Implementing change in primary care practice: lessons from a mixed-methods evaluation of a frailty initiative

© 2018, BJGP Open. Background: The NHS is facing increasing needs from an aging population, which is acutely visible in the emerging problem of frailty. There is growing evidence describing new models of care for people living with frailty, but a lack of evidence on successful implementation of these complex interventions at the practice level. Aim: This study aimed to determine what factors enable or prevent implementation of a wholesystem, complex intervention for managing frailty (the PACT initiative) in the UK primary care setting. Design & setting: A mixed-methods evaluation study undertaken within a large clinical commissioning group (CCG). Design and analysis was informed by normalisation process theory (NPT). Method: Data collection from six sites included: observation of delivery, interviews with staff, and an online survey. NPT-informed analysis sought to identify enablers and barriers to implementation of change. Results: Seven themes were identified. PACT was valued by professionals and patients but a lack of clarity on its aims was identified as a barrier to implementation. Successful implementation relied on champions pushing the work forward, and dealing with unanticipated resistance. Contracts focused on delivery of service outcomes, but these were sometimes at odds with professional priorities. Implementation followed evidence-informed rather than evidence-based practice, requiring redesign of the intervention and potentially created a new body of knowledge on managing frailty. Conclusion: Successful implementation of complex interventions in primary care need inbuilt capacity for flexibility and adaptability, requiring expertise as well as evidence. Professionals need to be supported to translate innovative practice into practice-based evidence

Learning from the transfer of a fellowship programme to support primary care workforce needs in the UK: a qualitative study

Objectives Service redesign, including workforce development, is being championed by UK health service policy. It is allowing new opportunities to enhance the roles of staff and encourage multiprofessional portfolio working. New models of working are emerging, but there has been little research into how innovative programmes are transferred to and taken up by different areas. This study investigates the transferability of a 1-year post-Certification of Completion of Training fellowship in urgent and acute care from a pilot in the West Midlands region of England to London and the South East. Design A qualitative study using semistructured interviews supplemented by observational data of fellows’ clinical and academic activities. Data were analysed using a thematic framework approach. Setting and participants Two cohorts of fellows (15 in total) along with key stakeholders, mentors, tutors and host organisations in London and the South East (LaSE). Fellows had placements in primary and secondary care settings (general practice, emergency department, ambulatory care, urgent care and rapid response teams), together with academic training. Results Seventy-six interviews were completed with 50 participants, with observations in eight clinical placements and two academic sessions. The overall structure of the West Midlands programme was retained and the core learning outcomes adopted in LaSE. Three fundamental adaptations were evident: broadening the programme to include multiprofessional fellows, changes to the funding model and the impact that had on clinical placements. These were felt to be key to its adoption and longer-term sustainability. Conclusion The evaluation demonstrates a model of training that is adaptable and transferable between National Health Service regions, taking account of changing national and regional circumstances, and has the potential to be rolled out widely

Patient and public involvement mobile workshops - convenient involvement for the un-usual suspects

Background Patient and public involvement in research is a quickly-evolving area, with investigators developing new approaches in recent years. One concern about patient and public involvement is that it only appeals to certain individuals. When designing research into online GP services – a topic relevant to the general population – we recognised the importance of involving members of the public with a broad range of backgrounds who may not have the time, resources and inclination to volunteer normally. Methods We devised a strategy that aimed to involve members of the public from varied backgrounds, who would not typically be able to be involved. We ran a series of one-off mobile workshops at existing organisations where potential volunteers were already in situ. The workshops were kept short, making them convenient and easily accessible. Volunteers were also paid, to ensure taking part was appealing. Results We ran a series of 4 workshops involving 26 members of the public with office workers, supermarket staff, gym members (and their friends) and parents attending a toddler group. Overall the workshops were successful, as they enabled us to gain varied perspectives from volunteers with a broad range of backgrounds, many of whom had not previously been involved in research. A key challenge was making initial contact with members of approached organisations. This indicates that it may be beneficial to consider how to make the workshops appealing, not just onan individual level, but at an organisational level too. A carefully planned design worked as it enabled large amounts of input in a limited amount of time, apart from one workshop (the parent group) due to practical reasons. This highlighted some limitations of this approach that could be addressed by adapting the workshop design, according to the organisation with which they are being run. Conclusion Running one-off mobile workshops at already existing organisations allowed us to involve members of the public from a broad range of backgrounds, who would not typically volunteer to be involved in research. This was particularly suitable as the topic we were designing research for – booking GP appointments – is relevant to the general public

