Enhancing primary care support for informal carers: a scoping study with professional stakeholders

Informal carers (i.e. people who provide unpaid care to family and/or friends) are crucial in supporting people with long‐term conditions. Caring negatively impacts on carers’ health and experiences of health services. Internationally and nationally, policies, legislation, professional guidance and research advocate for health and care services to do more to support carers. This study explored the views of health and social care providers, commissioners and policy makers about the role and scope for strengthening health service support for carers. Twenty‐four semi‐structured interviews, with 25 participants were conducted, audio‐recorded, transcribed verbatim and analysed by thematic analysis. Three main themes emerged: (a) identifying carers, (b) carer support, and (c) assessing and addressing carer needs. Primary care, and other services, were seen as not doing enough for carers but having an important role in identifying and supporting carers. Two issues with carer identification were described, first people not self‐identifying as carers and second most services not being proactive in identifying carers. Participants thought that carer needs should be supported by primary care in collaboration with other health services, social care and the voluntary sector. Concerns were raised about primary care, which is under enormous strain, being asked to take on yet another task. There was a clear message that it was only useful to involve primary care in identifying carers and their needs, if benefit could be achieved through direct benefits such as better provision of support to the carer or indirect benefit such as better recognition of the carer role. This study highlights that more could be done to address carers’ needs through primary care in close collaboration with other health and care services. The findings indicate the need for pilots and experiments to develop the evidence base. Given the crucial importance of carers, such studies should be a high priority

Systematic review of the uptake and design of action research in published nursing research, 2000-2005

Action research (AR) is promoted for health care development. A systematic review was undertaken to gain insight into the uptake and designs of practice-based AR. Empirical research papers from 2000 to 2005 were extracted from CINAHL, MEDLINE and British Nursing Index, and two specialist AR journals. The initial search identified 335 papers: 38% were AR (20% were phenomenology; 32% ethnography; 10% randomised-controlled trials). Further filtering produced 62 AR papers for detailed analysis. Eighty-seven per cent of AR studies involved ‘organisational/professional development’, or ‘educational’ settings; only 13% were directly ‘clinical’. Practitioners were the main participants in 90% of studies. Seventy-two per cent of all participant groups were rated ‘active’ in the research process, yet 70% of first (lead) authors were from an academic institution. Patients/carers were generally passive in the research process and absent from the authorship. Ninety per cent of studies used two or more methods, predominantly qualitative. Forty-four per cent of articles identified external funding sources, relatively high for nursing research. Participatory AR has a strong identity in practice-based research, with a diversity of methods. The focus reflects that of nursing research generally. A high level of participation by practitioners is evident but with little equity in authorship. Service user/carer involvement should be given more prominence by researchers

Primary care challenges in diagnosing and referring patients with suspected rheumatoid arthritis: a national cross-sectional GP survey

Objective: National guidelines advocate referring patients with persistent synovitis to rheumatology within 3 working days of presentation to primary care. This occurs infrequently. We aimed to identify modifiable barriers to early referral of suspected RA patients among English general practitioners (GPs). Methods: We carried out a national cross-sectional survey of 1388 English GPs (RA Questionnaire for GPs [RA-QUEST] study). Questions addressed GPs’ confidence in diagnosing RA, clinical factors influencing RA diagnosis/referral, timeliness of referrals and secondary care access. Data were captured using 10-point visual analog scales, five-point Likert scales, yes/no questions or free text, and were analysed descriptively. Results: Small joint swelling and pain were most influential in diagnosing RA (91 and 84% rated the importance of these as 4 or 5 on a five-point Likert scale, respectively); investigations including RF (61% rating 4 or 5) and anti-CCP antibody (72% rating 4 or 5) were less influential. Patient history had the greatest impact on the decision to refer (92% rating this 4 or 5 on a 5-point Likert scale), with acute phase markers (74% rating 4 or 5) and serology (76% rating 4 or 5) less impactful. Despite the importance placed on history and examination, only 26% referred suspected RA immediately without investigations; 95% of GPs organizing further tests opted to test for RF. Conclusion: For suspected RA patients to be referred within 3 days of presentation to primary care there needs to be a paradigm shift in GPs’ approaches to making referral decisions, with a focus on clinical history and examination findings, and not the use of investigations such as RF

