Realising the full potential of primary care: uniting the ‘two faces’ of generalism

Faced with an unprecedented mismatch between presented health needs and resources available, we must rethink both how we deliver healthcare and what care we deliver. Work has already started on the ‘how’: notably with efforts to strengthen access and integration (improved coordination of the comprehensive care needed to meet a diverse range of needs). It is defining ‘what’ to deliver that is proving more challenging. To address emerging problems of over- and under-treatment associated with the undue specialisation of healthcare, we need to strengthen delivery of generalist medical care. Meaning we need to bolster capacity to decide if and when medical intervention is the right approach for this individual (whole person) in their lived context. We need to put the interpretive expertise of the medical generalist back at the core of our primary healthcare systems

Bridging the second gap in translation: a case study of barriers and facilitators to implementing Patient-initiated Clinics into secondary care

Rationale: Patient-initiated Clinics (PIC) have been found to be safe and have patient and service benefits in terms of satisfaction and cost. This paper reports our experiences of implementing PIC and the practical challenges of translating research into practice.Methods: The Knowledge to Action framework was used to inform the design of implementation plans in three different departments in one secondary healthcare organisation. A focused ethnographic approach was utilised to collect data on barriers and facilitators to implementation which were analysed using iterative qualitative analytic techniques. The Promoting Action on Research Implementation in Health Services framework was used to develop the analysis and data presentation. Results: The success of implementation was mixed across the three departments. Despite evidence of effectiveness, contextual issues at a department level, such as empowered leadership and team members, trust in colleagues and patients and capacity to make changes, impacted on the progress of implementation. Discussion: Patient-initiated Clinics can offer a useful and feasible alternative for follow-up care of some groups of patients with long-term conditions in secondary care and can be implemented through strong leadership and teamwork and a positive attitude to change. Although Implementation Science as an emerging field offers useful tools and theoretical support, its complexity may create additional challenges to implementation of specific interventions and so further contribute to the second gap in translation

Bridging the second gap in translation:A case study of barriers and facilitators to implementing Patient-initiated Clinics into secondary care

Abstract Rationale: Patient-initiated clinics (PIC) have been found to be safe and have patient and service benefits in terms of satisfaction and cost. This paper reports our experiences of implementing PIC and the practical challenges of translating research into practice. Methods: The Knowledge to Action framework was used to inform the design of implementation plans in three different departments in one secondary health care organisation. A focused ethnographic approach was utilised to collect data on barriers and facilitators to implementation which were analysed using iterative qualitative analytic techniques. The Promoting Action on Research Implementation in Health Services framework was used to develop the analysis and data presentation. Results: The success of implementation was mixed across the three departments. Despite evidence of effectiveness, contextual issues at a department level, such as empowered leadership and team members, trust in colleagues and patients and capacity to make changes, impacted on the progress of implementation. Discussion: Patient Initiated Clinics can offer a useful and feasible alternative for follow-up care of some groups of patients with long-term conditions in secondary care, and can be implemented through strong leadership and teamwork and a positive attitude to change. Although Implementation Science as an emerging field offers useful tools and theoretical support, its complexity may create additional challenges to implementation of specific interventions, and so further contribute to the second gap in translation.This research was funded by the South West Academic Health Science Network (AHSN) and the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The AHSN and the NIHR had no involvement in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication

Engaging Without Exposing: Use of a Fictional Character to Facilitate Mental Health Talk in Focus Groups With Men Who Have Been Subject to the Criminal Justice System.

