Using the SF-36 with older adults: a cross-sectional community-based survey

OBJECTIVES: To assess the practicality and validity of using the SF-36 in a community-dwelling population over 65 years old, and obtain population scores in this age group. DESIGN: Postal survey, using a questionnaire booklet containing the SF-36 and other health related items, of all those aged 65 or over registered with twelve general practices. Non-respondents received up to two reminders at three-weekly intervals. SETTING: Twelve randomly selected general practices in Sheffield. SAMPLE: 9897 subjects aged 65 to 104. MAIN OUTCOME MEASURES: Scores for the eight dimensions of the SF-36 and a modified version of the physical functioning dimension. RESULTS: The SF-36 achieved a response rate of 82% (n=8117) and dimension completion rates of 86.4% to 97.7%. Internal consistency measured by Cronbach’s a exceeded 0.80 for all dimensions except social functioning. These results compare favourably with postal surveys of younger adults. Scores for older adults were calculated by age and sex. Comparison with data from younger people showed how physical health declines steeply with age, in marked contrast with mental health. CONCLUSIONS: The SF-36 is a practical and valid instrument to use in postal surveys of older people living in the community. The population scores provided here may facilitate its use in future surveys of older adults

Response to requests for general practice out of hours: geographical analysis in north west England

The organisation of out of hours general practice (GP) in the UK has changed rapidly in recent years as practice based rotas and deputising services have given way to GP cooperatives in many areas. At the same time, the proportion of patients contacting an out of hours service who receive telephone advice only, rather than a face to face consultation, has risen substantially, although patients continue to express strong preferences for personal contact with a doctor out of hours. We examined the effect of the distance of the patient from the primary care centre on the doctor’s decision to see the patient face to face

General practitioners' reasons for removing patients from their lists: postal survey in England and Wales

The removal of patients from doctors' lists causes con­ siderable public and political concern, with speculation that patients are removed for inappropriate, including financial, reasons. In 1999 the House of Commons Select Committee on Public Administration noted that little evidence was available on either the frequency of, or the reasons for, removal of patients. National statistics do not distinguish between patients removed after moving out of a practice area and those removed for other reasons. Two postal surveys have reported why general practitioners might, in general, remove patients, and one small study has described the reasons doctors give for particular removals. We therefore determined the current scale of, and doctors' reasons for, removal of patients from their lists in Eng­ land and Wales

Evaluation of NHS Direct ‘‘referral’’ to community pharmacists

OBJECTIVES: To evaluate a pilot scheme of referrals from a nurse-led telephone helpline (NHS Direct) to community pharmacists. METHODS: A multi-method approach, including analysis of routine data from NHS Direct, postal surveys of NHS Direct callers, analysis of anonymised transcripts of calls, a postal survey of callers referred to pharmacists, and face-to-face interviews with NHS Direct nurses. SETTING: Essex, Barking and Havering. KEY FINDINGS: During the first three months of the pilot scheme, 6% (1,995/31,674) of NHS Direct calls triaged by nurses were logged as referred to pharmacists. This built on an existing foundation of informal referral to pharmacists of 4%. There was no measurable change in callers’ views of the helpfulness of advice, enablement, or caller satisfaction associated with the scheme. Conditions sent to pharmacists included skin rash, cough, sore throat, stomach pain, and vomiting and/or diarrhoea. 86% (54/63) of callers referred to pharmacists during the scheme felt the referral was very or quite appropriate and 75% (48/64) attempted to contact a pharmacist. In general, those who did so found the experience a positive one: 65% (31/48) spoke to the pharmacist, and 80% (28/35) of people expressing an opinion were satisfied with the advice offered, but the lack of privacy in the pharmacy was of some concern. Although routine data indicated high usage of the scheme, nurse referral of callers to pharmacists declined over time. Their initial enthusiasm diminished due to concerns about the appropriateness of guidelines, their lack of understanding of the rationale behind some referrals, and the lack of feedback about the appropriateness of their referrals. CONCLUSIONS: The evaluation of the pilot scheme has generated a range of recommendations for the wider national roll-out of the scheme, including revision of the guidelines and review of NHS Direct nurse training for referral to pharmacy. NHS Direct and pharmacists should consider how to strengthen the system of pharmacist feedback to NHS Direct