Does radiography advanced practice improve patient outcomes and health service quality? A systematic review

yesObjectives To investigate the impact of radiographer advanced practice on patient outcomes and health service quality. Methods Using the World Health Organisation definition of quality, this review followed the Centre for Reviews and Dissemination guidance for undertaking reviews in healthcare. A range of databases were searched using a defined search strategy. Included studies were assessed for quality using a tool specifically developed for reviewing studies of diverse designs and data were systematically extracted using electronic data extraction proforma. Results 407 articles were identified and reviewed against the inclusion/exclusion criteria. Nine studies were included in the final review, the majority (n=7) focussing on advanced radiography practice within the UK. Advanced practice activities considered were radiographer reporting, leading patient review clinics and barium enema examinations. The papers were generally considered to be of low to moderate quality with most evaluating advanced practice within a single centre. With respect to specific quality dimensions, included studies considered cost reduction, patient morbidity, time to treatment and patient satisfaction. No papers reported data relating to time to diagnosis, time to recovery or patient mortality. Conclusions Radiographer advanced practice is an established activity both in the UK and internationally. However, evidence of the impact of advanced practice in terms of patient outcomes and service quality is limited. Advances in knowledge This systematic review is the first to examine the evidence base surrounding advanced radiography practice and its impact on patient outcomes and health service quality. Powered b

The effectiveness and cost-effectiveness of a participative community singing programme as a health promotion initiative for older people: protocol for a randomised controlled trial

Background The growth in numbers of older people represents a considerable cost to health and social care services in the United Kingdom. There is an acknowledged need to address issues of social exclusion and both the physicial and mental health of this age group. In recent years there has been much interest in the potential contribution of the arts to the health of communities and individuals. There is some evidence that participative singing may be of benefit to older people, however studies to date are limited in number and have lacked rigour. There is therefore a need to build on this knowledge base to provide more quantifiable evidence of both effectiveness and cost efffectness of singing as a health intervention of this population group. Methods The proposed study is a pragmatic randomised controlled trial with two parallel arms. The primary hypothesis is that singing groups for older people improve both physical and mental aspects of qualaity of life when compared to usual activities. Potential participants will be volunteers over 60 years living in the community and recruited through publicity. Eligible and consenting participants will be randomized to either a singing group or a control group. Singing groups will take part in a twelve week planned programme of singing and control groups will continue with usual activities. The primary outcome measure will be the York SF-12, a health related quality of life measure which will be administered at baseline, three and six months after baseline. The study will evaluate both effectiveness and cost-effectiveness. Discussion This study proposes to add to the exisiting body of evidence on the value of singing for older people by using a rigorous methodological design, which includes a power calucation, a standardised intervention and assessment of cost-effectiveness. It should be regarded as a stage in a progressive programme of studies in this area. If group singing is found to be effective and cost-effective it may offer an alternative means to maintaining the health of people in later life

Quality of Care Provided in Two Scottish Rural Community Maternity Units: a retrospective case review.

Background: Women in Scotland with uncomplicated pregnancies are encouraged by professional bodies and national guidelines to access community based models of midwife-led care for their labour and birth. The evidence base for these guidelines relates to comparisons of predominantly urban birth settings in England. There appears to be little evidence available about the quality of the care during the antenatal, birth and post birth periods available for women within the Scottish Community Maternity Unit (CMU) model. The research aim was to explore the safety and effectiveness of the maternity services provided at two rural Community Maternity Units in Scotland, both 40 miles by main road access from a tertiary obstetric unit. Methods: Following appropriate NHS and University ethical approval, an anonymous retrospective review of consecutive maternity records for all women who accessed care at the CMUs over a 12 month period (June 2011 to May 2012) was undertaken in 2013 -14. Data was extracted using variables chosen to provide a description of the socio-demographics of the cohort and the process and outcomes of the care provided. Data were analysed using descriptive statistics. Results: Regarding effectiveness, the correct care pathway was allocated to 97.5% of women, early access to antenatal care achieved by 95.7% of women, 94.8% of women at one CMU received continuity of carer and 78.6% of those clinically eligible accessed care in labour. 11.9% were appropriately transferred to obstetrician-led care antenatally and 16.9% were transferred in labour. All women received one-to one care in labour and 67.1% of babies born at the CMUs were breastfed at birth. Regarding safety, severe morbidity for women was rare, perineal trauma of 3rd degree tear occurred for 0.3% of women and 1.0% experienced an episiotomy. Severe post partum haemorrhage occurred for 0.3% of women. Babies admitted to the Neonatal unit were discharged within 48 hours. Conclusion: These findings support the recommendations of professional bodies and national guidelines. Maternity service provision at rural CMUs achieved a consistently high standard of safety and effectiveness when measured against national standards and international evidence

