Qualitative study of patient views on a 'telephone-first' approach in general practice in England: speaking to the GP by telephone before making face-to-face appointments.

This is the final version. Available from BMJ Publishing Group via the DOI in this record.OBJECTIVE: To understand patients' views on a 'telephone-first' approach, in which all appointment requests in general practice are followed by a telephone call from the general practitioner (GP). DESIGN: Qualitative interviews with patients and carers. SETTING: Twelve general practices in England. PARTICIPANTS: 43 patients, including 30 women, nine aged over 75 years, four parents of young children, five carers, five patients with hearing impairment and two whose first language was not English. RESULTS: Patients expressed varied views, often strongly held, ranging from enthusiasm for to hostility towards the 'telephone-first' approach. The new system suited some patients, avoiding the need to come into the surgery but was problematic for others, for example, when it was difficult for someone working in an open plan office to take a call-back. A substantial proportion of negative comments were about the operation of the scheme itself rather than the principles behind it, for example, difficulty getting through on the phone or being unable to schedule when the GP would phone back. Some practices were able to operate the scheme in a way that met their patients' needs better than others and practices varied significantly in how they had implemented the approach. CONCLUSIONS: The 'telephone-first' approach appears to work well for some patients, but others find it much less acceptable. Some of the reported problems related to how the approach had been implemented rather than the 'telephone-first' approach in principle and suggests there may be potential for some of the challenges experienced by patients to be overcome.National Institute for Health Researc

Living with Plenty: Meeting the Challenge of Diabetes. The Twenty First Century Role of Pharmacy and Pharmaceutical Innovation in the Prevention and Treatment of Diabetes Mellitus.

This report describes recent developments in bio-medical, behavioural and social understandings of diabetes and how it can be prevented and treated. Its most important objectives relate to the further development of pharmacy-based health care as a cost-effective part of the overall pattern of support available to people with diabetes. This should facilitate a combination of better medicines use and positive health related behaviour changes. This report also seeks to contribute to wider public and professional debate about the nature of diabetes and how individuals and communities should respond to the threat it represents. It seeks to promote a balanced awareness of the fact that although there is no such thing as a 'mild' case of diabetes – everyone who is diagnosed with any variant of the disorder is at raised risk of disability or death – appropriate management can significantly reduce the harm that it would otherwise caus

Women Filmmakers in the United Arab Emirates

This entry provides an introduction to the work of and the challenges faced by women filmmakers in the United Arab Emirates while at the same time providing an overview of the emerging film industry in the country. The fact that these women claim the power of representation and start telling their stories against the backdrop of a conservative, patriarchal society, obviously opens up space for gender redefinition. Overall, it seems that their films reveal a preference for strong, interesting women that fight for a meaningful life against the backdrop of a globalized society that has left women weaker and more fragile, with less obvious choices and possibilities for fulfillment. As their female characters claim center stage, both traditional and contemporary constructions of gender are called into question and popular stereotypes about Emirati women are challenged

Investigating the meaning of 'good' or 'very good' patient evaluations of care in English general practice: A mixed methods study

This is the final version. Available from the publisher via the DOI in this record.The data set is available on request from the authors: please email Jenni Burt ( [email protected]) for details.Objective: To examine concordance between responses to patient experience survey items evaluating doctors' interpersonal skills, and subsequent patient interview accounts of their experiences of care. Design: Mixed methods study integrating data from patient questionnaires completed immediately after a video-recorded face-to-face consultation with a general practitioner (GP) and subsequent interviews with the same patients which included playback of the recording. Setting: 12 general practices in rural, urban and inner city locations in six areas in England. Participants: 50 patients (66% female, aged 19-96 years) consulting face-to-face with 32 participating GPs. Main outcome measures: Positive responses to interpersonal skills items in a postconsultation questionnaire ('good' and 'very good') were compared with experiences reported during subsequent video elicitation interview (categorised as positive, negative or neutral by independent clinical raters) when reviewing that aspect of care. Results: We extracted 230 textual statements from 50 interview transcripts which related to the evaluation of GPs' interpersonal skills. Raters classified 70.9% (n=163) of these statements as positive, 19.6% (n=45) neutral and 9.6% (n=22) negative. Comments made by individual patients during interviews did not always express the same sentiment as their responses to the questionnaire. Where questionnaire responses indicated that interpersonal skills were 'very good', 84.6% of interview statements concerning that item were classified as positive. However, where patients rated interpersonal skills as 'good', only 41.9% of interview statements were classified as positive, and 18.9% as negative. Conclusions: Positive responses on patient experience questionnaires can mask important negative experiences which patients describe in subsequent interviews. The interpretation of absolute patient experience scores in feedback and public reporting should be done with caution, and clinicians should not be complacent following receipt of 'good' feedback. Relative scores are more easily interpretable when used to compare the performance of providers.NHS Cambridgeshire and Peterborough CCGNational Institute for Health Researc

Greater Expectations. Pharmacy based health care: The future for Europe?