Impact of NHS Direct on demand for immediate care: observational study

OBJECTIVES: To quantify the impact of NHS Direct on the use of accident and emergency, ambulance, and general practitioner cooperative services. DESIGN: Observational study of trends in use of NHS Direct and other immediate care services over 24 months spanning introduction of NHS Direct. Setting Three areas in England in first wave of introduction of NHS Direct, and six nearby general practitioner cooperatives as controls. SUBJECTS: All contacts with these immediate care services. MAIN OUTCOME MEASURES: Changes in trends in use after introduction of NHS Direct. Results NHS Direct received about 68 500 calls from a population of 1.3 million in its first year of operation, of which 72% were out of hours and 22% about a child aged under 5 years. Changes in trends in use of accident and emergency departments and ambulance services after introduction of NHS Direct were small and non­significant. Changes in trends in use of general practitioner cooperatives were also small but significant, from an increase of 2.0% a month before introduction of NHS Direct to - 0.8% afterwards (relative change - 2.9% (95% confidence interval - 4.2% to - 1.5%)). This reduction in trend was significant both for calls handled by telephone advice alone and for those resulting in direct contact with a doctor. In contrast, the six control cooperatives showed no evidence of change in trend; an increase of 0.8% a month before NHS Direct and 0.9% after (relative change 0.1% ( - 0.9% to 1.1%)). CONCLUSION: In its first year NHS Direct did not reduce the pressure on NHS immediate care services, although it may have restrained increasing demand on one important part—general practitioners' out of hours services

Integrating community pharmacy and NHS Direct - pharmacists' views

AIM:To establish the views of community pharmacists on NHS Direct and its forthcoming integration with community pharmacy. DESIGN: Postal questionnaire survey. SUBJECTS AND SETTING: Pharmacists working in community pharmacies within the area of the NHS Direct Pharmacy pilot scheme - Essex, Barking and Havering. RESULTS: The response rate to the postal survey was 72% (263/364). Most pharmacies were generally supportive of NHS Direct (80%) and the pharmacy scheme in principle (83%), although their experience of the scheme in practice was limited. Perhaps because of this, the majority of pharmacists were unsure as to whether NHS Direct was referring appropriately, or whether the pharmacy would be able to meet the needs of patients without further referral. Almost half believed that patients referred by NHS Direct should be seen in a quiet area, away from the counter. Over two-thirds of pharmacists were willing to accommodate an NHS Direct information point in their pharmacy, although space was an issue. CONCLUSION: Overall the results of this study suggested that community pharmacists welcome their increasing involvement in the developing immediate care system. As the Government commitment in the NHS plan to integrate community pharmacy with NHS Direct becomes a reality across England and Wales over coming months the implications for pharmacists, in terms of workload and the adequacy of premises, will become clearer. Careful audit of the operation of the scheme will be essential

How helpful is NHS Direct? Postal survey of callers

NHS Direct, the new 24 hour telephone advice line staffed by nurses, was established to “provide easier and faster information for people about health, illness and the NHS so that they are better able to care for themselves and their families.” In March 1998, three first wave sites started in Lancashire, Milton Keynes, and Northumbria. As part of an extensive evaluation of this new service, we surveyed callers to determine how helpful they found the advice offered

Cost effectiveness of a community based exercise programme in over 65 year olds: cluster randomised trial

