General practitioners’ perceptions on their role in light of the NHS five year forward view: a qualitative study

Background: The NHS is undergoing unprecedented change, central to which is policy aimed at integrating health and social care services, resulting in the implementation of new care models. GPs are at the forefront of this change. However, there is lack of academic literature on General Practitioners’ perceptions on their role in light of the new models of care proposed by the NHS Five Year Forward View which this small-scale study begins to address. Objectives: This study aims to produce a description of how GP’s construct their current and future general practice, professional status and identify within the context of the current NHS transformation agenda. Methods: Qualitative study using semi-structured interviews and one focus group to gather the perspective of GPs (n = 10) working across three clinical commissioning groups in South East England. Results: While the GPs embraced the principles underpinning the new care models, they were both willing and reluctant to adopt their new roles, struggled with inter-organisational and cultural barriers and their changing professional identity. Conclusion: Multi-professional education in primary and community care could be an effective model to offer support and resources to the development of the clinical and leadership skills GPs will require to respond effectively to the transformation agenda. The emergence of community education provider networks, innovative network organisations designed to support workforce transformation through education and training, can provide the vehicle through which clinical and leadership skills training are sourced and coordinated

Crisis resolution teams for people experiencing mental health crises: the CORE mixed-methods research programme including two RCTs

Background Crisis resolution teams (CRTs) seek to avert hospital admissions by providing intensive home treatment for people experiencing a mental health crisis. The CRT model has not been highly specified. CRT care is often experienced as ending abruptly and relapse rates following CRT discharge are high. Aims The aims of CORE (Crisis resolution team Optimisation and RElapse prevention) workstream 1 were to specify a model of best practice for CRTs, develop a measure to assess adherence to this model and evaluate service improvement resources to help CRTs implement the model with high fidelity. The aim of CORE workstream 2 was to evaluate a peer-provided self-management programme aimed at reducing relapse following CRT support. Methods Workstream 1 was based on a systematic review, national CRT manager survey and stakeholder qualitative interviews to develop a CRT fidelity scale through a concept mapping process with stakeholders (n = 68). This was piloted in CRTs nationwide (n = 75). A CRT service improvement programme (SIP) was then developed and evaluated in a cluster randomised trial: 15 CRTs received the SIP over 1 year; 10 teams acted as controls. The primary outcome was service user satisfaction. Secondary outcomes included CRT model fidelity, catchment area inpatient admission rates and staff well-being. Workstream 2 was a peer-provided self-management programme that was developed through an iterative process of systematic literature reviewing, stakeholder consultation and preliminary testing. This intervention was evaluated in a randomised controlled trial: 221 participants recruited from CRTs received the intervention and 220 did not. The primary outcome was re-admission to acute care at 1 year of follow-up. Secondary outcomes included time to re-admission and number of days in acute care over 1 year of follow-up and symptoms and personal recovery measured at 4 and 18 months’ follow-up. Results Workstream 1 – a 39-item CRT fidelity scale demonstrated acceptability, face validity and promising inter-rater reliability. CRT implementation in England was highly variable. The SIP trial did not produce a positive result for patient satisfaction [median Client Satisfaction Questionnaire score of 28 in both groups at follow-up; coefficient 0.97, 95% confidence interval (CI) –1.02 to 2.97]. The programme achieved modest increases in model fidelity. Intervention teams achieved lower inpatient admission rates and less inpatient bed use. Qualitative evaluation suggested that the programme was generally well received. Workstream 2 – the trial yielded a statistically significant result for the primary outcome, in which rates of re-admission to acute care over 1 year of follow-up were lower in the intervention group than in the control group (odds ratio 0.66, 95% CI 0.43 to 0.99; p = 0.044). Time to re-admission was lower and satisfaction with care was greater in the intervention group at 4 months’ follow-up. There were no other significant differences between groups in the secondary outcomes. Limitations Limitations in workstream 1 included uncertainty regarding the representativeness of the sample for the primary outcome and lack of blinding for assessment. In workstream 2, the limitations included the complexity of the intervention, preventing clarity about which were effective elements. Conclusions The CRT SIP did not achieve all its aims but showed potential promise as a means to increase CRT model fidelity and reduce inpatient service use. The peer-provided self-management intervention is an effective means to reduce relapse rates for people leaving CRT care. Study registration The randomised controlled trials were registered as Current Controlled Trials ISRCTN47185233 and ISRCTN01027104. The systematic reviews were registered as PROSPERO CRD42013006415 and CRD42017043048. Funding The National Institute for Health Research Programme Grants for Applied Research programme

The 'Choice and Autonomy Framework' : implications for occupational therapy practice

Introduction This paper presents findings from a PhD study exploring autonomy of adults with physical disability. The plethora of descriptions of autonomy in psychological, occupational therapy and rehabilitation literature (e.g. Ryan and Deci 2000, Rogers 1982, Cardol et al 2002) detracts from the centrality of autonomy and results in difficulty incorporating it into occupational therapy practice. This paper presents a framework providing an integrated, clinically useful approach to autonomy. Methods Sixteen people were recruited, based on age, gender, impairment and living circumstances (community/residential settings). All have significant physical disability, use a wheelchair and require personal assistance for some/all self-care activities. Qualitative methods were used for data collection, including life-history narrative, diary information and extensive interview. An integrated method of analysis was used, including content analysis and bracketing. Results The ‘Choice and Autonomy Framework’ consists of five strands, including: • the meaning of autonomy • whether or not autonomy is a goal or value • the experience of autonomy • personality factors that impact autonomy • environmental features that enhance or negate autonomy. This paper will describe each strand, as derived from the research. The results suggest that, contrary to common wisdom (Hmel and Pincus 2002), autonomy is not necessarily a universal goal for people with physical disability; an understanding of the person’s own perspective will enhance person-centred practice and enable therapists to further recognise individuality of clients. It will argue that the concept of autonomy needs to be further understood and incorporated into occupational therapy practice