Europe’s network of 140,000 community pharmacies provides easy access to medicines to the entire population. It should be seen as an important health care asset for the future. Primary care doctors and nurses are becoming more involved in treating people with complex needs in community settings. Community pharmacists in many parts of Europe are starting to provide extended pharmaceutical care services. As more effective medicines become available as pharmacy only products, pharmacists will play a more significant part in directly supporting self management and improving public health through preventive interventions

Wasting the doctor's time? A video-elicitation interview study with patients in primary care

Reaching a decision about whether and when to visit the doctor can be a difficult process for the patient. An early visit may cause the doctor to wonder why the patient chose to consult when the disease was self-limiting and symptoms would have settled without medical input. A late visit may cause the doctor to express dismay that the patient waited so long before consulting. In the UK primary care context of constrained resources and government calls for cautious healthcare spending, there is all the more pressure on both doctor and patient to meet only when necessary. A tendency on the part of health professionals to judge patients' decisions to consult as appropriate or not is already described. What is less well explored is the patient's experience of such judgment. Drawing on data from 52 video-elicitation interviews conducted in the English primary care setting, the present paper examines how patients seek to legitimise their decision to consult, and their struggles in doing so. The concern over wasting the doctor's time is expressed repeatedly through patients' narratives. Referring to the sociological literature, the history of ‘trivia’ in defining the role of general practice is discussed, and current public discourses seeking to assist the patient in developing appropriate consulting behaviour are considered and problematised. Whilst the patient is expected to have sufficient insight to inform timely consulting behaviour, it becomes clear that any attempt on the part of doctor or patient to define legitimate help-seeking is in fact elusive. Despite this, a significant moral dimension to what is deemed appropriate consulting by doctors and patients remains. The notion of candidacy is suggested as a suitable framework and way forward for encompassing these struggles to negotiate eligibility for medical time.The Improve Programme was funded by the National Institute for Health Research's Programme Grant for Applied Research. This paper summarises independent research funded by the National Institute for Health Research (NIHR) under its Programme Grant for Applied Research (Grant Reference Number RP-PG-0608-10050)

Evaluation of telephone first approach to demand management in English general practice: observational study

Objective: To evaluate a “telephone first” approach, in which all patients wanting to see a general practitioner (GP) are asked to speak to a GP on the phone before being given an appointment for a face to face consultation. Design: Time series and cross sectional analysis of routine healthcare data, data from national surveys, and primary survey data. Participants: 147 general practices adopting the telephone first approach compared with a 10% random sample of other practices in England. Intervention: Management support for workload planning and introduction of the telephone first approach provided by two commercial companies. Main outcome measures: Number of consultations, total time consulting (59 telephone first practices, no controls). Patient experience (GP Patient Survey, telephone first practices plus controls). Use and costs of secondary care (hospital episode statistics, telephone first practices plus controls). The main analysis was intention to treat, with sensitivity analyses restricted to practices thought to be closely following the companies’ protocols. Results: After the introduction of the telephone first approach, face to face consultations decreased considerably (adjusted change within practices −38%, 95% confidence interval −45% to −29%; P<0.001). An average practice experienced a 12-fold increase in telephone consultations (1204%, 633% to 2290%; P<0.001). The average duration of both telephone and face to face consultations decreased, but there was an overall increase of 8% in the mean time spent consulting by GPs, albeit with large uncertainty on this estimate (95% confidence interval −1% to 17%; P=0.088). These average workload figures mask wide variation between practices, with some practices experiencing a substantial reduction in workload and others a large increase. Compared with other English practices in the national GP Patient Survey, in practices using the telephone first approach there was a large (20.0 percentage points, 95% confidence interval 18.2 to 21.9; P<0.001) improvement in length of time to be seen. In contrast, other scores on the GP Patient Survey were slightly more negative. Introduction of the telephone first approach was followed by a small (2.0%) increase in hospital admissions (95% confidence interval 1% to 3%; P=0.006), no initial change in emergency department attendance, but a small (2% per year) decrease in the subsequent rate of rise of emergency department attendance (1% to 3%; P=0.005). There was a small net increase in secondary care costs. Conclusions: The telephone first approach shows that many problems in general practice can be dealt with over the phone. The approach does not suit all patients or practices and is not a panacea for meeting demand. There was no evidence to support claims that the approach would, on average, save costs or reduce use of secondary care

Repeatability and reproducibility of multiparametric magnetic resonance imaging of the liver

