource which examines common lay beliefs and scientific evidence could help improve health literacy and uptake of risk reduction strategies. The impact of environmental and social factors on health-related behaviour deserves greater attention.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697469

Gestational diabetes mellitus: are mothers being followed-up? A retrospective study

Rebecca Ward 1, Fahmy W Hanna 2, Ann Shelley-Hitchen 3, Ellen Hodgson 4, Adrian Heald 5, Anthony A Fryer 6, Christopher J Duff 7

Abstract

Background

Women with gestational diabetes (GDM) have an elevated risk of developing type 2 diabetes (T2DM). NICE Guidance recommends women who develop GDM are screened 6 weeks post-partum and annually thereafter.

Aim

To evaluate conformity to guidance of screening in women with GDM by 6-week post-partum fasting plasma glucose (FPG) and annual FPG and determine time between delivery and development of T2DM.

Method

Records at a tertiary referral centre were used to identify women (n = 54) diagnosed with GDM by antenatal oral glucose tolerance test between July 1999 and January 2007. Data from laboratory records were used to collect investigations of glycaemic status during the follow-up period (median follow-up 12.4 years, range 9.5–17.1 years).

Results

Of 252 women, 102 (40.2%) did not have a FPG at 6 weeks (+/−2 weeks). Of these, median time to first test was 1.2 years (range 0.04–10.8 years), with only 43.1% followed-up within 1 year. In those who had a 6-week FPG, 17 (11.3%) women had no further tests. A total of 84 (33% of those with gestational diabetes in the index pregnancy) women were diagnosed with T2DM; median time from delivery to diagnosis was 5.2 years (range 0.35–15.95). We found the only significant factor for a follow-up test at 1-year post-partum was the use of insulin.

Conclusion

Our data suggest an alternative approach is needed for monitoring women with a history of GDM. This needs to be appropriate for a generally healthy group in which traditional screening mechanisms may not be adequate or sufficient.

Br J Gen Pract. 2018 Jun;68(Suppl 1):bjgp18X697529. doi: 10.3399/bjgp18X697481

Primary care direct access cerebral imaging in Lothian, Scotland: a 5-year retrospective analysis of referrals, assessment of utility of referral guidelines, and determination of incidence of abnormalities

Karolis Zienius 1, Chak Ip 2, Mio Ozawa 3, Robin Grant 4, Yoav Ben-Shlomo 5, Paul M Brennan 6

Abstract

Background

Direct Access Cerebral Imaging (DACI) from Primary Care has been recommended by NICE for patients with symptoms suspicious of cancer.

Aim

We analysed the predictive value of the NICE (2005) and Kernick referral guidance for suspicion of brain tumour in a real-world setting

Method

DACI referrals from Lothian-based GPs (31/3/2010 to 1/4/2015) were categorised according to the symptom classifications of NICE 2005 and Kernick referral guidelines. Radiological findings were grouped into 1) normal/non-significant-incidental, 2) abnormal-significant, 3) intracranial tumour.

Results

In total, 3257 head scans were performed, and after exclusions, 2938 records were analysed. Mean age was 55.6 (SD 18.56), 1748 (60%) females. Forty-two scans (1.43%) revealed significant intracranial tumours, including 17 (40%) metastases, 10 primary intracerebral tumours (24%), 8 pituitary (19%), 7 meningioma (17%). Non-significant incidental findings were observed on 571 (19%) scans, of which 175 (6%) correlated with symptoms. Based on NICE (2005) guidelines, 39% referrals were for ‘symptoms related to the CNS’, 16% for ‘Headache of raised ICP’, 18% for ‘Sub-acute deficits’ and 27% for ‘Unexplained headache’. Kernick guidelines classified 39% referrals red-flag, 25% orange-flag, and 36% yellow-flag symptoms. NICE ‘Symptoms related to CNS’ (OR 5.21, 95% CI = 1.81 to 14.9; PPV 2.9, 95% CI 2.0 to 4.0) and Kernick’s red-flag symptoms (OR 5.73, 95% CI =2.21 to 14.84; PPV 2.8, 95% CI = 1.9 to 3.9) were the only features to have significantly increased risk of brain tumour.

Conclusion

Referral guidelines confirm the urgency for rapid access head imaging for symptoms ‘highly suspicious’ of brain tumour. We are now assessing diagnostic value of different symptom complexes for intracranial tumour including headache-plus.

Articles from The British Journal of General Practice are provided here courtesy of Royal College of General Practitioners

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