OBJECTIVE: To assess the cost effectiveness of a community based exercise programme as a population wide public health intervention for older adults. DESIGN: Pragmatic, cluster randomised community intervention trial. Setting: 12 general practices in Sheffield; four randomly selected as intervention populations, and eight as control populations. PARTICIPANTS: All those aged 65 and over in the least active four fifths of the population responding to a baseline survey. There were 2283 eligible participants from intervention practices and 4137 from control practices. INTERVENTION: Eligible subjects were invited to free locally held exercise classes, made available for two years. MAIN OUTCOME MEASURES: All cause and exercise related cause specific mortality and hospital service use at two years, and health status assessed at baseline, one, and two years using the SF-36. A cost utility analysis was also undertaken. RESULTS: Twenty six per cent of the eligible intervention practice population attended one or more exercise sessions. There were no significant differences in mortality rates, survival times, or admissions. After adjusting for baseline characteristics, patients in intervention practices had a lower decline in health status, although this reached significance only for the energy dimension and two composite scores (p,0.05). The incremental average QALY gain of 0.011 per person in the intervention population resulted in an incremental cost per QALY ratio of J17 174 (95% CI =J8300 to J87 120). CONCLUSIONS: Despite a low level of adherence to the exercise programme, there were significant gains in health related quality of life. The programme was more cost effective than many existing medical interventions, and would be practical for primary care commissioning agencies to implement

Nurses' views of using computerized decision support software in NHS Direct

Background. Nurses working in NHS Direct, the 24-hour telephone advice line in England, use computerized decision support software to recommend to callers the most appropriate service to contact, or to advise on self-care. Aims. To explore nurses' views of their roles and the computerized decision support software in NHS Direct. Methods. Qualitative analysis of semi-structured interviews with 24 NHS Direct nurses in 12 sites. Findings. Nurses described both the software and themselves as essential to the clinical decision-making process. The software acted as safety net, provider of consistency, and provider of script, and was relied upon more when nurses did not have clinical knowledge relevant to the call. The nurse handled problems not covered by the software, probed patients for the appropriate information to enter into the software, and interpreted software recommendations in the light of contextual information which the software was unable to use. Nurses described a dual process of decision-making, with the nurse as active decision maker looking for consensus with the software recommendation and ready to override recommendations made by the software if necessary. However, nurses' accounts of the software as a guide, prompt or support did not fully acknowledge the power of the software, which they are required to use, and the recommendation of which they are required to follow under some management policies. Over time, the influence of nurse and software merges as nurses internalize the software script as their own knowledge, and navigate the software to produce recommendations that they feel are most appropriate. Conclusions. The nurse and the software have distinct roles in NHS Direct, although the effect of each on the clinical decision-making process may be difficult to determine in practice

Impact of NHS Direct on other services: the characteristics and origins of its nurses

OBJECTIVE:: To characterise the NHS Direct nurse workforce and estimate the impact of NHS Direct on the staffing of other NHS nursing specialties. METHOD: A postal survey of NHS Direct nurses in all 17 NHS Direct call centres operating in June 2000. RESULTS: The response rate was 74% (682 of 920). In the three months immediately before joining NHS Direct, 20% (134 of 682, 95% confidence intervals 17% to 23%) of respondents had not been working in the NHS. Of the 540 who came from NHS nursing posts, one fifth had come from an accident and emergency department or minor injury unit (110 of 540), and one in seven from practice nursing (75 of 540). One in ten (65 of 681) nurses said that previous illness, injury, or disability had been an important reason for deciding to join NHS Direct. Sixty two per cent (404 of 649) of nurses felt their job satisfaction and work environment had improved since joining NHS Direct. CONCLUSION: The NHS Direct nurse workforce currently constitutes a small proportion (about 0.5%) of all qualified nurses in the NHS, although it recruits relatively experienced and well qualified nurses more heavily from some specialties, such as accident and emergency nursing, than others. However, its overall impact on staffing in any one specialty is likely to be small. NHS Direct has succeeded in providing employment for some nurses who might otherwise be unable to continue in nursing because of disability