As the burden of liver disease reaches epidemic levels, there is a high unmet medical need to develop robust, accurate and reproducible non-invasive methods to quantify liver tissue characteristics for use in clinical development and ultimately in clinical practice. This prospective cross-sectional study systematically examines the repeatability and reproducibility of iron-corrected T1 (cT1), T2*, and hepatic proton density fat fraction (PDFF) quantification with multiparametric MRI across different field strengths, scanner manufacturers and models. 61 adult participants with mixed liver disease aetiology and those without any history of liver disease underwent multiparametric MRI on combinations of 5 scanner models from two manufacturers (Siemens and Philips) at different field strengths (1.5T and 3T). We report high repeatability and reproducibility across different field strengths, manufacturers, and scanner models in standardized cT1 (repeatability CoV: 1.7%, bias -7.5ms, 95% LoA of -53.6 ms to 38.5 ms; reproducibility CoV 3.3%, bias 6.5 ms, 95% LoA of -76.3 to 89.2 ms) and T2* (repeatability CoV: 5.5%, bias -0.18 ms, 95% LoA -5.41 to 5.05 ms; reproducibility CoV 6.6%, bias -1.7 ms, 95% LoA -6.61 to 3.15 ms) in human measurements. PDFF repeatability (0.8%) and reproducibility (0.75%) coefficients showed high precision of this metric. Similar precision was observed in phantom measurements. Inspection of the ICC model indicated that most of the variance in cT1 could be accounted for by study participants (ICC = 0.91), with minimal contribution from technical differences. We demonstrate that multiparametric MRI is a non-invasive, repeatable and reproducible method for quantifying liver tissue characteristics across manufacturers (Philips and Siemens) and field strengths (1.5T and 3T)

Investigating the meaning of 'good' or 'very good' patient evaluations of care in English general practice: a mixed methods study

$\textbf{OBJECTIVE}$: To examine concordance between responses to patient experience survey items evaluating doctors' interpersonal skills, and subsequent patient interview accounts of their experiences of care. $\textbf{DESIGN}$: Mixed methods study integrating data from patient questionnaires completed immediately after a video-recorded face-to-face consultation with a general practitioner (GP) and subsequent interviews with the same patients which included playback of the recording. $\textbf{SETTING}$: 12 general practices in rural, urban and inner city locations in six areas in England. PARTICIPANTS: 50 patients (66% female, aged 19-96 years) consulting face-to-face with 32 participating GPs. $\textbf{MAIN OUTCOME MEASURES}$: Positive responses to interpersonal skills items in a postconsultation questionnaire ('good' and 'very good') were compared with experiences reported during subsequent video elicitation interview (categorised as positive, negative or neutral by independent clinical raters) when reviewing that aspect of care. $\textbf{RESULTS}$: We extracted 230 textual statements from 50 interview transcripts which related to the evaluation of GPs' interpersonal skills. Raters classified 70.9% (n=163) of these statements as positive, 19.6% (n=45) neutral and 9.6% (n=22) negative. Comments made by individual patients during interviews did not always express the same sentiment as their responses to the questionnaire. Where questionnaire responses indicated that interpersonal skills were 'very good', 84.6% of interview statements concerning that item were classified as positive. However, where patients rated interpersonal skills as 'good', only 41.9% of interview statements were classified as positive, and 18.9% as negative. $\textbf{CONCLUSIONS}$: Positive responses on patient experience questionnaires can mask important negative experiences which patients describe in subsequent interviews. The interpretation of absolute patient experience scores in feedback and public reporting should be done with caution, and clinicians should not be complacent following receipt of 'good' feedback. Relative scores are more easily interpretable when used to compare the performance of providers.This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Programme (Grant Reference Number RP-PG-0608-10050)

The Evaluation of Physicians' Communication Skills From Multiple Perspectives.

This is the author accepted manuscript. The final version is available from Annals of Family Medicine via the DOI in this record.PURPOSE: To examine how family physicians', patients', and trained clinical raters' assessments of physician-patient communication compare by analysis of individual appointments. METHODS: Analysis of survey data from patients attending face-to-face appointments with 45 family physicians at 13 practices in England. Immediately post-appointment, patients and physicians independently completed a questionnaire including 7 items assessing communication quality. A sample of videotaped appointments was assessed by trained clinical raters, using the same 7 communication items. Patient, physician, and rater communication scores were compared using correlation coefficients. RESULTS: Included were 503 physician-patient pairs; of those, 55 appointments were also evaluated by trained clinical raters. Physicians scored themselves, on average, lower than patients (mean physician score 74.5; mean patient score 94.4); 63.4% (319) of patient-reported scores were the maximum of 100. The mean of rater scores from 55 appointments was 57.3. There was a near-zero correlation coefficient between physician-reported and patient-reported communication scores (0.009, P = .854), and between physician-reported and trained rater-reported communication scores (-0.006, P = .69). There was a moderate and statistically significant association, however, between patient and trained-rater scores (0.35, P = .042). CONCLUSIONS: The lack of correlation between physician scores and those of others indicates that physicians' perceptions of good communication during their appointments may differ from those of external peer raters and patients. Physicians may not be aware of how patients experience their communication practices; peer assessment of communication skills is an important approach in identifying areas for improvement.This work was funded by a National Institute for Health Research Programme Grant for Applied Research (NIHR PGfAR) program (RP-PG-0608-10050)