Which patients miss appointments with general practice and why? A systematic review

Background: Missed GP appointments have considerable time and cost implications for healthcare services. Aim: This systematic review aims to explore the rate of missed primary care appointments, what the reported reasons are for appointments being missed, and which patients are more likely to miss appointments. Design: This study reports the findings of a systematic review. Setting: Included studies report the rate or reasons of missed appointments in a primary care setting. Method: Databases were searched using a pre-defined search strategy. Eligible studies were selected for inclusion based on detailed inclusion criteria through title, abstract and full text screening. Quality was assessed on all included studies, and findings were synthesised to answer the research questions. Results: A total of 26 studies met the inclusion criteria for inclusion in the review. Of these, 19 reported a rate of missed appointments, with a mean rate of 15.2% and a median of 12.9% appointments being missed. Twelve studies reported a reason appointments were missed, with work or family commitments, forgetting the appointment and transportation difficulties were most commonly reported. 20 studies reported characteristics of people likely to miss appointments. Patients who were likely to miss appointments were those from minority ethnicity, low socio-demographic status and younger patients. Conclusions: Findings from this review have potential implications for targeted interventions to address missed appointments in primary care. This is the first step for clinicians being able to target interventions to reduce the rate of missed appointments

Internet videoconferencing for patient-clinician consultations in long-term conditions : a review of reviews and applications in line with guidelines and recommendations

Introduction The use of internet videoconferencing in healthcare settings is widespread, reflecting the normalisation of this mode of communication in society and current healthcare policy. As the use of internet videoconferencing is growing, increasing numbers of reviews of literature are published. Methods The authors conducted a review of the existing reviews of literature relating to the use of internet videoconferencing for consultations between healthcare professionals and patients with long-term conditions in their own home. The review was followed with an assessment of UK National Institute for Health and Clinical Excellence guidelines for patient care in the context of common long-term illnesses to examine where videoconferencing could be implemented in line with these recommendations. Results The review of reviews found no formal evidence in favour of or against the use of internet videoconferencing. Patients were satisfied with the use of videoconferencing but there was limited evidence that it led to a change in health outcomes. Evidence of healthcare professional satisfaction when using this mode of communication with patients was limited. The review of guidelines suggested a number of opportunities for adoption and expansion of internet videoconferencing. Implementing videoconferencing in line with current evidence for patient care could offer support and provide information on using a communication channel that suits individual patient needs and circumstances. The evidence base for videoconferencing is growing, but there is still a lack of data relating to cost, ethics and safety. Conclusions While current evidence base for the internet videoconferencing is equivocal, it is likely to change as more research is undertaken and evidence published. With more videoconferencing services added in more contexts, research needs to explore how internet videoconferencing can be implemented in ways that it is valued by patients and clinicians, and how it can fit within organizational and technical infrastructure of the healthcare services

Use of a pharmacy-based GP video consultation service : a mixed methods study

Background Little is known about private general practice appointment services offered via video. This study aimed to explore which patients are using a video pharmacy-based general practitioner (GP) appointment service, including patterns of use, reasons for using the service, and satisfaction with the service. Methods Descriptive statistics and parametric and nonparametric tests were used to conduct a retrospective cross-sectional analysis of routinely collected data on consultations, and postconsultation questionnaires. Interviews were conducted with patients and GPs. Results A total of 7,928 consultations were included in the analysis. More than half of appointments were booked for the same day, with lunchtime appointments being popular. The most common health condition was respiratory conditions, and 9% of consultations were used by patients using the service more than once. At least one prescription was issued in over half of all consultations. Overall, satisfactions of consultations were high. Conclusions The characteristics of those patients using the video consultation service match data on who uses online services in general practice. This study shows that some patients are willing to pay to use this private service because they feel it is more convenient, NHS services do not have capacity to see them at the time they need, or they do not have access to regular GP services

Ethical implications of digital communication for the patient-clinician relationship : analysis of interviews with clinicians and young adults with long term conditions (the LYNC study)