Mental health and Probation: a systematic review of the literature

A narrative systematic review was undertaken of the literature concerning the health of people on probation. In this paper, we provide an up-to-date summary of what is known about the most effective ways of providing mental healthcare for people on probation, and what is known about the relationship between different systems and processes of mental healthcare provision, and good mental health outcomes for this population. A total of 5125 papers were identified in the initial electronic searches but after careful double-blind review only four papers related to mental health that met our criteria, although a further 24 background papers and 13 items of grey literature were identified which are reported. None of the included studies was a randomized controlled trial although one was quasi-experimental. Two of the other papers described mental health disorders in approved premises and the other described the impact and learning from an Offender Personality Disorder project. We conclude that the literature is bereft of evidence on how to effectively provide mental healthcare for people on probation

Experiences of User Involvement in Mental Health Settings: User Motivations and Benefits

Introduction: Despite guidance promoting user involvement, meaningful involvement continues to be debated within services. To effectively implement involvement, it is important to acknowledge why users devote time to such activities. Aim: This study explores user representatives’ experiences of involvement, including motivations and personal benefits. Method: Thirteen user representatives involved in activities such as staff training and interviews were recruited from a UK National Health Service mental health Trust during 2015. Themes within semi-structured interviews were developed using constructivist grounded theory analysis. Memo-writing, process and focused coding, and core categories supported development of the conceptual framework of being a user representative. Findings: Being a user representative was inextricably linked to wellness, yet staff governed opportunities. Making a difference to others and giving back were initial motivating factors. Experiences depended on feeling valued, and the theme of transition captured shifts in identity. Discussion: User representatives reported increased confidence and wellbeing when supported by staff. However, involvement triggered mental health difficulties, and identified need for regular monitoring and reflection of involvement activities and practice. Implications for practice: Services should consider coproduction, where users and staff agree together on involvement definitions. Dedicated involvement workers are crucial to supporting individual wellbeing and monitoring involvement

Impact of the introduction and withdrawal of financial incentives on the delivery of alcohol screening and brief advice in English primary health care : an interrupted time–series analysis

Aim To evaluate the impact of the introduction and withdrawal of financial incentives on alcohol screening and brief advice delivery in English primary care. Design Interrupted time–series using data from The Health Improvement Network (THIN) database. Data were split into three periods: (1) before the introduction of financial incentives (1 January 2006–31 March 2008); (2) during the implementation of financial incentives (1 April 2008–31 March 2015); and (3) after the withdrawal of financial incentives (1 April 2015–31 December 2016). Segmented regression models were fitted, with slope and step change coefficients at both intervention points. Setting England. Participants Newly registered patients (16+) in 500 primary care practices for 2006–16 (n = 4 278 723). Measurements The outcome measures were percentage of patients each month who: (1) were screened for alcohol use; (2) screened positive for higher‐risk drinking; and (3) were reported as having received brief advice on alcohol consumption. Findings There was no significant change in the percentage of newly registered patients who were screened for alcohol use when financial incentives were introduced. However, the percentage fell (P < 0.001) immediately when incentives were withdrawn, and fell by a further 2.96 [95% confidence interval (CI) = 2.21–3.70] patients per 1000 each month thereafter. After the introduction of incentives, there was an immediate increase of 9.05 (95% CI = 3.87–14.23) per 1000 patients screening positive for higher‐risk drinking, but no significant further change over time. Withdrawal of financial incentives was associated with an immediate fall in screen‐positive rates of 29.96 (95% CI = 19.56–40.35) per 1000 patients, followed by a rise each month thereafter of 2.14 (95% CI = 1.51–2.77) per 1000. Screen‐positive patients recorded as receiving alcohol brief advice increased by 20.15 (95% CI = 12.30–28.00) per 1000 following the introduction of financial incentives, and continued to increase by 0.39 (95% CI = 0.26–0.53) per 1000 monthly until withdrawal. At this point, delivery of brief advice fell by 18.33 (95% CI = 11.97–24.69) per 1000 patients and continued to fall by a further 0.70 (95% CI = 0.28–1.12) per 1000 per month. Conclusions Removing a financial incentive for alcohol prevention in English primary care was associated with an immediate and sustained reduction in the rate of screening for alcohol use and brief advice provision. This contrasts with no, or limited, increase in screening and brief advice delivery rates following the introduction of the scheme