In an effort to encourage men with experience of being subject to the criminal justice system to contribute to focus group discussions on the sensitive topic of mental health, while also doing our utmost to protect them from discomfort or risk of exploitation, we used a novel technique involving the creation of a fictional character, supplemented by an audio-recorded vignette. We studied the role played by this technique in achieving our stated aims of "engaging without exposing." In this article, we report on the use of this technique in three focus groups, showing how in very different ways it shaped the interaction between participants and generated crucial insights into the lives and service needs of each group. We conclude that the technique may lend itself to being used in focus groups with other marginalized or seldom-heard populations

The reflexive imperative in the digital age:Using Archer’s ‘fractured reflexivity’ to theorise widening inequities in UK general practice

‘Reflexivity’, as used by Margaret Archer, means creative self-mastery that enables individuals to evaluate their social situation and act purposively within it. People with complex health and social needs may be less able to reflect on their predicament and act to address it. Reflexivity is imperative in complex and changing social situations. The substantial widening of health inequities since the introduction of remote and digital modalities in health care has been well-documented but inadequately theorised. In this article, we use Archer’s theory of fractured reflexivity to understand digital disparities in data from a 28-month longitudinal ethnographic study of 12 UK general practices and a sample of in-depth clinical cases from ‘Deep End’ practices serving highly deprived populations. Through four composite patient cases crafted to illustrate different dimensions of disadvantage, we show how adverse past experiences and structural inequities intersect with patients’ reflexive capacity to self-advocate and act strategically. In some cases, staff were able to use creative workarounds to compensate for patients’ fractured reflexivity, but such actions were limited by workforce capacity and staff awareness. Unless a more systematic safety net is introduced and resourced, people with complex needs are likely to remain multiply disadvantaged by remote and digital health care

The reflexive imperative in the digital age:Using Archer’s ‘fractured reflexivity’ to theorise widening inequities in UK general practice

‘Reflexivity’, as used by Margaret Archer, means creative self-mastery that enables individuals to evaluate their social situation and act purposively within it. People with complex health and social needs may be less able to reflect on their predicament and act to address it. Reflexivity is imperative in complex and changing social situations. The substantial widening of health inequities since the introduction of remote and digital modalities in health care has been well-documented but inadequately theorised. In this article, we use Archer’s theory of fractured reflexivity to understand digital disparities in data from a 28-month longitudinal ethnographic study of 12 UK general practices and a sample of in-depth clinical cases from ‘Deep End’ practices serving highly deprived populations. Through four composite patient cases crafted to illustrate different dimensions of disadvantage, we show how adverse past experiences and structural inequities intersect with patients’ reflexive capacity to self-advocate and act strategically. In some cases, staff were able to use creative workarounds to compensate for patients’ fractured reflexivity, but such actions were limited by workforce capacity and staff awareness. Unless a more systematic safety net is introduced and resourced, people with complex needs are likely to remain multiply disadvantaged by remote and digital health care

Variation in referral and access to new psychological therapy services by age: an empirical quantitative study.

Background: Older people with common mental health problems (CMHPs) are known to have reduced rates of referral to psychological therapy. Aim: We aimed to assess referral rates to the Improving Access to Psychological Therapies (IAPT) service, contact with a therapist and clinical outcome by age. Design and Setting: Empirical research using patient episodes of care from South West IAPT. Method: By analysing 82,513 episodes of care (2010-2011), referral rates and clinical improvement were compared to both total population and estimated prevalence in each age group using IAPT data. Probable recovery of those completing treatment were calculated for each group. Results: Estimated prevalence of CMHPs peaks in 45–49 year olds (20.59% of population). The proportions of patients identified with CMHPs being referred peaks at 20-24 years (22.95%) and reduces with increase in age thereafter to 6.00% for 70-74 year olds. Once referred, the proportion of those attending first treatment increases with age between 18 years (57.64%) and 64 years (76.97%). In addition, the percentage of those having a clinical improvement gradually increases from the age 20 years (12.94%) to 69 years (20.74%). Conclusion: Younger adults are more readily referred to IAPT services. However, as a proportion of those referred, probabilities of attending once, attending more than once, and clinical improvement, increase with age. It is uncertain whether optimum levels of referral have been reached for young adults. It is important to establish whether changes to service configuration, treatment options, and GP behaviour can increase referrals for middle-aged and older adults