Background: Digital communication between a patient and their clinician offers the potential for improved patient care, particularly for young people with long term conditions who are at risk of service disengagement. However, its use raises a number of ethical questions which have not been explored in empirical studies. The objective of this study was to examine, from the patient and clinician perspective, the ethical implications of the use of digital clinical communication in the context of young people living with long-term conditions. Methods: A total of 129 semi-structured interviews, 59 with young people and 70 with healthcare professionals, from 20 United Kingdom (UK)-based specialist clinics were conducted as part of the LYNC study. Transcripts from five sites (cancer, liver, renal, cystic fibrosis and mental health) were read by a core team to identify explicit and implicit ethical issues and develop descriptive ethical codes. Our subsequent thematic analysis was developed iteratively with reference to professional and ethical norms. Results: Clinician participants saw digital clinical communication as potentially increasing patient empowerment and autonomy; improving trust between patient and healthcare professional; and reducing harm because of rapid access to clinical advice. However, they also described ethical challenges, including: difficulty with defining and maintaining boundaries of confidentiality; uncertainty regarding the level of consent required; and blurring of the limits of a clinician’s duty of care when unlimited access is possible. Paradoxically, the use of digital clinical communication can create dependence rather than promote autonomy in some patients. Patient participants varied in their understanding of, and concern about, confidentiality in the context of digital communication. An overarching theme emerging from the data was a shifting of the boundaries of the patient-clinician relationship and the professional duty of care in the context of use of clinical digital communication. Conclusions: The ethical implications of clinical digital communication are complex and go beyond concerns about confidentiality and consent. Any development of this form of communication should consider its impact on the patient-clinician-relationship, and include appropriate safeguards to ensure that professional ethical obligations are adhered to

Nxt1 Is Necessary for the Terminal Step of Crm1-Mediated Nuclear Export

Soluble factors are required to mediate nuclear export of protein and RNA through the nuclear pore complex (NPC). These soluble factors include receptors that bind directly to the transport substrate and regulators that determine the assembly state of receptor–substrate complexes. We recently reported the identification of NXT1, an NTF2-related export factor that stimulates nuclear protein export in permeabilized cells and undergoes nucleocytoplasmic shuttling in vivo (Black, B.E., L. Lévesque, J.M. Holaska, T.C. Wood, and B.M. Paschal. 1999. Mol. Cell. Biol. 19:8616–8624). Here, we describe the molecular characterization of NXT1 in the context of the Crm1-dependent export pathway. We find that NXT1 binds directly to Crm1, and that the interaction is sensitive to the presence of Ran-GTP. Moreover, mutations in NXT1 that reduce binding to Crm1 inhibit the activity of NXT1 in nuclear export assays. We show that recombinant Crm1 and Ran are sufficient to reconstitute nuclear translocation of a Rev reporter protein from the nucleolus to an antibody accessible site on the cytoplasmic side of the NPC. Further progress on the export pathway, including the terminal step of Crm1 and Rev reporter protein release, requires NXT1. We propose that NXT1 engages with the export complex in the nucleoplasm, and that it facilitates delivery of the export complex to a site on the cytoplasmic side of NPC where the receptor and substrate are released into the cytoplasm

A preliminary review of cyber-detection factors: offering from a systematic review

Aim The current paper aims to provide a preliminary exploration of the characteristics associated with cyber-deception, by focusing on motivations for engagement and the psychological characteristics of those perpetrating such behaviour. It aims to further outline gaps in the literature and suggest what areas any potential model of cyber-deception could include to benefit future research. Method A systematic search of 11 databases was undertaken, with additional manual searching for relevant journals and sources. This was followed by data extraction and thematic analysis. Results A total of 21 studies were identified as meeting eligibility criteria. Six motivational themes emerged (i.e. acquiring attention and sympathy; a response to negative childhood experiences; preserving identity and presenting your ‘true’ self; to cause intentional harm and to pursue personal enjoyment; to exploit materially; deception as a stress-reliever in response to life strain), and one individual theme (i.e. perpetrator personality). Conclusions Perpetrator motivation included a varied range of factors, with more static characteristics (i.e. personality) less well captured in the literature. Future research could determine if psychological differences are of value or if the area is better understand through consideration of more dynamic (motivational) factors